Abdominal

Imaging

Springer Science+Business Media New York 2015

Published online: 13 June 2015

Abdom Imaging (2015) 40:25892599

DOI: 10.1007/s00261-015-0472-2

Cesarean scar ectopic pregnancy: imaging

features, current treatment options, and clinical
outcomes
Rehan M. Riaz, Todd R. Williams, Brian M. Craig, Daniel T. Myers
Department of Radiology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI 48202, USA

Abstract
Purpose: Cesarean scar ectopic pregnancy (CSEP) is
considered to be quite rare, but the frequency is
increasing given the increasing number of cesarean
sections being performed, along with increased detection
due to widespread use of early endovaginal sonography.
The normal sonographic and magnetic resonance findings of this phenomenon will be discussed, including the
appearance of complications associated with abnormal
placentation, such as the placenta accreta spectrum.
Cases of CSEP at our institution will be illustrated, along
with clinical presentations and treatment outcomes.
Methods: The study included women who were diagnosed with a CSEP in the first trimester, which was
confirmed by ultrasound. The clinical presentations,
imaging findings, and treatment outcomes of these
pregnancies were recorded.
Results: In our series, treatment ranged from no intervention with fetal demise on short-term follow-up
ultrasound to viable near-term deliveries requiring
cesarean section, urgent blood products, and emergent
surgery. The majority of our cases 75 % (15 of 20)
underwent successful early first trimester termination by
a combination of systemic methotrexate administration,
ultrasound-guided injection of embryocidal agents, and/
or surgery.
Conclusion: Early imaging recognition and diagnosis of
CSEP is critically important to minimize maternal
complications, maintain treatment options, and potentially preserve future fertility.
Key words: Cesarean sectionEctopic pregnancyScar
pregnancyComplicationsTreatmentPlacenta
accreta

Correspondence to: Rehan M. Riaz; email: rehanr@rad.hfh.edu

Cesarean section ectopic pregnancy (CSEP), also known

as cesarean scar pregnancy or cesarean scar ectopic
pregnancy, occurs when an early pregnancy (blastocyst)
implants on myometrial tissue from an existing cesarean
section scar. This phenomenon is considered rare,
occurring in 1 out of 1800 to 1 out of 2500 pregnancies
[13]. However, it is becoming more common due to the
increased number of cesarean sections being performed
as well as the decline in vaginal deliveries after previous
cesarean section and now accounts for 6.1 % of all ectopic pregnancies [1, 4]. The myometrial defect, which
consists of a thin band of fibrous tissue, is located in the
anterior lower uterine segment (LUS) and communicates
with the endometrial canal (Fig. 1). If this abnormal
implantation is unrecognized and allowed to progress, it
may result in devastating complications including placental abnormalities such as accreta, life-threatening
maternal hemorrhage, and uterine rupture [57]. Multiple cesarean sections increase the risk of scar implantation [1], presumably due to an increased surface area of
the scar. Early diagnosis with sonography (Fig. 2), in
conjunction with magnetic resonance imaging (MRI) in
problematic cases, can limit maternal morbidity and
mortality. Early recognition also directly impacts the
success of available treatment options. We review the
diagnostic US and MRI findings, current medical, and
surgical treatment options and catalog the clinical presentations and outcomes of 20 confirmed cases of CSEP
at our institution.
While there is no expert consensus on the single best
therapy, rst trimester termination is recommended to
minimize complications. Although successful deliveries
have been described in the literature there are signicant
risks associated with this non-interventional approach
[8]. In our series, treatment varied from close observation
resulting in a failed pregnancy to term or near-term
deliveries with maternal complications requiring blood
products and emergent surgery. The majority of our

2590

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

Fig. 1. AP image from a hysterosalpingogram (A) shows

contrast filling the cesarean section defect (arrow) along the
anterior lower uterine segment (LUS). Sagittal transvaginal
US (B) highlighting a large anterior LUS myometrial defect

(arrow). Sagittal FSE T2 MRI (C) showing the myometrial

defect (asterisks) and low signal scar tissue (arrow) along the
serosal surface of the LUS.

