Title: First Trimester Cesarean Scar Implantation Ectopic Pregnancy: Case Report
Authors: Student Dr. Oak J. Sonfist, BA, OMS3, Pacific Northwest University of Health Sciences in Yakima, WA; Dr. Neil Ponder, DO, FACOOG, Medical Director of Desert Sky Women’s Health Care in Kennewick, WA.
Introduction:
Extrauterine pregnancies are dangerous with a high risk for maternal hemorrhage and mortality. Cesarean scar ectopic pregnancies are a rare form extrauterine pregnancies, however with increasing rates of cesarean procedures, are becoming more common in subsequent embryo fertilization and implantation.
Case Presentation:
This case study presents a 25-year-old gravida 3, para 2 woman presenting with a newly diagnosed pregnancy at 11 week and 1 day gestation, with a history of one prior cesarean delivery. The patient presented with vaginal bleeding and was found to have a visible singleton gestation bulging at the anterior lower uterine segment consistent with cesarean ectopic. After the initial ultrasound this diagnosis was missed by the initial rural hospital radiologist, but after discussion, a second imaging study and opinion, an addendum was made to confirm the diagnosis. There was no evidence of intraabdominal bleeding. The patient was extensively counseled, with the decision made to proceed with dilation and suction curettage of the lower uterine segment pregnancy under laparoscopic visualization. The procedure was successful with no complications.
Discussion:
Ectopic pregnancies are life threatening, and a delayed diagnosis of cesarean scar ectopic pregnancy (CSEP) can result in death. The diagnosis of CSEP is often difficult but establishing an accurate diagnosis of CSEP in the early first trimester is utmost important to prevent its detrimental consequences of uterine rupture and fatal hemorrhage. This case report highlights the importance of early diagnosis and treatment of CSEP; as well as best practices for rural medicine, encouraging the use of telemedicine for second opinions and maintaining a high index of suspicion complicated diagnoses. This case report also notes that at 11 week and 3 day gestation, without access to a safe medically induced abortion, the fetus and the patient would have died.
Abstract updated: 4/8/22
I am one of the judges for the case you have presented here. You mention that ectopic pregnancies are 2% of all pregnancies, and CSEP are 1% of those pregnancies, but you state that they should be screened for with all patients who have had a previous c-section. What other criteria, besides a previous c-section, within the history or case presentation should a provider look for to potentially rule in this as a potential diagnosis?
Dear Dr. Callan,
Thank you for this excellent question. Because CESP is potentially deadly it is necessary to always have a high index of suspicion in subsequent pregnancies in individuals who have had prior c-sections; comparing U/S readings with past readings to assess if the pregnancy may be on or within the scar. It is important to note that 1/3 of individuals with CESP are asymptomatic at diagnosis. For the 2/3 of patients who are symptomatic, the most common symptom is vaginal bleeding with or without abdominal pain (90% according to one study) [1]. Vaginal bleeding with or without abdominal pain there is the most common symptom that could present for individuals who have CES; this usually presents late in the first trimester of early in the second trimester. However maintaining a high index of suspicion for all individuals with a history of prior c-sections is necessary as the range of symptoms associated with CESP vary from mild (e.g. vaginal bleeding with/without abdominal pain) to severe (e.g. uterine rupture with hypovolemic shock).
Additionally, a provider should look for other risk factors in a patient’s history to rule-in CSEP as a potential diagnosis, such as: individuals who have had additional uterine surgeries; individuals with multiple cesarean procedures (it is debated if incidence increases with multiple c-sections); individuals who have experienced manual removal of placenta in previous pregnancies; and individuals who have used in-vitro fertilization. On another note, it is suspected the risk for CSEP significantly increases for individuals who have had CSEP in the past. There has been one meta-analysis that showed a risk of recurrence in 17.6% of patients [2]. More research is required for definitive association. So if an individual has a subsequent pregnancy after experiencing CSEP that person should be closely monitored for additional CSEP. If additional CSEP occurs I would also highly recommend the provider to publish a case report to help further the research on this topic.
