Cesarean-scar pregnancy—which is defined as the implantation of a gestational sac into deficient myometrium at the site of a uterine incision—is a late serious complication of Cesarean section1. There is currently no consensus as to the most effective management of Cesarean-scar ectopic pregnancy, and little is known about the outcome of subsequent pregnancies2. In this report, we present a case of a woman diagnosed with three consecutive Cesarean-scar ectopic pregnancies. She underwent a successful repair of the uterine defect, resulting in normal intrauterine implantation of her subsequent pregnancies.
A 39-year-old woman, gravida 3 para 2, attended for an early pregnancy ultrasound scan with a history of vaginal bleeding. Her two children had both been delivered by Cesarean section. On ultrasound scan a diagnosis of a viable 12-week Cesarean-scar ectopic pregnancy was made. The placenta was implanted low within the anterior uterine wall. The myometrium at the implantation site appeared severely deficient, with only a thin layer of tissue separating the pregnancy from the urinary bladder. After discussion she opted for a laparoscopy and suction evacuation of the pregnancy under ultrasound-scan guidance. The procedure was complicated by profuse vaginal bleeding, which was eventually controlled by the insertion of a Shirodkar suture. Five units of blood were transfused peri-operatively. The postoperative recovery was uneventful and she attended for the removal of the cervical suture 5 days later.
Ten months later she attended for another scan, which showed a 7-week viable recurrent Cesarean-scar pregnancy. The pregnancy was removed by suction curettage without complications. Six months later she attended again with a 4-week Cesarean-scar ectopic, which was also removed surgically without complications. Three months following her third Cesarean-scar ectopic a laparotomy was performed to repair the uterine-scar defect. The deficient scar was completely excised and the uterine wall was then closed in three layers including the visceral peritoneum. Her postoperative recovery was uneventful and she was discharged a week later.
On histological examination, the excised uterine scar tissue contained an old suture remnant and it showed evidence of chronic inflammation and fibrosis. A follow-up scan 2 months after laparotomy revealed a well-healed uterine scar with no evidence of residual myometrial defect (Figures 1 and 2).
Eight months after the operation she had a biochemical pregnancy, which was not detectable on the scan. Following this she had two pregnancies, which were both located normally within the uterine cavity. Although the pregnancies initially contained embryos with evidence of cardiac activity, they both miscarried spontaneously at 7 and 8 weeks' gestation, respectively.
Until this case, there have been only two previous reports of recurrent Cesarean-scar pregnancies in the world literature3, 4. This low prevalence of recurrent scar pregnancies indicates that implantation into the scar is more likely to be a chance event, rather than the result of a particular affinity of a pregnancy for implanting into the scar. It is possible that the risk of scar implantation may be proportional to the size of the anterior uterine wall defect. The patient described in this report had a particularly large defect on the scan, which supports this hypothesis.
Our case report also shows that laparotomy and repair of a uterine defect may be successful in preventing recurrent Cesarean-scar ectopics. Major open surgery and uterine repair may be complicated by poor scar healing and postoperative intra-abdominal adhesions, both of which may have a detrimental effect on the patient's future fertility. Therefore, we suggest that repair should only be considered in recurrent cases or in women with unusually large uterine defects.