Fig. 2. Sagittal transvaginal (A) and transabdominal (B) US

images in two different patients, presenting at 5 and 9 weeks,
respectively, both with a history of multiple prior cesarean
sections. The gestational sac is implanted on the cesarean
section scar (arrow) in the anterior LUS, with thinned myo-

metrium (M) anteriorly and an empty endometrial cavity (EC).

There is an anterior bulge to the anterior lower uterine segment causing mass effect on the urinary bladder in the 9 week
old gestation.

patients (75%) underwent first trimester termination with

systemic methotrexate (MTX), systemic methotrexate
plus local therapy with US- guided embryocidal injection, and/or surgery.

imaging diagnosis at the time of initial presentation and/

or the image-guided local treatment with embryocidal
injection.

Materials and methods

After obtaining IRB approval, we retrospectively reviewed radiology reports and images from our picture
archive and communication system (PACS) utilizing a
medical search engine (Softek, Illuminate, Prairie Village, KS, USA) over an 8-year period from January 2008
to January 2015. Key search phrases included cesarean
or scar combined with ectopic. In the potential cases
of CSEP, the relevant electronic medical records and
imaging examinations were reviewed by the authors (a
third year radiology resident and three radiologists, each
with over 20 years of experience) to conrm the CSEP
diagnosis, catalog the clinical presentation, treatment,
and clinical outcomes. Additionally, two of the authors
(TW and BC) were prospectively aware of the majority
of cases as they directly participated in the US/MRI

Results
The review of our PACS data and electronic medical
record review conrmed 20 cases of cesarean section scar
ectopic pregnancy at our institution. The patients ranged
in age from 2642 years old with a mean age of
34.9 years. Demographics included 9 African-American,
6 Caucasian, 3 Hispanic, and 2 Middle-Eastern women.
The range of prior cesarean section deliveries was 14 in
our study. Seventy-ve percent of the patients in our
series had multiple prior cesarean sections, with a mean
of 2.2 prior cesarean deliveries. Three women had four
prior cesarean sections. Most women were symptomatic
at the time presentation with 18 of 20 (90 %) patients
presenting with bleeding, pain, or both. Vaginal bleeding
was the most common presentation with 11/20 (55 %)
patients presenting with vaginal bleeding or spotting, and
9/20 (45 %) patients presented with pain or cramping as

Race

AA
AA

C
H
AA
H
AA
C

C
C
H
C
C
Ar

AA

AA

AA
AA

AA
Ar

Age

35
23

42
40
34
28
32
37

41
35
42
39
27
33

36

26

33
40

36
40

G5P2
G10P7

G7P5
G8P3

G4P2

G6P3

G4P2
G3P2
G6P3
G4P1
G4P3
G3P2

G6P2
G5P4
G2P1
G2P1
G3P2
G5P4

G2P1
G3P2

GP

5W0D
5W5D

<5W
5W2D

5W0D

7W5D

5W3D
5W3D
6W4D
6W6D
11W1D
9W1D

10W0D
<5 W
No YS/FP
demise
5 W2D
6W0D

8W3D
7W6D

Age at
presentation

2
4

2
3

2
1
3
1
3
2

2
4
1
1
2
4

1
2

Prior Csection(s)

Pain
Vaginal bleeding

Pain
Vaginal bleed

Abdominal pain,dysuria

Vaginal bleeding

Spotting
Bleeding and pain
Bleeding
Asymptomatic
Pain
Pain

Vaginal bleeding
Pain
Spotting 9 2 days
Spotting x 1 week
Gestational diabetes
Pain

