Cesarean scar ectopic pregnancy: Case report
The present case has been reported in the Journal of Radiology Case Reports.

A 29-year-old woman (G4P3003) presented with vaginal bleeding and discharge. The patient had a history of 3 cesarean deliveries in the past due to hypertension in her first pregnancy and 2 subsequent scheduled cesarean deliveries after normal pregnancies. Her most recent pregnancy was 3 years prior to presentation. Three weeks prior to presentation, a transvaginal ultrasound suggested an intrauterine pregnancy at 7 weeks and 5 days with a gestational sac visualized in the lower uterine segment.

Transvaginal ultrasound at the treating hospital demonstrated a gestational sac (dated at 10 weeks and 4 days) located at the level of the internal cervical os. A fetal pole was noted with the presence of fetal cardiac motion. The gestational sac was located in an anterior position toward the anterior lower uterine segment at the level of prior cesarean scar with little visible myometrium noted anterior to the gestational sac in the lower uterine segment.

The gestational sac was found to communicate with the endometrial cavity, while being located in the lower uterine segment of uterus, and was without involvement of the cervix. Given concern for cesarean scar ectopic pregnancy, possibility of implantation on the prior cesarean scar compared to within the scar with lower risk of morbidity, and limitations of the ultrasound given the maternal BMI of 38, an MRI was performed.

MRI of the abdomen and pelvis without contrast revealed a gestational sac located in the anterior aspect of the lower uterine segment superior to the internal cervical os at the site of prior cesarean scar. Disruption of the myometrium was suspected between the gestational sac and bladder, with only intact uterine serosa suspected, most consistent with implantation into the prior cesarean scar.

After discussion with the patient regarding her imaging findings, potential complications of continuation of cesarean scar pregnancy, and reproductive goals, the patient stated that she desired permanent sterilization. She underwent an uncomplicated total laparoscopic hysterectomy with removal of the cesarean scar pregnancy, bilateral salpingectomy, and cystoscopy. She was discharged postoperative day 1 and scheduled for close follow-up with obstetrics and gynaecology.

Key takeaways:-
- There should remain a high clinical suspicion for a cesarean scar ectopic in a patient with a history of cesarean deliveries presenting with first trimester bleeding.

- These patients should be diagnosed with transvaginal ultrasound with confirmation with MRI if diagnosis is unable to be made via ultrasound.

- To prevent maternal hemorrhage, a patient presenting with a cesarean scar ectopic pregnancy should undergo prompt treatment depending on her clinical status and reproductive preferences.

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