Adel Al-Nazer

CJ Hamilton

CL Lee

CM Yan

D Jurkovic

DL Fylstra

G Tan

J Ben Nagi

J Hasegawa

JM Ayoubi

JV Larsen

KM Seow

Lama Omar

LJ Salomon

Manal Wahba

Mariam Abdulkarim

O Graesslin

S Marcus

Tahrir Abbas

Y Shufaro

English

PubMed

Springer - Publisher Connector

Ectopic intramural pregnancy developing at the site of a cesarean section scar: a case report

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BioMed CentralCases Journal
ssOpen AcceCase Report
Ectopic intramural pregnancy developing at the site of a cesarean 
section scar: a case report
Adel Al-Nazer*, Lama Omar, Manal Wahba, Tahrir Abbas and 
Mariam Abdulkarim
Address: Department of Obstetrics and Gynocology Dubai Hospital, Dubai, UAE
Email: Adel Al-Nazer* - anazer@tedata.net.eg; Lama Omar - anazer@tedata.net.eg; Manal Wahba - anazer@tedata.net.eg; 
Tahrir Abbas - anazer@tedata.net.eg; Mariam Abdulkarim - anazer@tedata.net.eg
* Corresponding author    
Abstract
Introduction: Cesarean section scar pregnancy is a rare but serious complication. It occurs in
women with previous uterine scar when implantation takes place at the site of this scar. If early
diagnosis is missed the woman's future fertility and eve her life are at risk. Earlier reports on the
condition suggesting different management approaches have been described.
Case presentation: A 37 year-old woman gravida 4, para 3, was referred to our emergency
department, as a case of missed miscarriage following 14 weeks amenorrhea. Ultrasound
examination revealed a picture suggestive of intramural pregnancy near the Cesarean section scar.
The case was managed by laparotomy evacuation of products of conception and repair of the scar.
Conclusion: The diagnosis of ectopic intramural pregnancy in a cesarean section scar is possible
with ultrasound and high level of suspicion. This serious complication must be suspected in a
pregnant woman with previous uterine scar when early ultrasound show a gestational sac that is
implanted anteriorly in the lower uterine segment, near the uterine scar. Ultrasound criteria for
diagnosis include empty uterus, empty cervical canal and a discontinuity on the anterior wall of the
uterus demonstrated on a sagittal plane of the uterus running through the amniotic sac. Early
intervention is recommended to avoid serious consequences in such cases.
Introduction
Pregnancy in a Cesarean Section scar (CSS pregnancy) is a
rare complication that may have serious consequences
affecting the woman's future fertility and may even affect
her own life. It is believed to develop as a result of the
presence of a microscopic tract in the scar allowing the
blastocyst to be implanted deep in the myometrium [1].
Early diagnosis of CSS pregnancy is essential to avoid seri-
ous complication such as sever hemorrhage which may
require hysterectomy and endanger the woman's' life.
Diagnosis is based on high level of suspicion when a ges-
tational sac is seen at sonography on the anterior lower
part of the uterus in a woman with a previous Cesarean
section [1].
The differential diagnosis includes spontaneous abortion
and cervico-isthmical pregnancy. It is essential to get a
proper history and a high resolution ultrasound scanning
in order to avoid wrong diagnosis [2].
Published: 30 December 2009
Cases Journal 2009, 2:9404 doi:10.1186/1757-1626-2-9404
Received: 6 November 2009
Accepted: 30 December 2009
This article is available from: http://www.casesjournal.com/content/2/1/9404
© 2009 Al-Nazer et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Cases Journal 2009, 2:9404 http://www.casesjournal.com/content/2/1/9404Treatment modalities are diverse with no one option
being superior to others. Most reported cases are sporadic
and subject of trials.
Surgical treatment by evacuation of the sac, excision and
repair of the gaped scar through laparotomy [3] or lapar-
oscopy [4] has been tried. Dilatation and evacuation was
also reported [5]. Medical treatments using local [1] or
systemic Methotrexate (MTX) [6] have been used fre-
quently. Potassium chloride with or without MTX was
also reported [7]. Uterine artery embolisation was also
used in combination with either medical or surgical
approaches [8]. A combination of surgeries and medical
treatment was also tried. There is no optimum line of
treatment that can be universally recommended and each
case should be treated individually.
Case presentation
A 37 year-old United Arab Emaerite woman gravida 4,
para 3, was referred to our emergency department, as a
case of missed miscarriage following 14 weeks amenor-
rhea. The patient's obstetric history included three Cesar-
ean sections last one 9 years back. The first Cesarean
section was done at 7 month gestation due to placental
abruption, the second was done for placenta previa and
the third was done electively. The patient presented with
history of lower abdominal pain and bleeding per vagina
for the last 12 days. Vaginal examination revealed an
enlarged uterus of 8 weeks size that is slightly tender on
movement. The cervical os was closed with no vaginal
bleeding. Trans-abdominal ultrasound in transverse scan
(Figure 1) shows enlarged uterus, empty uterine cavity
and cervical canal and a gestational sac (4.57 × 4.36 cm)
situated in the lower part of the anterior uterine wall at the
site of the Cesarean section scar. In a longitudinal scan
(Figure 2) the sac is seen protruding through the anterior
uterine wall and pushing towards the bladder with a thin
layer of myometrium (0.8 cm thick) separating them. A
