Vol. 4, No.
1, Jan-Jun 2020
ANDALAS OBSTETRICS AND GYNECOLOGY JOURNAL
Alamat Korespondensi:
Ruang Redaksi Andalas Obstetrics and Gynecology Journal, Lantai 3 PPDS Obstetri dan Ginekologi Universitas
Andalas, RSUP DR. M. Djamil Padang, Jl. Perintis Kemerdekaan Padang, Sumatera Barat 25127
Website:
eISSN : 2579-8324 pISSN : 2579-8323
[Link]
CASE REPORT
Pregnancy in Caesarean Scar: Accurate Diagnosis and Success
in Conservative Management
Satrio Budhi Purnomo1, Dovy Djanas2
Affiliations: 1. Resident of Obstetrics and Gynecology, Faculty of Medicine, Andalas University, Dr.
M. Djamil Central General Hospital Padang; 2. Sub Division of Maternal Fetal Medicine, Obstetrics
and Gynecology Department, Faculty of Medicine, Andalas University, Dr. M. Djamil Central General
Hospital Padang
Correspondence: Satrio Budhi Purnomo, email: dhimaz09@[Link], Hp: 08118585515
Abstract
Reported case in a woman aged 30 years, with a history of cesarean scar four years ago, diagnosed
with gravid two by one gravid 7-8 weeks with gestation on cesarean scar. The patient had a history of
accidental trauma two days prior to the complaint of bleeding from the genitals. Several obstetricians
have examined but still obtained different results (intrauterine pregnancy and ectopic pregnancy). An
accurate diagnosis is critical to the success of the management of a patient with a pregnancy with this
life-threatening cesarean scar. With a precise and accurate transvaginal ultrasound examination, the
diagnostic criteria with ultrasound on previous surgical scars have been fulfilled in this patient,
including an empty uterus, an empty cervical canal image, growth of a gestational pouch in the anterior
lower segment of the uterus, and the absence of myometral image between the bladder wall and the
gestational pocket. On B-HCG examination, the result was 58,808.70 mlU / mL. Conservative therapy
with metrotrexate (MTX) 50 mg / m2 intramuscularly. After giving metrotrexate (MTX) therapy for four
times, the results of B-HCG decreased significantly with 21.530, 12 mlU / mL, 2,949.47 mlU / mL, and
593.61 mlU / mL, respectively. After administration of metrotrexate (MTX) therapy, there was a
decrease in the size of the gestational bag.
Keywords: Ectopic, Pregnancy, Methotrexate, Cesarean Section
INTRODUCTION
Pregnancy in a cesarean scar is an ectopic pregnancy which is very rarely found, but with the
increase in the number of births by cesarean section more than 30 years, this incident is
increasing (currently recorded 1/2000 normal pregnancies). In a caesarean scar, the
gestational sac implants in the myometrium in the previous cesarean scar. Complications,
such as uterine rupture and massive bleeding can be life-threatening and have a negative
impact on fertility rates later.1 It is very important to diagnose this condition earlier in
conservative management. We report cases of pregnancy in cesarean scars managed by
metrotrexate (MTX).
114
Received : December 5th, 2019
Accepted : December 28th, 2019
Correspondence: Satrio Budhi Purnomo; email : dhimaz09@[Link]
Vol. 4, No. 1, Jan-Jun 2020
ANDALAS OBSTETRICS AND GYNECOLOGY JOURNAL
Alamat Korespondensi:
Ruang Redaksi Andalas Obstetrics and Gynecology Journal, Lantai 3 PPDS Obstetri dan Ginekologi Universitas
Andalas, RSUP DR. M. Djamil Padang, Jl. Perintis Kemerdekaan Padang, Sumatera Barat 25127
Website:
eISSN : 2579-8324 pISSN : 2579-8323
[Link]
CASE REPORT
Reported case of a woman, aged 30 years, with a history of cesarean scars four years ago, was
diagnosed with gravid two, one, one, 7-8 weeks gravid with pregnancy in a cesarean scar. The
patient had a history of accidental trauma two days before the complaint of spotting of blood
out of the genitals without pain. Several obstetricians have examined but different results are
still obtained (intrauterine pregnancy and ectopic pregnancy).2 Accurate diagnosis is crucial
in the management of patients with pregnancy in cesarean scars that can be life-
threatening.3,4
By conducting an ultrasound examination (ultrasound) through transvaginal that is precise
and accurate, the diagnostic criteria by ultrasonography on the previous scar / surgical scar
have been fulfilled in these patients17, including empty uterus, empty cervical canal picture,
growth of gestational sacs in the anterior part lower uterine segment, and the absence of a
myometrum between the vesic wall and the gestational sac. The B-HCG examination showed
58,808.70 mlU / mL.5,6
Figure 1. The first ultrasound of the patient is 7-8 weeks' gestation
DISCUSSION
Conservative therapy was carried out with metrotrexate (MTX) 50 mg / m2 intramuscularly in
this patient. After administering metrotrexate (MTX) for four times, the B-HCG results were
significantly decreased with successive results of 21,530.12 mlU / mL, 2,949.47 mlU / mL, and
593.61 mlU / mL.7,8
115
Received : December 5th, 2019
Accepted : December 28th, 2019
Correspondence: Satrio Budhi Purnomo; email : dhimaz09@[Link]
Vol. 4, No. 1, Jan-Jun 2020
ANDALAS OBSTETRICS AND GYNECOLOGY JOURNAL
Alamat Korespondensi:
Ruang Redaksi Andalas Obstetrics and Gynecology Journal, Lantai 3 PPDS Obstetri dan Ginekologi Universitas
Andalas, RSUP DR. M. Djamil Padang, Jl. Perintis Kemerdekaan Padang, Sumatera Barat 25127
Website:
eISSN : 2579-8324 pISSN : 2579-8323
[Link]
Figure 2. An overview of the results of the US after the first MTX administration
Figure 3. An overview of the results of the US after the second MTX administration.
