🌟 Caesarean Scar Ectopic Pregnancy: Essential Insights 🌟 reference : Cesarian scar ectopic preg tog 2017.

Introduction

Caesarean scar ectopic pregnancy (CSP) is a rare but increasingly common form of ectopic pregnancy where the gestational sac implants within the scar of a previous caesarean section. With the rise in caesarean deliveries, understanding and managing CSP is crucial for obstetricians and gynecologists.

Incidence and Diagnosis

📈 Rising Incidence:The number of CSP cases is climbing due to the increased frequency of caesarean sections.

Estimates of CSP incidence range from 1/1800 to 1/2500 of all pregnancies.

It has been estimated that 6.1% of pregnancies in women with at least one previous CS and a diagnosis of ectopic pregnancy will be CSP

🩺 Diagnosis:

 Early and accurate diagnosis is vital. A high index of suspicion is necessary, particularly in women with a history of caesarean delivery presenting with atypical bleeding. Ultrasound, especially transvaginal with color Doppler, is the gold standard for diagnosing CSP.

if suspicion we can use MRI

Pathophysiology

🔬 Mechanism: CSP occurs when the blastocyst implants into the scar tissue of a previous caesarean section. Factors contributing to this include endometrial and myometrial disruption.

⚠️ Risk Factors:

CSP can occur even after a single caesarean section, with higher risk noted in those who had caesarean sections for breech presentations.

Clinical Presentation

🤒 Symptoms:Patients may present with minimal symptoms like slight vaginal bleeding and abdominal discomfort. Severe cases may involve acute pain and significant bleeding, indicating possible rupture.

🚨 Complications:

 CSP poses risks such as

 major hemorrhage and potential hysterectomy, making early diagnosis and management crucial.

Management Options

👉Medical Management

1) Methotrexate:The primary medical treatment involves systemic administration of methotrexate, particularly effective in stable, unruptured cases with low hCG levels (<5000 IU/L) and early gestational age (<8 weeks).

2) Local Embryocides:Agents such as methotrexate, potassium chloride, and etoposide can be injected locally into the gestational sac under ultrasound guidance.

👉Surgical Management

1) Dilatation and Curettage:Suitable for endogenic CSP with adequate myometrial thickness, performed under ultrasound guidance to ensure complete tissue removal.

2) Hysteroscopic Resection: Used to remove the CSP mass, either as primary treatment or following medical management.

3) Laparoscopic/Abdominal Resection:Preferred for exogenic CSP with thin myometrium, offering quicker recovery and early discharge.

👉Combined and Sequential Management

1) Chemo-embolisation and Surgical Resection: This approach combines uterine artery embolisation (UAE) with surgical removal, reducing bleeding risks and enabling quicker recovery.

2) Sequential Management: Involves initial medical management followed by surgical intervention, particularly beneficial for persistent CSP masses.

Follow-Up and Recurrence

🔍 Monitoring: Continuous follow-up is required until the CSP mass completely resolves. This includes monitoring hCG levels and ultrasound assessments.

🔄 Recurrence Risk:

Recurrence of CSP ranges from 3.2% to 5.0%, particularly higher if the myometrial thickness is less than 5 mm. Surgical repair of the uterine defect can help reduce recurrence risk.

Future Pregnancies

🩺 Early Monitoring:

Future pregnancies should be closely monitored with early ultrasounds to rule out CSP recurrence.

🤰 Delivery: 

Subsequent deliveries are typically via cesarean section to minimise the risk of uterine rupture and ensure proper closure of the lower uterine segment.

Conclusion

Managing CSP requires a multidisciplinary approach and significant expertise to prevent complications. Preventive strategies should focus on reducing unnecessary caesarean sections. Clinicians must emphasize the long-term risks associated with CSP, such as placenta accreta, when counselling women considering caesarean delivery for non-medical reasons.

reference : Cesarian.scar ectopic.preg tog 2017.