Cesarean scar ectopic pregnancies (CSEP) are becoming increasingly more common due to rising rates of cesarean deliveries worldwide. Approximately 21% of pregnancies are currently delivered by cesarean delivery, with a projected increase to 33% by 20301.. This method of delivery whether by classical, low transverse, or low vertical incision requires incision and subsequent sutured closure of the uterus at time of delivery, which can result in varying degrees of scarring within the myometrium. CSEP is a rare form of ectopic pregnancy in which the gestational sac implants within the myometrial defect of a previous cesarean scar. It poses significant risks, including uterine rupture and severe hemorrhage. According to the Society for Maternal-Fetal Medicine, it is a Grade B recommendation not to proceed with expectant management.2. Diagnosis is primarily achieved through transvaginal ultrasound, which typically reveals a gestational sac embedded in the anterior lower uterine segment with absent or thin overlying myometrium. Doppler imaging can further confirm the diagnosis by demonstrating increased vascularity around the implantation site. Due to the potential for a thin myometrium at that scar site, the potential for morbidly adherent placentation due to placenta accreta spectrum can add additional morbidity, as this can frequently result in significant hemorrhage at time of delivery, necessitating hysterectomy. Combining these two co-morbid conditions with history of postpartum cardiomyopathy presents a significantly high risk to the life of a pregnant patient and necessitates collaboration and insight from a multiprofessional team in order to develop the most appropriate treatment plan. Case: A 30yr G3P1102 at 9 weeks gestation presented to clinic to establish care. She had a medical history significant for recent postpartum cardiomyopathy with an ejection fraction of 20-25%, history of preeclampsia, hypertension, obesity, and history of two cesarean deliveries. She had discontinued her sacubitril, valsartan, carvedilol, dapagliflozin, spironolactone, and furosemide in December 2024 following loss of insurance coverage and learning she was pregnant. She was symptomatic at intake and was sent to the hospital for evaluation. Her electrocardiogram showed no evidence of acute myocardial infarction, but a possible old infarct was noted. Echocardiogram demonstrated global left ventricular hypokinesis with ejection fraction of 20-25%. A V/Q scan was negative for pulmonary thromboembolism. Cardiology recommended to avoid pregnancy and adjusted the patient’s medication regimen to metoprolol succinate 12.5 mg daily. On ultrasound, a CSEP was noted along with thin overlying myometrium and early trophoblastic invasion anteriorly concerning for possible placenta accreta spectrum. The patient was counseled regarding the extreme morbidity of her condition and termination was discussed. Patient requested a week to process the information and had her metoprolol increased to 25mg daily. At follow-up, the patient elected to proceed with termination of pregnancy. She requested a bilateral tubal ligation at time of the procedure. A multidisciplinary meeting was held between Maternal Fetal Medicine, Gynecologic Oncology, Academic Generalist Specialists, and Anesthesiology to discuss possible management options for addressing this patient’s CSEP: hysterectomy en bloc, potassium chloride and methotrexate injection, and/or ultrasound guided suction dilation and curettage (D&C). Given the patient’s cardiac risks, desire to minimize fluid shifts/blood loss, and gestational sac communication with cervical/endometrial cavity, the group recommended suction D&C via ultrasound guidance with neuraxial anesthesia. Due to concerns of general anesthesia, laparoscopy could not be performed for sterilization. The requirements for termination of pregnancy in compliance with Alabama law were completed. She was re-evaluated twenty-four hours prior to procedure and was stratified to moderate/high risk. The patient was counseled about the option to start with hysteroscopy, and she consented. On day of surgery, spinal anesthesia was administered without complication. Her cervix was serially dilated under ultrasound guidance. An operative hysteroscope was then introduced into the uterus. The ectopic pregnancy was visualized near the cervical-uterine junction, which was confirmed with ultrasound. A tissue removal device was utilized to remove the ectopic tissue under ultrasound guidance. When the fluid deficit reached 1000 cc of normal saline, the decision was made to transition to suction curettage to remove the remaining anterior placenta, under ultrasound guidance. At the end of the procedure, a levonorgestrel releasing intrauterine device (IUD) was placed under ultrasound guidance. The patient tolerated the procedure well with minimal blood loss and was admitted for observation. She received a dose of methotrexate for the treatment of potential residual tissue. The patient was discharged later that day with no apparent complications. Discussion: This high risk patient was able to have a minimally invasive procedure to manage a complex CSEP with potential placenta accreta spectrum under spinal anesthesia. She is currently asymptomatic, and her beta-hcg levels are nearing zero. Currently there exist several alternative measures of management, which were considered individually and in combination as part of treatment planning above.
Crider et al. (Sat,) studied this question.