Vaginal bleeding
Bleeding and cramping

Symptoms

First trimester intervention

Fetal demise

First trimester intervention

First trimester intervention

First trimester intervention

First trimester intervention

Continued pain after systemic therapy

First trimester intervention
First trimester intervention
First trimester intervention
First trimester intervention
First trimester intervention

Carried to term, developed placenta increta

Carried to term, developed placenta increta,
percreta found during surgery
Carried to term, developed placenta accreta
Intractable pain
Desired delivery but persistent bleeding
Desired to attempt delivery but fetal demise
Desired to attempt delivery but fetal demise
Continued pain after systemic therapy

Clinical outcome

Table 1. Demographics, presentations and clinical outcomes in 20 cases of cesarean scar ectopic pregnancies

C-section
Surgical removal and repair of LUS
Intramuscular MTX (1)
Hysterotomy and Intramuscular MTX (1)
Fetal demise on f/u US 1 wk later
Intramuscular MTX* (3) and oral cytotec x 2
surgical removal and hysterectomy
Intramuscular MTX (1) supracervical hysterectomy
Intramuscular MTX (2)
Intramuscular MTX (1)
Intramuscular MTX (2)
Intramuscular MTX (2)
Intravenous MTX (1) and oral folinic acid
Ultrasound-guided KCl injection
Intramuscular MTX (1) Ultrasound-guided
KCl and MTX injection
Intramuscular MTX (1) US-guided MTX +
Intramuscular MTX (1)
Ultrasound-guided MTX (1)
Intramuscular MTX (1) Ultrasound-guided KCL
injection + Intramuscular MTX (1)
Systemic MTX and then D&C (at outside hospital)
No intervention, returned 6 weeks later with fetal demise

C-section and emergent hysterectomy

C-section with emergent hysterectomy

Treatment

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

2591

2592

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

Fig. 3. Transabdominal and endovaginal grayscale and

color US images in a 40-year old patient presenting at
7 weeks with pelvic pain. Eccentrically located gestational sac
in the LUS (A) in close proximity to the bladder, causing a
bulge in the uterine contour at the scar (B,C). There is focal

anterior thinning of the myometrium measuring 3-4 mm at the

scar defect with beaking (arrow) of the gestational sac. A yolk
sac and embryo are seen with significant Doppler flow (D). EC
endometrial canal, B urinary bladder, E embryo.

Fig. 4. Sagittal transabdominal color Doppler US images of

the lower uterine segment in a 35-year-old patient who opted
to carry to term at 33 weeks gestational age, demonstrating
several hypoechoic vascular lacunae and increased vascular

flow in the scar defect on color Doppler, findings which are

associated with placenta accreta spectrum. This patient had
placental increta confirmed at surgery.

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

2593

Fig. 5. Transvaginal sagittal US in a 28-year old presenting

at 8 weeks showing a gestational sac, embryo, and exuberantly surrounding echogenic trophoblastic tissue (arrow)
within a cesarean section scar in a retroflexed uterus (A).
Sagittal (B) and oblique coronal (C) MRI fast-spin echo (FSE)
T2-weighted images at 9 weeks gestational age confirm the

location within the myometrial defect and an empty endometrial cavity (EC), illustrating myometrial thinning and proximity
of the trophoblastic tissue (arrow) to the urinary bladder B. A
yolk sac and embryo were identified (not shown) concordant
with the menstrual history provided for a 9-week gestation

Fig. 6. Oblique sagittal (A) and coronal (B) T2-weighted

FSE MRI images in a 33-year-old patient with two prior cesarean sections, presenting with pelvic and back pain at
9 weeks. There is bulging of the LUS contour and a focal
9 mm absence of the myometrium anteriorly (arrow). This

appearance suggests placentation abnormality in this early

pregnancy with extension of the placenta to the serosal surface of the uterus. She was treated with systemic
methotrexate and local US-guided embryocide (KCl) injection.
B bladder.