From the description of the results of ultrasound after the administration of
metrinotrexate (MTX) therapy, it was found that there was a decrease in gestational bag
size.9,10 Pregnancy in a cesarean scar is a very rare form of ectopic pregnancy. This case occurs
in line with the increase in the cesarean delivery process.11,12,13 Although it is very rare, it can
lead to life-threatening complications such as uterine rupture and catastrophic bleeding
which can increase maternal morbidity and mortality even though it occurs early in
pregnancy.14
Pregnancy in a cesarean scar occurs when the gestational sac implants in the lower
uterine segment of a previous cesarean scar.15 Although the pathophysiology of pregnancy in
a cesarean scar is still not clearly known, it may becaused by penetrating the blastosis into
the myometrium on the first day through the lesion microscopy of fibroid tissue in previous
cesarean scars, associated with a history of previous operative trauma such as cesarean
section, myomectomy, hysteroscopy and even manual placenta.16,17
It is very important to diagnose this condition early in conservative management.
Almost all cases of pregnancy in cesarean scar are found in the first trimester. The most
common symptoms in this case are abdominal pain and vaginal bleeding, as experienced by
the patient.18
116
Received : December 5th, 2019
Accepted : December 28th, 2019
Correspondence: Satrio Budhi Purnomo; email : dhimaz09@[Link]
Vol. 4, No. 1, Jan-Jun 2020
ANDALAS OBSTETRICS AND GYNECOLOGY JOURNAL
Alamat Korespondensi:
Ruang Redaksi Andalas Obstetrics and Gynecology Journal, Lantai 3 PPDS Obstetri dan Ginekologi Universitas
Andalas, RSUP DR. M. Djamil Padang, Jl. Perintis Kemerdekaan Padang, Sumatera Barat 25127
Website:
eISSN : 2579-8324 pISSN : 2579-8323
[Link]
It is not easy to diagnose pregnancy in this cesarean scar, but through careful
examination with endovaginal ultrasonography and Doppler color flow, it is very possible that
pregnancy in a cesarean scar can be detected by several criteria such as an empty uterus, 7
depictions of an empty cervical canal, growth gestational pouches in the anterior segment of
the lower uterus, and absence of a myometrum between the vesic wall and gestational
pockets.19
Previously this patient had visited several obstetricians, but different results were
obtained (intrauterine pregnancy and ectopic pregnancy).14 By conducting a careful and
careful examination, the ultrasound examination can finally find signs of pregnancy in the
previous cesarean scar as mentioned in the diagnostic criteria on the above ultrasound
examination.19
Specific guidelines regarding the management of patients with pregnancy in this
cesarean scar are currently missing. Medical and surgical approaches have been tried with
the aim of removing the sac of pregnancy and maintaining fertility, including systemic
therapy, local injection, aspiration surgery of pregnancy sacs, as well as hysteroscopy,
laparoscopy, and open surgery. This approach may be appropriate for women with stable
haemodynamics in unresolved cesarean scar at less than 8 weeks' gestation and myometrium
thickness less than 2 mm between the gestational sac and bladder.4 Systemic methotrexate
therapy has a success rate of 71% to 80 % with only 6% requiring hysterectomy.5 The best
results are achieved when the human chorionic gonadotropin β level is less than 5000 mU /
mL.18,19
In this patient conservative treatment with metrotrexate (MTX) 50 mg / m2 was
intramuscularly.9 After administering metrotrexate (MTX) for 4 times, the B-HCG results were
significantly decreased with successive results of 21,530.12 mlU / mL, 2,949.47 mlU / mL, and
593.61 mlU / mL.20
CONCLUSION
Pregnancy in a cesarean scar can be diagnosed by ultrasound if examined carefully and
thoroughly. In this patient an empty uterine picture is found, an empty cervical canal picture,
growth of gestational pouches in the anterior segment of the uterine lower segment, and
absence of a myometrum picture between the vesic wall and gestational pouches. Giving
intramuscular serial MTX can give the best results in the management of this case.20
117
Received : December 5th, 2019
Accepted : December 28th, 2019
Correspondence: Satrio Budhi Purnomo; email : dhimaz09@[Link]
Vol. 4, No. 1, Jan-Jun 2020
ANDALAS OBSTETRICS AND GYNECOLOGY JOURNAL
Alamat Korespondensi:
Ruang Redaksi Andalas Obstetrics and Gynecology Journal, Lantai 3 PPDS Obstetri dan Ginekologi Universitas
Andalas, RSUP DR. M. Djamil Padang, Jl. Perintis Kemerdekaan Padang, Sumatera Barat 25127
Website:
eISSN : 2579-8324 pISSN : 2579-8323
[Link]
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118
Received : December 5th, 2019
Accepted : December 28th, 2019
Correspondence: Satrio Budhi Purnomo; email : dhimaz09@[Link]
Vol. 4, No. 1, Jan-Jun 2020
ANDALAS OBSTETRICS AND GYNECOLOGY JOURNAL
Alamat Korespondensi:
Ruang Redaksi Andalas Obstetrics and Gynecology Journal, Lantai 3 PPDS Obstetri dan Ginekologi Universitas
Andalas, RSUP DR. M. Djamil Padang, Jl. Perintis Kemerdekaan Padang, Sumatera Barat 25127
Website:
eISSN : 2579-8324 pISSN : 2579-8323
[Link]
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119
Received : December 5th, 2019
Accepted : December 28th, 2019
Correspondence: Satrio Budhi Purnomo; email : dhimaz09@[Link]