This document reviews caesarean scar ectopic pregnancy (CSP), a rare type of ectopic pregnancy where the gestational sac implants in a previous caesarean section scar. It discusses the pathogenesis, risk factors, diagnostic criteria using ultrasound, classification into Types 1 and 2, and management options which aim to end the pregnancy as soon as possible to prevent complications. Management may include expectant, medical, surgical or combined approaches depending on factors like symptoms, fertility wishes, sac size, viability and surgical resources available. Prompt diagnosis and treatment can help reduce morbidity associated with this condition.

1. Dr. HAFSA ASIM

2. CAESAREAN SCAR ECTOPIC PREGNANCY
(Diagnostic challenges and management options)
REVIEW published in TOG volume 19 2017

3. Caesarean scar pregnancy is a rare form of ectopic pregnancy whereby the
gestational sac is fully or partially implanted within the caesarean scar.
The first case was reported in 1978.
INTRODUCTION:

4. It has been estimated that 6.1% of pregnancies in women with atleast one
previous CS.
Estimates of CSP range from 1/1800 to 1/2500.
To date more than 1000 cases have been reprted.
INCIDENCE

5. Endometrial and myometrial disruption or scarring could be predisposing
factors in abnormal pregnancy implantation.
Most probable mechanism is invasion by implanting blastocyst through a
microscopic tract.
There is no correlation between the risk of CSP and number of previous CS.
PATHOPHYSIOLOGY

6. The risk of recurrence has been reported as 3.2-5.0% in women with one
previous CSP.
RECURRENCE

7. HISTORY:
slight vaginal bleeding or discomfort
(hemodynamically instability or collapse is rare)
IMAGING:
Ultrasound is the main diagnostic tool.
DIAGNOSIS

8. Empty uterine cavity/cervical canal.
Placenta or gestational sac embedded in the scar.
A triangular/oval/round shape GS filling the niche of scar.
Thin or absent myometrial layer between GS and bladder.
Yolk sac,embryo or cardiac activity may or may not be present.
Absence of sliding sign.
USG CRITERIA FOR CSP

9. CSP can be classified into two types based on imaging findings
TYPE 1 OR ENDOGENIC:
Where implantation occurs on the scar and gestational sac grows towards
uterine cavity.
TYPE2 OR EXOGENIC:
GS is deeply embedded in the scar and grows towards bladder.
CLASSIFICATION

10. There is no consensus on the preferred mode of treatment.
All treatment options carry risk of hemorrhage and hysterectomy.
In principle , pregnancy should be ended as soon as possible after diagnosis.
MANAGEMENT

11. EXPECTANT MANAGEMENT  USED RARELY
MEDICAL MANAGEMENT  SYSTEMIC METHOTREXATE
LOCAL
INJECTION/EMBOLISATION
 LOCAL INJECTIONOF
METHOTREXATEWITH SAC
ASPIRATION
 UTERINEARTERY
CHEMOAMBOLISATION
SURGICAL MANAGEMENT  DILATATION & SURGICAL
EVACUATION
 HYSTEROSCOPIC RESECTION
 VAGINAL EXCISION
 LAPROSCOPIC EXCISION
 OPEN EXCISION
 HYSTERECTOMY
COMBINED MANAGEMENT  UTERINEARTERY
CHEMOEMBOLISATION FOLLOWED
BY DILATATIONAND
EVACUATION/SURGERY
 METHOTREXATE FOLLOWED BY
SURGICAL EVACUATION OR

12. PATIENT FACTOR SYMPTOMS
FERITILITYWISH
ASSOCIATED LESIONS
PROLONG FOLLOW UP
SURGICAL RISKS
RESPONSETO INITIALTEATMENT
CSP GESTATIONAL SAC
hCG
Size of CSP
TYPE OF CSP
VIABILITY
MYOMETRIALTHICKNESS
FACILITIES INTERVENTIONAL RADIOLOGY
SURGICAL FACILITIES
MONITORING FACILITIES
FACTORS INFLUENCING
MANAGEMENT CHOICES

13. Diagnosis and management of CSP needs expertise and multidisciplinary
approach to prevent complications.
A primary prevention is to reduce primary caesarean sections.
Prompt and accurate diagnosis , treatment and follow up is required to
reduce morbidity.
CONCLUSION

14. A 30yr old G3P2A0 with previous II LSCS at 8 weeks admitted on 16-12-2015
with pain lower abdomen and vaginal spotting for 10 days. She was vitally
stable except tenderness in hypogastrium.
Clinically ectopic pregnancy was suspected,TVS showed empty uterus,
empty cervical canal, intact gestational sac in the lower uterine segment
with absent myometrium between bladder wall and gestational sac raising
the diagnosis of CSEP.Her βhCG 71057mIU/ml
Emergency Laparotomy was done and intact gestational sac was dissected
bilateral uterine artery ligation and restoration of anatomy done.
CASE SUMMARY

15. uterovesical pouch opened
Uterine artery ligation

16. gestational sac dissection
Intact gestational sac