Abstract
INTRODUCTION AND IMPORTANCE: The increasing prevalence of cesarean sections has raised concerns regarding associated risks such as ectopic pregnancy, placenta previa, and placenta accreta. Cesarean scar ectopic pregnancy (CSEP), although uncommon, has become more frequent with the rising rate of cesarean deliveries. This condition involves implantation of an embryo within the myometrial defect of a previous cesarean uterine incision. It requires early detection to mitigate life-threatening complications due to its potential rupture. CLINICAL PRESENTATION: A 27-year-old G5P3L3A1 female was referred to our facility presenting with vaginal bleeding post-medical termination of pregnancy at 16 weeks of gestation. Ultrasound and MRI findings indicated an adherent placenta at the previous C-section scar site, suggestive of placenta accreta complex and scar site ectopic gestation. To navigate the diagnostic dilemma, a laparoscopy was planned. The omentum was found covering a ruptured area. Once it was removed, the patient began bleeding profusely at the rupture site. Thus, the omentum had sealed the ruptured CSEP, preventing massive blood loss and keeping the patient hemodynamically stable. CLINICAL DISCUSSION: Transabdominal ultrasound is currently the primary method of CSEP diagnosis. Other methods include color Doppler, transvaginal ultrasound, and MRI. Due to the rarity of the diagnosis, there are no established treatment guidelines, and case reports and small case series make up the majority of management evidence. CSEP can be treated by methotrexate or surgery. Our patient was treated through a laparoscopic procedure as the complex nature of the case required intervention. Forty percent of ectopic pregnancies found on cesarean scars are asymptomatic while some patients present with abdominal pain or vaginal bleeding. Our patient had clinical manifestations of severe bleeding, pointing toward rupture of the ectopic pregnancy. The omentum however covered the ruptured uterine area in a rare occurence, limiting blood loss. CONCLUSION: CSEP cases always pose a diagnostic dilemma that could lead to severe maternal morbidity if not managed accurately. The diagnostic methods for CSEP need to be reviewed based on accuracy and efficiency. From this case, we can also conclude that the existence of a rupture should not be eliminated based on clinical findings as the patient was hemodynamically stable. This highlights the varied complex presentations that patients with ruptured CSEP may have.