I hope this sufficiently addressed your question. If you have any additional questions please feel free to ask.
Sincerely,
Oak Sonfist
Sources
[1]: Riaz RM, Williams TR, Craig BM, Myers DT. Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging. 2015;40(7):2589-2599. doi:10.1007/s00261-015-0472-2
[2]: Morlando M, Buca D, Timor-Tritsch I, et al. Reproductive outcome after cesarean scar pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2020;99(10):1278-1289. doi:10.1111/aogs.13918
Thank you for your presentation. You mention that the patient is writing up her story. What kind of write up is she doing, a blog post, a journal article?
Dear Dr. Walser,
Thank you for your interesting question. The patient is writing up her story for a journal article. In the follow up appointments after the CSEP the patient expressed a desire to share her perspective and experience around the loss of her wanted pregnancy. While the procedure that was performed saved her life, it also terminated her pregnancy. Subsequently, it had a deep emotional impact. She is writing about her experience in hopes that when completed we can submit it to a medical journal along with a case report, for publication to further medical research. The intention is to eventually generate scientific literature combining the medical perspective and the patient’s emotional and personal experience.
I think this future publication will greatly benefit the medical community, particularly regarding changing laws around access to the termination of pregnancies. It is important to note in this situation this was a desired pregnancy, and the procedures performed to terminate the pregnancy were medically necessary to save the patient’s life. It was a very hard decision the patient had to make. Having a humanistic, patient centered, scientific publication could help provide additional perspective to lawmakers as well as the medical community.
If you have any additional follow up questions please feel free to ask.
Sincerely,
Oak Sonfist
Judge: You mention the importance of using telemedicine for second opinions in diagnosing and treating CSEPs. Is this the recommended best practice only when a CSEP is suspected but initially missed? What other circumstances of a CSEP may warrant a second opinion through the use of telemedicine?
Dear Ms. Garehime,
Thank you for your thoughtful questions. Currently there is no official recommended best practice when CSEP is suspected but initially missed, this case presentation suggests that this should be an official recommendation in the future. It is important to note that the first ultrasound was obtained from a community based hospital where often radiologists are overworked. It is possible in the hospital they did not have access to past ultrasound records, or did not have the time to compare this ultrasound to past ultrasound. Employing the use of telemedicine, which recently has increased in popularity with the COVID-19 pandemic, could be an advantageous method for second opinions for all medical providers. We as authors recommend using telemedicine when there is limited local resources for second opinions, such as in this case where a second opinion from an alternative radiologist assisted in the life saving diagnosis of CSEP.
The use of telemedicine has been proven to be helpful for medical crisis in rural communities [1]. Other circumstances related to CSEP that may warrant a second opinion though the use of telemedicine include treatment option consultation and discussion with the patient; emergency crisis consultation with a high risk obstetrics specialists if a patient were to present with severe complications of a CSEP (e.g. uterine rupture and hemorrhage); if the patient were to live in a state where access to abortive procedures were outlawed telemedicine could help the patient receive lifesaving care. During the COVID-19 pandemic medical abortion using telemedicine and mail has been effective. This method of service delivery can improve access to abortion care in the United States [2]. In theory if a patient lives in a state that has outlawed abortive procedures, this use of telemedicine may save the life of a patient with CSEP.
I hope this answers your questions. If you have any additional questions please feel free to ask.
Sincerely,
Oak Sonfist
Sources:
[1]: Palozzi G, Schettini I, Chirico A. Enhancing the Sustainable Goal of Access to Healthcare: Findings from a Literature Review on Telemedicine Employment in Rural Areas. Sustainability. 2020; 12(8):3318. https://doi.org/10.3390/su12083318
[2]: Erica Chong, et al., Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception. 2021; 104(1):43-48. https://doi.org/10.1016/j.contraception.2021.03.019