non viable embryonic echo was observed inside the sac
measuring 3.5 cm at Crown Rump Length (CRL) corre-
sponding to 10 weeks plus three day gestation. No fluid
was seen in the cul-de-sac. With these ultrasound criteria
present an ectopic implantation in the previous Cesarean
section scar was considered. The mother was counselled
regarding the treatment options, but due the possibility of
prolonged follow up period with medical treatment she
preferred to go for surgical intervention.
A laparotomy was performed with Pfannenstiel incision
under general anesthesia. The bladder was adherent to the
lower part of the uterus so the peritoneum was incised and
the bladder was dissected down to the cervix. The gesta-
tional sac was seen bulging and thinning out the uterine
wall anteriorly at the scar site (Figure 3). Most of the scar
was in fact disrupted except for a thin layer of fibro-mus-
cular tissue. When this layer was gently incised the sac
bulged out with its bluish color (Figure 4). Approximately
4-5 cm intact gestational sac was delivered followed by a
placental tissue. The implantation of the ectopic preg-
nancy caused dehiscence of the previous Cesarean section
scar. A trial to identify the cervical canal by retrograde
probing was not easy as there was a thin layer of uterine
tissue separating the implantation site from the uterine
cavity. When this layer was overcome a communication
was created between the implantation site and the uterine
cavity. The dehiscent scar was then repaired, haemostasis
was assured and bilateral tubal ligation was done accord-
ing the request of the patient and her husband. The esti-
mated blood loss was less than 500 ml and there was no
Abdominal ultrasound, transverse scan showing a gestational sac measuring 4.57 × 4.36 cm betwee t e uterus and he urinary bladdeFigu  1
Abdominal ultrasound, transverse scan showing a 
gestational sac measuring 4.57 × 4.36 cm between 
the uterus and the urinary bladder.
Abdominal ultrasound, longitudinal scan showing a gesta-tional sac p shing itself towards the urinary bladderFigure 2
Abdominal ultrasound, longitudinal scan showing a 
gestational sac pushing itself towards the urinary 
bladder. An 8 mm layer of fibro-muscular tissue separates 
the sac from the bladder.Page 2 of 5
(page number not for citation purposes)
Cases Journal 2009, 2:9404 http://www.casesjournal.com/content/2/1/9404need for blood transfusion. The patient had an uneventful
postoperative recovery and was discharged from the hos-
pital on postoperative day 5.
Discussion
The increasing number of Cesarean Sections in recent
years has brought into light a set of complications that
were not so frequently observed in the past. Intramural
implantation through a Cesarean scar is a rare complica-
tion that is diagnosed with increasing frequency in recent
years. Larsen & Solomom reported the first case in 1978 as
a post-abortal haemorrhage due to what they described as
uterine scar saculus [9]. Since then cases have been
reported with increasing frequency leading to better
understanding of the condition. The possible incidence of
this abnormality ranges from 1:1800 to 1:2200 pregnan-
cies [2].
It is possible that this complication is related to the poor
healing of the cesarean section scar and the implantation
of the gestational sac into it. It may also result from a
defect in the endometrium caused by trauma created by
minor procedures as embryo transfer in the assisted repro-
duction techniques [10]. The natural history of this abnor-
mal implantation is not clear but it may result in a
pregnancy that grow towards the uterine cavity and looses
its vascular connection causing spontaneous abortion. Or
it may continue to grow to near term gaining new stronger
vascular connections ending into a low-lying adherent
placenta with or without invasion of surrounding organs.
If the gestational sac grows away from the uterine cavity
and pushes towards the bladder this may result what is
referred to in the literature as Cesarean Scar Pregnancy.
This abnormal pregnancy can't continue to term, and if
left to grow it end in rupture and massive hemorrhage and
may endanger the woman's life. Early diagnosis by ultra-
sonography is thus important to avoid serious conse-
quences. The sonographic criteria essential for diagnosis
are (i) Empty uterus (ii) Empty cervical canal (iii) Devel-
opment of the sac in the anterior part of the isthmic por-
tion and (iv) A discontinuity on the anterior wall of the
uterus demonstrated on a sagittal plane of the uterus run-
ning through the amniotic sac. Another important ultra-
sound criterion is absent or diminished healthy
myometrium between the bladder and the sac [11]. Also
Jurkovic et al proposed Doppler examination that shows
high velocity with low impedance peri-trophoblastic vas-
cular flow clearly surrounding the sac [12].
Although most reported cases are misdiagnosed in the
beginning for miscarriage yet with high level of suspicion
and with the aid of ultrasonography the two conditions
can be easily differentiated. Cervicoisthmical pregnancy is
another rare condition that can be a source of confusion.
This pathological condition may be very similar to CSS
pregnancy. The differentiating points include the absence
of healthy uterine tissue between the sac and the bladder
[11]. Another differentiating sign is the absence of "slid-
ing organ sign" which is defined as the inability to dis-
place gestational sac from its position at the level of the
internal os using gentle pressure applied by the transvagi-
