Explanation:
Cesarean sections are associated with increased maternal morbidity and mortality at the time of delivery and with subsequent pregnancies. Patients with a history of cesarean section are at risk of poor outcomes such as placenta accreta spectrum, uterine rupture, and ectopic pregnancy in the cesarean scar. While the condition is rare, incidence has been increasing with the rise in cesarean deliveries.
Similar to other forms of ectopic pregnancy, presentation varies from asymptomatic to nonspecific symptoms of vaginal bleeding and mild discomfort or emergent symptoms of hemorrhage and significant pain. Diagnosis relies on ultrasound findings of a visible endometrium, empty uterus and cervical canal, and a visible gestational sac implanted in the hysterotomy scar. There is also myometrial thinning between the gestational sac and the bladder. If the diagnosis cannot be confirmed by ultrasound, an MRI is often useful.
Multiple treatment modalities have been used to manage cesarean scar ectopic pregnancy. Given the lack of established guidelines, treatment must be tailored to the clinical scenario and employ principles of shared decision-making. Treatment modalities include systemic and intragestational administration of methotrexate, uterine artery embolization combined with dilation and curettage, hysteroscopic resection, transvaginal or laparoscopic wedge resection, and transvaginal ultrasound-guided pregnancy aspiration. Expectant management is an option for limited clinical scenarios. Compared to medical management, interventional management is highly effective (e.g., no need for repeat therapy and less risk of retained products of conception) and has a lower risk of serious complications like hemorrhage.
Cesarean scar ectopic pregnancy is a complex condition that often requires multistep therapy (B). Prophylactic uterine artery embolization (UAE) may be used before resection or aspiration to decrease the risk of intraoperative hemorrhage. Dilation and curettage should not be performed unless combined with UAE because as single therapy, 15% are complicated by blood loss > 1,000 mL or postoperative blood transfusion. Multistep follow-up (A) is recommended for all treatment modalities and should include clinical assessment, serial quantitative hCG, and ultrasounds. The risk of cesarean scar ectopic pregnancy recurrence in a subsequent pregnancy (C) is high regardless of the treatment choice.
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