the indication for the US. Two patients were asymptomatic, one being scanned to establish gestational age
and the other as part of a gestational diabetes evaluation
(Table 1).
Two patients presented at 5 weeks gestation were not
treated medically or surgically, with instructions to return for short-term follow-up. The rst patient had an
empty gestational sac and returned in 1 week with
declining B-hCG levels, no change in gestational sac size,

and non-visualization of a yolk sac or embryo; she was

subsequently diagnosed with a failed pregnancy. Cardiac
activity was documented in the second patient, who was
requested to return for evaluation of myometrial integrity.
However, she did not return for her follow-up appointment until 6 weeks later, at which time her gestational sac
was irregularly shaped and no embryonic heart tones were
seen; in conjunction with her dropping B-hCG levels she
was also diagnosed with failed pregnancy.

2594

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

Fig. 7. Sagittal (A) transabdominal US in a 23-year old at

17 weeks 1 day gestational age showing a complete absence
of the anterior uterine myometrium (M) at the level of the csection scar with extension of the placenta through this defect
(asterisks), illustrating placenta increta/percreta in the second
trimester. A single vascular lacunae (arrow) is identified. This
patient opted to carry to term and coronal (B) T2WI-FSE
pelvic MRI at 25 weeks gestational age demonstrates the

placenta increta/percreta (P) invading through the cesarean

section scar and myometrium (arrow). Sagittal (C, D) images
show the placenta is adherent to the anterior abdominal wall
at the site of prior surgery (asterisks), which was confirmed
during hysterectomy. Dark T2 placental bands (^), thought to
represent areas of placental hemorrhage and infarction as
pregnancy progresses, are associated with placentation
abnormalities and are seen extending to the placental surface.

Fifteen of twenty patients (75 %) underwent early

treatment for CSEP using some combination of intramuscular (IM) methotrexate, local embryocidal injection, or surgery for rst trimester intervention.
Termination was performed with IM MTX with a dose
range of 2550 mg, local image-guided embryocidal
injection of 25 mg MTX with or without KCl 8 mEq
into the embryo/gestational sac or a combination of
systemic and local therapy. Five patients were treated

successfully with IM MTX alone, however, three of these

patients required repeat IM MTX doses. Four patients
underwent rst trimester termination by combination of
IM MTX and local US-guided embryocide injection.
One patient had local US-guided embryocide injection
only.
Four patients had unsuccessful IM MTX therapy and
ultimately required surgical intervention including dilation and curettage (D & C), hysterotomy, or hysterec-

2595

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

developed the placenta increta/percreta spectrum, with

placental extension to the bladder and abdominal wall.

Imaging findings
Ultrasound

Fig. 8. Sagittal EV US in a patient at 11 weeks gestational

age who presented to the ED with passage of tissue. There
is an empty gestational sac centered in the endometrial canal
at the LUS/endocervical junction consistent with an abortion
in progress. Note the lack of vascularity surrounding the
gestational sac.

tomy. One patient underwent hysterectomy without

systemic or local medical therapy due to imaging ndings
of uterine rupture.
The three remaining patients decided against early
rst trimester termination. They were informed of the
potential risks, but opted to attempt to carry to term. All
three underwent cesarean section deliveries, at 31, 33,
and 38 weeks. In two cases, there was signicant hemorrhage with an estimated blood loss of up to 2500 mL,
requiring transfusions and emergent hysterectomies. Two
pregnancies developed signicant placentation abnormalities including increta/percreta. In two of these cases,
the placenta was located posteriorly with placenta previa
extending into the C-section defect. In the third case, the
placenta was located anteriorly and extended into the Csection defect without placenta previa. This patient

