A 23-year-old woman, gravida 2, para 1 was admitted to the emergency department of our institute with preterm premature rupture of the membranes when she was 16 weeks’ pregnant. The patient had undergone one prior cesarean delivery 5 years previously. She had an early ultrasound report of 12 weeks’ gestation at another hospital. She complained of mild suprapubic pain with irregular per vaginal spotting since 8 weeks’ gestation. On sterile speculum examination, amniotic fluid was draining from the cervix. Initial transabdominal ultrasound was performed at our emergency unit showed a live single fetus and reduced liquor (anhidrosis). The patient was hospitalized for antibiotic treatment and follow up. The following day, transvaginal ultrasound in a sagittal position showed clear uterine cavity, empty cervical canal with a live fetus compatible with its gestational age on the uterine scar of a prior pregnancy (Fig. 1). When a gentle pressure was applied by endovaginal probe, the fetus didn’t displace from its position at the level of the internal os (negative sliding organ sign). Based on these findings, a diagnosis of cesarean scar pregnancy was determined. After that transabdominal sonography was performed with a well-distended bladder confirmed cesarean scar pregnancy, the thickness of the myometrium between the bladder and the sac very thin to an immeasurable extent (Fig. 2). There were a loss of hypoechoic appearance of retroplacental zone and lacunes in placenta, placenta accreta was suspected. A laparotomy was performed and the uterus was incised over the ballooning lower uterine segment which was stuck to the bladder. The products of conception were immediately removed from the lower uterine cavity (Fig. 3A, 3B). A placenta previa and focal placenta accreta (30%) were observed. The placenta was excised together with the surrounding myometrium and the bleeding area on the lower uterine segment was sutured. The bilateral uterine arteries were ligated due to failing to provide adequate bleeding control with sutures. At the end an intracavitary Foley balloon (30cc) was placed to tamponade the uterine cavity and control minimal bleeding. The hysterotomy incision was closed, and a drain was left in the pelvis in order to monitor potential blood loss. The fully extracted placenta was transferred to the pathology laboratory for further study. Histopathology showed placental tissue within the fibromuscular tissue of the old cesarean section scar. The patient received 4 units of blood transfusion totally and antibiotic therapy. Her drain and intracervical balloon were removed on postoperative day 1. Her subsequent clinical course was uneventful. She was discharged on postoperative day 7 without any complications and followed for 3 months, and had used oral contraceptives.
Keywords
Cesarean scar pregnancy, placenta accreta, ectopic pregnancy
