Clinical spectrum and management outcomes of caesarean scar ectopic pregnancy: a case series

Abstract

Caesarean scar ectopic pregnancy (CSEP) is uncommon in routine obstetric practice, but when it occurs it can become rapidly dangerous. Implantation within a previous caesarean scar carries a real risk of severe haemorrhage, uterine rupture and loss of fertility if the diagnosis is missed or delayed. With rising caesarean section rates in India, clinicians encounter this condition more often, yet management remains individualized rather than protocol driven. We reviewed seven consecutive women diagnosed with CSEP at a tertiary care centre in India. All patients were haemodynamically stable at presentation. Diagnosis was based primarily on transvaginal ultrasound, with MRI used selectively when imaging was equivocal or myometrial thinning was significant. All women were initially offered medical management using methotrexate, with folinic acid and letrozole added in selected cases. Patients were followed with serial β-hCG measurements and repeat imaging. Surgical intervention was reserved for non-responders or those who developed clinical deterioration. Five of seven women (71.4%) responded well to conservative medical treatment, showing a gradual fall in β-hCG levels and resolution of the scar pregnancy on imaging. Two patients (28.6%) ultimately required surgery. One underwent laparoscopic excision of the scar ectopic with uterine repair, while the other required obstetric hysterectomy following uncontrolled bleeding during attempted hysteroscopic evacuation. Our experience suggests that stable women diagnosed early in the first trimester can often be managed successfully with medical therapy under close surveillance. Nevertheless, CSEP remains unpredictable and timely escalation to surgery is crucial when clinical or biochemical trends are unfavourable.