First trimester transvaginal ultrasound plays an essential

part in early diagnosis of CSEP in symptomatic pregnant
patients with reported detection rates of 84.6 % [3]. The
diagnostic features of an early pregnancy (Fig. 3) primarily include location of the gestational sac within the
anterior myometrium of the LUS at the scar site, usually
with little or no separation from the urinary bladder.
Most cases show less than 5 mm of myometrium or scar
tissue separating the sac from the bladder. There is significant color Doppler flow around the sac, and in some
cases the sac may produce an outward bulge in the scar.
Additionally, no gestational sac is present within the
endometrial cavity or in the cervical canal.
When the pregnancy develops into the endometrial
cavity following scar implantation, varying degrees of
placental invasion can be seen in the second and third
trimesters, including partial invasion into the myometrium (placenta accreta), complete invasion of the myometrium (placenta increta), and the most severe form of
extension through the myometrium (placenta percreta).
There are several sonographic ndings that indicate or
suggest the development of this placenta accreta spectrum. These include loss of the normal myometrial placental interface with increased or focal loss of Doppler
color ow, vascularized lacunae within the placenta, and
outward bulging of the uterine contour. Loss of the
bladder wall reector and the presence of placental tissue
or vessels within the urinary bladder are diagnostic of
placenta percreta. It has been reported that lacunae and
abnormally increased color Doppler imaging patterns on

Fig. 9. Endovaginal sagittal US demonstrating a live cervical ectopic pregnancy (calipers), with the gestational sac centered in
the endocervical canal (ECC) at 8 weeks (A). Color Doppler (B) shows the hypervascular trophoblast ring.

2596

US (Fig. 4) are two of the strongest predictors of the

placenta accreta spectrum [9, 10].

MRI
Although the diagnosis of CSEP is primarily made by
ultrasound, MR imaging can be helpful in cases when
there is a need to conrm the ectopic location of the
gestational sac, evaluate placentation, and to precisely
determine the gestation position relative to adjacent
structures. The MR ndings of early CSEP are similar to
those seen on ultrasound, including implantation of the
gestation on the cesarean section scar, initially centered
in the myometrial defect, in conjunction with an empty
endometrial cavity and endocervical canal (Figs. 5, 6).

Fig. 10. Sagittal endovaginal US in a 40-year old at 6 weeks

presenting with bleeding (A). A CSEP is in the anterior LUS,
with a visible gestational sac and yolk sac. Heterogeneous
echotexture material (asterisks) within the endometrial cavity
is consistent with blood products. A transverse image shows
the absence of myometrium (arrow) along the anterior border

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

Ultrasound is almost always the rst modality that

raises concern for abnormal placentation in the second
and third trimesters, but many of these cases will be referred for MR imaging to evaluate placental location and
degree of invasion. MR ndings that indicate the placenta accreta spectrum include dark, irregular intraplacental bands on T2-weighted sequences, thinning or loss
of the subplacental myometrium, abnormal vessels,
outward bulging of the uterine contour, and invasion of
the anterior abdominal wall or urinary bladder [11]. The
presence of low signal intraplacental bands on T2weighted MR images with varying width and a disordered distribution (Fig. 7), primarily on the maternal
side of the placenta, has a strong association with placentation abnormalities [9]. These low signal intrapla-

of the gestational sac (B). Cardiac activity was confirmed with

M-mode Doppler (C). US showing the needle during KCl
injection into the embryo using an endocavitary biopsy probe
with needle guide (D, arrows). This patient was also treated
with concurrent IM MTX therapy.

2597

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

cental bands on MRI and the intraplacental lacunae seen

on ultrasound are thought to correspond to areas of
placental hemorrhage and infarction, better seen as the
pregnancy progresses into the second and third trimesters.

