 |
Clinical Image
Implanted in the scar: A high-stakes case of cesarean scar ectopic pregnancy
1 Emergency Medicine, Ultrasound Fellow, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17821, USA
2 DO, FACEP, CAQSM, RMSK, Emergency Medicine, Ultrasound Program Director, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17821, USA
3 DO, Emergency Medicine Faculty, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17821, USA
4 PAC, Emergency Medicine, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17821, USA
5 DO, Emergency Medicine, Ultrasound Fellow, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17821, USA
Address correspondence to:
Hope Allen
Emergency Medicine, Ultrasound Fellow, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17821,
USA
Message to Corresponding Author
Article ID: 100218Z08HA2025
Access full text article on other devices
Access PDF of article on other devices
How to cite this article
Allen H, Davis R, McElroy E, Myers J, Burke K. Implanted in the scar: A high-stakes case of cesarean scar ectopic pregnancy. J Case Rep Images Obstet Gynecol 2025;11(2):47–49.ABSTRACT
No Abstract
Keywords: Cesarean scar implantation, Ectopic pregnancy
Case Report
A 37-year-old female patient, G2P1, presented to the Emergency Department with vaginal bleeding and lower abdominal cramping. The patient reported mild spotting over the last few days; however, the bleeding became severe around 4 AM in the morning, prompting her to be evaluated in the Emergency Department. The patient reported she was saturating pads every 30 minutes to 1 hour and endorsed the passage of large clots. She stated her last menstrual period was one month prior. The patient denied pregnancy, but reported no contraception use of any form. The patient reported her vaginal bleeding was constant, severe, and heavy. Her examination revealed tenderness on palpation across her lower abdomen. The patient’s BhCG was noted to be positive at 8769 mIU/mL. The patient underwent transvaginal ultrasound that revealed an empty uterine cavity and cervical canal, but noted a gestational sac with a fetal pole embedded in the myometrium at the site of the cesarean scar, unable to classify Type 1 (endogenic) vs Type 2 (exogenic) CSEP (Figure 1). Color Doppler imaging showed increased vascularity around the gestational sac consistent with a CSEP. Due to the risk of uterine rupture, the patient was admitted to the OBGYN service for further urgent surgical intervention. The patient underwent laparoscopic wedge resection of the uterus with removal of the ectopic pregnancy. Postoperatively, the patient recovered uneventfully and was discharged home in stable condition.
Discussion
This case illustrates a classic presentation of CSEP requiring urgent intervention. A review of the literature demonstrated an increased incidence and recognition of CSEP over the past two decades [1]. The clinical presentation of CSEP is variable, but is associated with severe maternal morbidity and mortality [1],[2]. This case emphasizes the critical importance of high clinical suspicion, early intervention and prompt use of ultrasonography with CSEP to prevent potential complications such as uterine rupture.
Timor-Tritsch et al. and Jurkovic et al. also emphasize how early diagnosis via transvaginal ultrasound is a critical tool to avoid catastrophic outcomes. The patient in our case underwent laparoscopic wedge resection, while many case reports discuss management of CSEP with systemic or local methotrexate [3],[4]. Laparoscopic wedge resection offers several advantages over conservative management for CSEP and hysteroscopy; including, completely excising the gestational tissue and repairing the uterine defect, rapid decline in BhCG, reduced recurrence risk, and preservation of fertility [5]. In contrast, while hysteroscopy allows for direct visualization and removal of tissue with minimal blood loss and uterine preservation, it does not permit full scar revision [6]. Thus, laparoscopic wedge resection is preferable in cases with deeper implantation or risk of uterine rupture. As the incidence of CSEP continues to increase, heightened awareness and utilization of ultrasonography are essential for improving patient outcomes and reducing maternal morbidity and mortality.
Conclusion
This case illustrates a classic presentation of CSEP requiring urgent intervention. With a rising incidence over the past two decades, CSEP remains a significant contributor to maternal morbidity and mortality. Early diagnosis—primarily through high clinical suspicion and prompt transvaginal ultrasound—is critical to preventing life-threatening complications such as uterine rupture. As demonstrated in this case, timely surgical management can lead to favorable outcomes, emphasizing the need for increased clinician awareness and early imaging in at-risk patients.
REFERENCES
1.
Society for Maternal-Fetal Medicine (SMFM). Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol 2020;222(5):B2–14. [CrossRef]
[Pubmed]
2.
Kennedy A, Debbink M, Griffith A, Kaiser J, Woodward P. Cesarean scar ectopic pregnancy: A do-not-miss diagnosis. Radiographics 2024;44(7):e230199. [CrossRef]
[Pubmed]
3.
Timor-Tritsch IE, Khatib N, Monteagudo A, Ramos J, Berg R, Kovács S. Cesarean scar pregnancies: Experience of 60 cases. J Ultrasound Med 2015;34(4):601–10. [CrossRef]
[Pubmed]
4.
Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 2003;21(3):220–7. [CrossRef]
[Pubmed]
5.
Moawad NS, Dayaratna S, Mahajan ST. Mini-cornual excision: A simple stepwise laparoscopic technique for the treatment of cornual pregnancy. JSLS 2009;13(1):87–91.
[Pubmed]
6.
Zhang Q, Lei L, Zhang A, Zou L, Xu D. Comparative effectiveness of laparoscopic versus hysteroscopic approach in patients with previous cesarean scar defect: A retrospective cohort study. Ann Transl Med 2021;9(20):1529. [CrossRef]
[Pubmed]
SUPPORTING INFORMATION
Acknowledgments
The authors acknowledge the assistance of ChatGPT (OpenAI, San Francisco, CA, USA) in identifying relevant research articles and refining portions of the discussion section. The final content was reviewed and verified by the authors for accuracy.
Author ContributionsHope Allen - Conception of the work, Design of the work, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Richard Davis - Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Erica McElroy - Conception of the work, Design of the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Jennifer Myers - Conception of the work, Design of the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Kelly Burke - Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2025 Hope Allen et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
