Cesarean section scar ectopic pregnancy: a clinical case series

Abstract

Cesarean scar implantation represents a rare, though growing subset of potentially life-threatening ectopic pregnancy. Because of the global increase in cesarean sections as well as the improved diagnostic abilities of transvaginal ultrasound, incidence rates have continued to rise since the first reported case in 1978. Uterine rupture and catastrophic hemorrhage can ensue when diagnosis is delayed. Additionally, a higher rate of concurrent trophoblastic myometrial invasion may increase the incidence of retained products of conception or post procedural bleeding. Endovaginal ultrasound has a reported sensitivity of 85 % for detection. In difficult cases, magnetic resonance imaging is often useful as a problem solving exam in confirming diagnostic suspicions and guiding therapeutic decisions. We present a series of five illustrative cases illustrating the range of clinical and imaging findings.Keywords Ectopic Á Cesarean section Á Pregnancy Á Ultrasound Sommario La cicatrice da taglio cesareo rappresenta nella gravidanza ectopica una rara seppur crescente concausa potenzialmente pericolosa per la vita. L'aumento su scala globale della pratica del taglio cesareo, nonostante il supporto dell'applicazione dell'ecografia trans-vaginale sempre più precisa, ha visto crescere i tassi di incidenza a partire dal primo caso riportato nel 1978. Quando la diagnosi è tardiva ne può derivare la rottura dell'utero con conseguente grave emorragia. Inoltre, il verificarsi concomitante di invasione trofoblastica a livello del miometrio potrebbe aumentare l'incidenza dei residui da concepimento o delle emorragie post intervento. L'ecografia trans vaginale ha una capacità diagnostica dell'85 %. Nei casi più difficili, la RM è spesso utile come esame risolutore nel confermare i sospetti diagnostici e guidare quindi verso la terapia appropriata. Vi presentiamo 5 casi esemplificativi che illustrano la varietà di dati clinici ed imaging.

Laparoscopic repair with hysteroscopy of cesarean scar diverticulum

“…Postmenstrual brown spotting and secondary infertility are the main clinical manifestations in gynecology offices . Ectopic pregnancy at the site, like CS scar pregnancy, could be another serious complication, which could be life‐threating because of CS uterine rupture and massive haemorrhage …”

“…5 Ectopic pregnancy at the site, like CS scar pregnancy, could be another serious complication, which could be life-threating because of CS uterine rupture and massive haemorrhage. 6 The etiopathogenesis of the CSD remains unknown. Fabres et al 7 have suggested that the defect might be bound up with the suturing technique when it is performed in relation to labor and uterine cervical changes.…”

MRI of Acute Gynecologic Conditions

“…A diagnosis of cesarean section scar pregnancy can be made when a gestational sac is in the lower uterine segment, anterior to the endometrial stripe, with less than 5 mm of overlying myometrium (Fig. ) . In 86% of cases, MRI identifies a cesarean scar defect, and demonstrates various degrees of protrusion of a low‐lying gestational sac through the defect .…”

Nesa Days 2015, Conference Report

“…They have overviewed the main problems associated with increased rate of cesarean section [8][9][10]. It seems the main reason of repeat cesarean sections is the uterine scar dehiscence after previous cesarean section, which can produce rupture of the uterus through dehiscence scar during pregnancy [43] or delivery in about 70% of cases. Authors believed that disturbances of wound healing and uterine wall repair are the main causative factor for scar deficiency due to: 1) inappropriate surgical procedure during abdominal birth; 2) inaccurate suturing; 3) pathological bleeding; 4) inflammation of uterine wall; 5) postpartum intrauterine procedures (repeat curettage of uterine cavity).…”