INTRODUCTION

Scar ectopic pregnancy is characterized by the implantation of a gestational sac within the scar tissue from a previous cesarean section. This atypical implantation presents significant risks and diagnostic challenges due to its rarity. With the rising rate of cesarean sections over time, the incidence of scar ectopic pregnancy is also increasing.¹   Spontaneous abortion and pre-term delivery are the common complications of this condition.^2,3 However, scar implantation becomes particularly dangerous when there is an adherent placenta, sometimes necessitating emergency hysterectomy.⁴ Consequently, the quality of life for women affected by this type of ectopic implantation within the scar deteriorates.

CASE REPORT

A 35-year-old woman, para 2CS+0, gravida 3^rd, with no history of vaginal bleeding or expulsion of product of conception after  taking abortificant drugs (combination of mifepristone and misoprostol) 1 week ago following 8 weeks of amenorrhea. Her last cesarean section was done 2.5 years ago. No other significant medical or gynecological history was noted.

 On clinical examination, she was found to be hemodynamically stable, with no signs of acute distress. Abdominal examination revealed no abnormality.

Abdominal ultrasound revealed retained product of conception measuring about 5cm X 3cm.

The patient underwent thorough evaluation for anesthesia fitness and was prepared for Manual Vacuum Aspiration (MVA).

During the MVA procedure brisk hemorrhage was noted per vaginally, and the patient became hemodynamically unstable. Consequently, the procedure was immediately postponed. After symptomatic management of haemorrhage transfusion of three units of fresh whole blood, the patient became hemodynamically stable. Then TVS was done to recheck it. Transvaginal ultrasound (TVS) was performed to recheck the findings, which were similar to those of the abdominal scan. Subsequently, exploratory laparotomy was planned. After proper counselling of the patient laparotomy was performed, revealing clotted products of conception on the previous cesarean scar. The Products were removed accordingly, and diagnosis was confirmed with histopathology.

DISCUSSION

Different sites of ectopic pregnancies are fallopian tube, cervix, ovary etc. In our case implantation was found within uterus but in a previous scar. Sometimes recurrent scar ectopic has been observed.¹ Uterus may have scars for different reasons such as caesarian section, dilation, evacuation and curettage (DE&C), myomectomy, etc. In our case, the patient had a history of previous caesarian section. 

Diagnosis of scar ectopic pregnancy is challenging due to its atypical location within the cesarean scar.² Ultrasound, the primary imaging modality for ectopic pregnancies, may not consistently identify scar ectopic pregnancies because of their location within the cesarean scar, potentially leading to missed or delayed diagnosis. Additionally, the absence of specific diagnostic criteria or established guidelines contributes to the difficulty in distinguishing these cases from other ectopic or intrauterine pregnancies.³ Initially, we missed the diagnosis but later were able to diagnose it.

Potential risks associated with scar ectopic pregnancy include rupture of hollow organs. Chance of rupture is higher beyond the first trimaster.⁴ In our case rupture did not occur. Scar ectopic pregnancies can be managed both conservatively and surgically. We opted for surgical treatment in this case.

CONCLUSION

Cesarean section ectopic pregnancy is an uncommon variety of ectopic pregnancy.  Now a days, this type of ectopic pregnancy is being observed more frequently as the rate of cesarean sections increases. Routine ultrasonography in early pregnancy can commonly diagnose this condition. Early diagnosis is essential for preventing complications.

REFERENCESS

1. Patel MA. Scar ectopic pregnancy. The Journal of Obstetrics and Gynecology of India. 2015 Dec;65(6):372-5.

2. Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstetrical & gynecological survey. 2002 Aug 1;57(8):537-43.

3. Herman A, Weinraub Z, Avrech O, Maymon R, Ron‐El R, Bukovsky Y. Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar. BJOG: An International Journal of Obstetrics & Gynaecology. 1995 Oct;102(10):839-41.

4. Ben Nagi J, Helmy S, Ofili-Yebovi D, Yazbek J, Sawyer E, Jurkovic D. Reproductive outcomes of women with a previous history of Caesarean scar ectopic pregnancies. Human Reproduction. 2007 Jul 1;22(7):2012-5.