First trimester US differential diagnosis

A spontaneous abortion in progress can mimic CSEP,
but the gestational sac will be located in the endometrial
canal and does not demonstrate the surrounding ow on
color Doppler (Fig. 8). Also, the sac position and shape
will change on short-term follow-up imaging as the
abortion progresses. The sliding organ sign has been
proposed to help differentiate a failed pregnancy in the
lower uterine canal/cervix from CSEP by the ability to
move a failed pregnancy within the endometrial canal
with transducer pressure [12, 13]. We found this less
reliable as we observed movement of the sac in the scar
towards the endometrial cavity with transducer pressure
in one of our surgically proven cases of CSEP.
A cervical ectopic pregnancy could also be mistaken
for CSEP, but the sac will be located within the endocervical canal rather than within the anterior LUS. The
myometrium remains intact and there is surrounding
color ow (Fig. 9). Both CSEP and cervical ectopic
pregnancies frequently contain live embryos with cardiac
activity [13, 14], while an abortion in progress will not.

Discussion
While cesarean scar ectopic pregnancy is rare, it is
increasing in frequency. This is due to the increasing
number of cesarean sections being performed, decreasing
vaginal deliveries following a previous cesarean section,
increased physician awareness of this entity, and more
frequent use of improved endovaginal US imaging. Patients with cesarean scar pregnancies usually present with
clinical symptoms of vaginal bleeding and/or abdominal
pain [3, 15], with most presenting in the first trimester
with a mean gestational age of 7.5 2.5 weeks [8]. More
than half of patients with CSEP have undergone 2 or
more cesarean deliveries [15]. In our series, all 20 patients
presented in the first trimester, most (85 %) before
8 weeks, and 90 % had symptoms of bleeding and/or
pain at the time of presentation. Our data also support a
higher risk with increasing number of cesarean sections
as 75 % of our patients had at least two prior cesarean
sections.
When the blastocyst implants ectopically in the brous scar, growth can occur in any direction. If the
implantation progresses anteriorly, it can penetrate the
anterior uterine wall, invade the bladder, and potentially
rupture the uterus with severe hemorrhage. If growth is
posterior into the endometrial cavity, these cases present
later with clinical symptoms and sonographic ndings of

placenta accreta spectrum [16]. Placenta previa and prior

cesarean section deliveries are two risk factors for the
development of placenta accreta spectrum abnormalities
[9, 10]. In our series, two of three patients allowed to
progress toward a term delivery had both placenta previa
and C-sections in prior pregnancies, subsequently
developing placenta increta/percreta during their CSEP.

Treatment options
There is no consensus on the best treatment option and
management guidelines for CSEP. The goals of treatment are termination of pregnancy, reduction of hemorrhage, prevention of uterine rupture, and preservation
of future fertility. A variety of treatment options have
been described in case reports from the literature that
range from observation, medical therapy given systemically or via local injection, uterine artery embolization
with chemotherapy or dilatation and curettage, local
resection using hysteroscopy/laparoscopy, or total hysterectomy. In many instances, a combination of these
approaches has been utilized to ensure complete termination of the pregnancy.
Observation is generally not recommended as the
risks of rst trimester complications increase as pregnancy progresses. This approach is reserved for patients
with ndings suspicious for pregnancy failure at the time
of diagnosis, such as empty gestational sacs without viable embryos, or if the patient desires to continue the
pregnancy after growth towards the uterine cavity has
been documented sonographically [16]. The natural
course of CSEP may be a spontaneous abortion [3, 17
20] even when carriage to term is desired. Many cases
result in surgical intervention for severe hemorrhage or
uterine rupture in the early 2nd trimester [21, 22].
Medical therapy for pregnancy termination is primarily performed using methotrexate, although mifepristone (RU-486) and misoprostol (Cytotec) can be used in
conjunction to stimulate uterine contraction and help
expel retained products of conception. MTX inhibits
folic acid metabolism and DNA synthesis, eliminating
the rapidly dividing cells in a trophoblast. It can be given
intramuscularly, intravenously, orally, or locally under
image guidance, and has the added benet of preserving
future fertility in younger patients. MTX is the consensus
treatment for tubal and cervical ectopic pregnancies with
an early gestational age (less than 9 weeks), embryo
smaller than 10 mm, serum B-hCG levels less than
10,000 mIU/mL, and lack of cardiac activity [3]. The
success of MTX in treating CSEP ranges from 57 to
100 % [2224] in published case series; this variability
may be attributed to the lack of established protocols.
Methotrexate has been shown to be effective at a dose of
50 mg/m2 when the B-hCG level is less than 5000 mIU/
mL [25, 26].

