ABSTRACT
IMPORTANCE: Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate. OBJECTIVE: This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes. EVIDENCE ACQUISITION: A literature review was performed utilizing the term cesarean scar ectopic pregnancy and subsequently selecting only meta-analyses and systematic reviews. Only articles published in English were included. Relevant articles within the reviews were analyzed as necessary. RESULTS: Five basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation. CONCLUSIONS: Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach. RELEVANCE: As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.
Subject(s)
Cesarean Section/adverse effects , Cicatrix , Pregnancy, Ectopic/therapy , Abortifacient Agents, Nonsteroidal/therapeutic use , Adult , Conservative Treatment , Dilatation and Curettage , Female , Humans , Hysterectomy/statistics & numerical data , Laparotomy/statistics & numerical data , Methotrexate/therapeutic use , Pregnancy , Pregnancy, Ectopic/diagnosis , Pregnancy, Ectopic/etiology , Ultrasonography , Uterine Artery Embolization/statistics & numerical data , Uterus/diagnostic imagingABSTRACT
Background. Heterotopic pregnancy is a multiple gestation with both intrauterine and ectopic fetuses. A cesarean scar ectopic pregnancy is when the fetus has implanted over the previous hysterotomy site. A known complication of cesarean scar ectopic pregnancy is uterine rupture, which can cause great morbidity and mortality. Case. 28-year-old G5P3105 at 10 weeks with a dichorionic diamniotic gestation was found to have a ruptured uterus with expulsion of a cesarean scar ectopic pregnancy and retention of the intrauterine fetus. After uterine repair, the singleton gestation reached viability was delivered by emergent cesarean section for placental abruption. Conclusion. Safe management of cesarean ectopic pregnancy requires early diagnosis by ultrasonography. With early detection, management can focus on preventing maternal morbidity of uterine rupture and life-threatening hemorrhage.
