C-SECTION SCAR ECTOPIC PREGNANCY A CASE REPORT AND REVIEW OF THE LITERATURE

*Dr. R. Kifani, Dr. H. Chimi, Dr. C. Nadim, Dr. A. Bentaleb, Dr. S. Dagdag and Pr. S. Bargach

ABSTRACT

Introduction: Uterine scar ectopic pregnancy occurs when an embryo implants in the myometrium due to a defect from a previous cesarean section scar. Its incidence is rising with the increase in both primary and repeat cesarean sections. This type of ectopic pregnancy has also been seen following other uterine procedures such as myomectomy, uterine evacuation, and in vitro fertilization. These cases are linked to prior uterine interventions or abnormalities. Case Report: A 29-year-old woman with a history of a previous stillbirth at 30 weeks and a live child delivered by planned cesarean section was found to have a cervical location of the gestational sac during her initial consultation. Despite an unremarkable clinical examination and stable hemodynamics, ultrasound revealed an anteverted uterus with an eccentric, posterior cervical gestational sac and a high βHCG level of 55,000 mIU/mL. Pelvic MRI confirmed the sac's location on a thin myometrium over the cesarean scar and identified a FIGO 3 myoma. Given these findings, the patient underwent a Pfannenstiel laparotomy for uterine evacuation and scar reinforcement. Discussion: Implantation of an ectopic pregnancy in a cesarean scar involves the gestational sac being encased in myometrium and scar tissue, completely separate from the uterine cavity, unlike placenta accreta, which features abnormal placental attachment within the uterine cavity. The risk is heightened by previous cesarean sections or other uterine procedures, with pregnancies presenting as either shallow or deep implantation. Diagnosis is typically made through endovaginal ultrasound, with additional imaging such as 3D ultrasound or pelvic MRI for detailed assessment, while hysteroscopy or laparoscopy can be used for both diagnosis and treatment. Treatment options include systemic methotrexate (MTX), often combined with local therapies, and surgical methods like hysteroscopic resection or laparotomy/laparoscopy, with uterine artery embolization and hysterectomy considered for severe cases or when other treatments fail. Conclusion: While the exact incidence of cesarean scar pregnancy is unclear, rising case reports reflect increased awareness among obstetricians. Early diagnosis with transvaginal ultrasound and Doppler imaging is crucial for managing this condition, as it can lead to severe hemorrhagic complications if unrecognized.

Keywords: extra-uterine pregnancy, ectopic pregnancy, c-section scare.