nal probe [13].
In this case report we present a CSS pregnancy that was
misdiagnosed as missed abortion. This confusion is com-
mon and most cases need repeated scanning before the
Operative view a gestational sac bulging into the anterior uterine wall after dissection of the uri ary bladderFigur 3
Operative view a gestational sac bulging into the 
anterior uterine wall after dissection of the urinary 
bladder.
Operative view the bluish gestational sac bulging out of the dehiscent scar after the fibro-muscular layer was gentlyincisedFigur  4
Operative view the bluish gestational sac bulging out 
of the dehiscent scar after the fibro-muscular layer 
was gently incised.Page 3 of 5
(page number not for citation purposes)
Cases Journal 2009, 2:9404 http://www.casesjournal.com/content/2/1/9404diagnosis is reached. When the patient was referred to us
at 10 weeks size (14 weeks amenorrhea) the ultrasound
picture was already clear.
The challenge in diagnosis is further complicated by a
challenge in treatment. Due to the relative rarity of the
condition there are no optimal lines for therapy. Treat-
ment modalities are either medical or surgical. The medi-
cal treatment consists of administration of MTX locally
[12] or systemically [6]. Others combine Potassium Chlo-
ride injected locally into the fetal thorax with MTX
injected into the sac [13]. The medical treatment requires
prolonged follow up for complete resolution of the
ectopic pregnancy. In many instances bleeding may com-
mence following the medical treatment which may
require surgical intervention. Failure of pregnancy resorp-
tion and persistence of a relatively large gestational sac
may also require intervention. Medical treatment also has
many side effects more with the systemic than with the
local rout. Another important issue is the condition of the
uterine scar left after medical treatment and its subsequent
behavior in future pregnancies. Hasegawa et al reported
dehiscence in some cases after successful medical treat-
ment with local MTX and a repeated scar pregnancy. They
believed that excision of the old scar and repair of its site
could reduce the risk of dehiscence and recurrence [14].
The surgical approach involves the traditional laparotomy
and evacuation of the sac and repair of the uterine defect
[11]. The same procedure can be done laparoscopically
[4]. Dilatation of the cervix and evacuation has also been
described by some with apparently good outcome [5].
This does not look to be a rational approach as the gesta-
tional sac is usually separated from the uterine cavity by a
layer of myometrium and an attempt to evacuate the sac
vaginally will result in unavoidable tearing of this layer
with possible excessive bleeding. Graesslin et al reported
successful use of systemic MTX prior to dilatation and
curettage in one case [15]. Some authors prefer to use uter-
ine artery embolization (UAE) in order to minimize
blood loss. Yan reported four cases in three of them UAE
was used either following systemic or before local admin-
istration of MTX [8]. Although UAE appears promising in
treating stable cases, it is too early to be recommended as
a primary line of therapy.
It is important however to emphasize that due to the lack
of enough available data no treatment modality can guar-
antee uterine integrity or can be promoted as optimal
[12]. Treatment thus must be individualized according to
the sac size, presence of fetal heart, BHCG level, the desire
for future fertility and the experience and facilities availa-
ble.
In our case although her condition was stable yet laparot-
omy was selected as a line of management as the mother
did not want to have a prolonged follow up period.
Although the pregnancy was nonviable and expectant
management by follow up with BHCG was possible, the
size of the gestational sac and the woman's refusal of a
long follow up period justified the active approach.
Counseling patients with CSS pregnancy is difficult. There
is no enough data regarding the optimum treatment or a
guideline for management. With the accumulation of
reported cases it may be soon possible to have a guideline
for optimum management as it is now clear regarding
diagnosis.
Conclusion
The incidence of Cesarean Section is increasing year after
year. The complications of this mode of delivery are not
limited to the time of surgery. Remote complications
especially in subsequent pregnancies are also of signifi-
cance. Cesarean Section scar pregnancy is also is one of
these possible complications that may lead to rupture of
the uterus, bleeding and may endanger the woman's life.
Early diagnosis is possible with high level of suspicion
and with the aid of high quality ultrasound scanning. The
appropriate treatment of such cases is not yet clear. The
accumulation of data may help to understand the disease
better and to develop the appropriate plan of manage-
ment.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AA analyzed and interpreted the patient data and contrib-
uted in preparation of the manuscript. LO performed the
ultrasound. MW assisted in the ultrasound and in the
preparation of the manuscript. TA was involved in the
imaging preparation and reviewed the manuscript. MA
reviewed the literature and participated in reviewing the
manuscript. All authors read and approved the final man-
uscript.
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Ectopic intramural pregnancy developing at the site of a cesarean section scar: a case report

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