Presentation
A G2P1+0 patient, with a history of a lower uterine caesarean section 12 years ago, presents with 5 days of lower abdominal pain and 6 weeks of amenorrhoea. The urine pregnancy test is positive, and there is no associated vaginal bleeding.
Patient Data
The uterus is bulky in size, anteverted, and retroflexed in position. Minimal fluid is seen in the upper part of the endometrial cavity. Two well-defined gestational sacs (GS) are noted at the lower part of the uterus, at the previous caesarian section scar site. No yolk sac or embryo is seen in either GS. Minimal peri-chorionic fluid is seen. The myometrium adjacent to the GS is thinned out. mSD of GS1 is 14.2 mm (6 weeks, 2 days) and GS2 is 12.8 mm (6 weeks, 1 day).
Both ovaries are normal in size. A corpus luteal cyst is seen in the right ovary.
Case Discussion
This is a case of caesarian scar ectopic with a twin pregnancy.
The presented case highlights the unique challenge of caesarean scar ectopic pregnancies, where implantation occurs at the site of a previous caesarean section scar. The absence of a yolk sac and embryo, along with thinned-out myometrium adjacent to the gestational sacs, emphasises the potential risks associated with this condition, including uterine rupture.
This patient was managed by openly removing the scar along with the ectopic pregnancies. This approach aims to mitigate the risk of complications associated with caesarean scar ectopic pregnancies, including the potential for uterine rupture.
Take-home message:
Ectopic pregnancies occurring within a previous caesarean section scar represent an exceptionally uncommon scenario, with the potential for severe complications such as uterine rupture and life-threatening bleeding. Timely detection through sonography is critical, emphasising the utmost importance of early diagnosis in caesarean scar ectopic gestation. While there have been instances of attempting expectant management, contemporary data advocates for the termination of such pregnancies upon an accurate diagnosis. This underscores the significance of proactive intervention to mitigate potential risks and ensure maternal well-being.
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