2598

The variable success of systemic MTX can also be

ascribed to the relative de-vascularized brous tissue
surrounding the gestational sac and short half-life of
MTX, which limits drug exposure when given systemically. Direct administration theoretically negates these
obstacles and lessens the potential systemic side effects
(Fig. 10) Side effects may include nausea, diarrhea,
leukopenia, hepatic dysfunction, arthralgias, and leg
swelling [27, 28]. Similar to systemic MTX therapy, there
is no established guideline regarding the dose, site, and
timing of MTX administration, although several case
series have suggested protocols [2931]. Additionally,
even local administration has been shown to have a
variable success rate with persistent gestational sacs,
bleeding, need for additional MTX treatments, and even
surgery [4, 32, 33] being reported. When embryonic
cardiac activity is present, local treatment with image
guidance is more effective than systemic therapy [34, 35].
Although MTX is considered the gold standard for
systemic and local therapy, a similar technique has been
described with ethanol, potassium chloride, and hypertonic glucose [15, 36].
Uterine artery embolization (UAE) was originally
introduced as a minimally invasive treatment option for
symptomatic uterine broids and postpartum hemorrhage. Although currently not performed at our institution for treatment of CSEP or cervical ectopic
pregnancies, several authors have described its utility and
efcacy [3739]. Isolated UAE has not been described in
the literature, but is always used in conjunction with
suction curettage [37], intra-arterial MTX [40], or polyvinyl alcohol particles [41].
Surgical treatment is the only choice when lifethreatening complications arise. However, the renement of minimally invasive techniques has made surgical
treatment a viable rst-line option as well. The least
invasive procedure is hysteroscopy, which allows direct
visualization of the vessels at the implantation site of the
gestational sac [42, 43]. This procedure has a short
operative time with less blood loss and a higher success
rate than laparoscopic or open surgery [42]. When the
CSEP is deeply implanted, laparoscopy is needed to
exclude bladder involvement while still providing a
balance between reducing patient morbidity and visualization needed to control intraoperative hemorrhage
[44]. Laparotomy is required when uterine rupture is
clinically suspected and can be beneficial in preventing
further cesarean scar implants by excising the old scar
and creating a new uterine closure [14, 45]. However,
this operation is associated with a large wound and
longer recovery time. Transvaginal hysterotomy is a
relatively new surgical method [46, 47] in the treatment
of CSEP, with early follow-up showing preservation of
fertility with subsequent normal intrauterine pregnancies
[48].

R. M. Riaz et al.: Cesarean scar ectopic pregnancy

Conclusion
Cesarean section scar pregnancy is increasing in frequency, especially in women with multiple prior cesarean
sections. Concordant with the existing medical literature,
75 % of our patients had 2 or more prior cesarean
deliveries. A majority of our patients presented were
diagnosed in the rst trimester with symptoms of bleeding
and/or abdominal pain. First trimester ultrasound in
symptomatic patients plays a critical role in the early
detection of cesarean scar ectopic pregnancy. Adjunct
MRI is useful in conrming difcult cases of CSEP and is
essential in the evaluation of placentation abnormalities
including the placenta accreta spectrum associated with
CSEP. Early recognition of CSEP with imaging can afford the patient a wider array of less invasive treatment
options, including systemic MTX, local embryocide
injection, or limited surgery without hysterectomy. These
choices all have fewer associated risks and can preserve
future fertility. Most importantly, early recognition and
treatment can prevent the potentially life-threatening
complications associated with an unrecognized and latepresenting cesarean scar ectopic pregnancy.
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