Abstract: The incidence of cesarean scar pregnancy is increasing and its management has proven to be challenging for Gynecologists. Scar ectopic is a form of pregnancy due to abnormal implantation of the embryo at the previous scar site following surgeries of the uterus like cesarean section, hysterotomy, myomectomy and metroplasty. Complications of scar ectopic pregnancy are uterine rupture, profuse hemorrhage and maternal death. Here we present, five cases of cesarean scar pregnancy treated at our tertiary care center over a period of 2 years. Various clinical presentations have been analyzed. Common to the cases wasa history of previous one lower segment cesarean section and presentation with vaginal bleeding. The First and the second patient presented at 8 weeks period of gestation and had taken medication for termination of pregnancy in view of the initial scan showing nonviable pregnancy. On follow up, an ultrasounds can diagnosis of cesarean scar ectopic was made and they were given a trial of medical management with methotrexate. As the medical management failed, they underwent a laparotomy and a laparoscopic surgery for excision of scar ectopic with repair respectively.
Third patient presented at 12weeks+4days period of gestation and was referred with the suspicion of gestational trophoblastic disease. Initial ultrasound scan showed nonviable fetus and was medically managed for termination of pregnancy. Follow up scan showed features of gestational trophoblastic disease. MRI was done to confirm the diagnosis of a scar ectopic. Laparotomy was done, to excise the scar ectopic with repair.
Fourth patient presented at 13weeks+4days period of gestation with ultrasound scan suggestive of scar ectopic and was medically managed followed by laparotomy.
Fifth patient presented at 9 weeks period of gestation with vaginal bleeding. Her ultrasound scan showed features suggestive of cesarean scar pregnancy. She underwent laparotomy for excision of scar ectopic with repair.
All post laparotomy biopsies were sent for histopathology and confirmed with features consistent with products of conception at the scar site. They were followed up with serial serum Beta HCG values, which showed a decreasing trend initially until they reached negative levels.
Conclusion: The diagnosis of a scar ectopic is challenging and a delay in the management could lead to maternal morbidity and mortality. Failure in medical termination of pregnancy should raise an alarm of a suspected ectopic pregnancy. The management of scar ectopic by excision could be carried out effectively through laparoscopy or laparotomy in experienced hands. Also, whenever patient comes with gestational trophoblastic disease and if the serum Beta HCG values are not falling, one should always suspect the possibility of cesarean scar pregnancy.
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