The pregnancy dating dilemma

Scar pregnancy, Caesarean scar pregnancy, Intracardiac KCl, Methotrexate.

With the increasing caesarean delivery rates, apart from the risk of pathologically adherent placenta, the risk of another entity of implantation of gestational sac into the myometrium of hysterotomy scar, called as caesarean scar pregnancy is increasing[1].

A 33 year old lady, G3P1L1A1 came to casualty at 8 weeks 3 days period of gestation with a transabdominal sonography reporting a suspected scar pregnancy.

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Diagnosis is difficult but transvaginal sonography and colour flow Doppler using the following criteria may be helpful[1].

• Visualization of an empty uterine cavity as well as an empty endocervical canal • Detection of the placenta and/or a gestational sac embedded in the hysterotomy scar • A thin or absent myometrial layer between the gestational sac and the bladder • A closed and empty cervical canal • The presence of embryonic or fetal pole or yolk sac with or without cardiac activity • The presence of prominent or rich vascular pattern in the area of caesarean scar.

The fetus was observed for 5 minutes for confirming absence of cardiac activity.

The patient was discharged on day 5 without complications and advised to follow up with weekly serum β HCG reports.

Caesarean scar pregnancy, though rare, is a potentially life threatening condition.

The exact cause of this entity has not been understood.

Her obstetric history included a full term uneventful caesarean section 12 years back and a spontaneous abortion 3 years back at 1½ months amenorrhea not followed by evacuation.

On admission, her general physical and systemic examination was normal.

On per vaginal examination, uterus was 8 weeks size, anteverted, soft, mobile and bilateral fornices were free and non-tender. A diagnosis of caesarean scar pregnancy was made on the basis of TVS showing- 1) Gestational sac of 3.3 × 3.8 × 3.2 cm corresponding to 10 2 weeks gestation with cardiac activity in the lower uterine segment at the site of previous caesarean scar (Figure 1), Figure 1: (A) Transabdominal ultrasound showing a gestational sac in the lower uterine cavity adjacent to the previous scar with thinning of anterior myometrium.

(B) Transvaginal scan with colour flow Doppler showing vascularity around the gestational sac.

However, many hypotheses have been proposed and one of them is that the conceptus enters into the myometrium through a microscopic tract between the prior caesarean scar and the endometrial canal[3].

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