A Second Trimester Caesarean Scar Pregnancy

Caesarean scar pregnancy, where conceptus is implanted on previous scar, is a rare entity. We present one such case of scar pregnancy presenting to us in the second trimester and was managed with methotrexate and uterine artery embolization, followed by hysterotomy. Uterus could be conserved and hysterectomy could be avoided. 1. Introduction Caesarean scar pregnancy, where conceptus is implanted on previous scar, is a rare entity. However, in recent years, there have been several reports on first trimester diagnosis of such pregnancies. Availability of high resolution transvaginal sonography and its increasing use in early gestation has resulted in early and more frequent diagnosis of this condition. Commonly scar pregnancy presents as threatened, incomplete, or complete abortion in the first trimester. Occasional pregnancies may progress to second and third trimester and develop into placenta previa/accreta. Currently there are no guidelines for the management of such pregnancies. We present one such case of scar pregnancy presenting to us in the second trimester and the difficulties in her management. 2. Case Report A 25-year-old gravida 3, para1 was admitted at 19 weeks of pregnancy with a history of vaginal bleeding for 1 week and pain in abdomen. She was told that she had a low lying placenta during her second trimester scan. A lower segment caesarean section for cephalopelvic disproportion was done 2 years back and the baby was alive and well. This was followed by a missed abortion at 8 weeks for which a curettage was done. At admission, her vitals were stable. Uterus was irritable. Hb was 7？gm/dL. Ultrasound done after admission showed a live fetus of 20 weeks and anterior placenta with a thin, bulging, and deficient lower uterine segment. The decidual interface between the placenta and myometrium was partially absent and there were large dilated vessels in the same area. These sonographic features were suggestive of a placenta accreta. Patient continued to bleed; 4 units of blood were crossmatched and injection of methotrexate 50？mg was given intramuscularly on the day of admission. Prophylactic uterine artery embolisation was done on day 2 but the bleeding continued. The next day she was taken up for hysterotomy under general anaesthesia. Entry into peritoneal cavity was difficult because of dense adhesions. There was no hemoperitoneum. Bladder was adherent to the lower uterine segment which was severely deficient. Placenta was encroaching on the left broad ligament and was covered by a thin layer of peritoneum. Bladder was dissected from the