Caesarean scar pregnancy presenting at 17 weeks with a journey involving an exploratory laparotomy, continuing pregnancy and delivery at 34 weeks: A case report

Caesarean scar pregnancy (CSP) occurs when the gestational sac implants in the region of a scar from a previous caesarean delivery. CSP can lead to life-threatening complications, including severe haemorrhage, uterine rupture, placenta accreta spectrum (PAS) and hysterectomy.

A 40-year-old woman with one previous caesarean was referred to the specialist centre at 17⁺¹ weeks of gestation with concerns about CSP. At 19 weeks, she was admitted with abdominal pain. Due to raised body habitus, accurate ultrasound assessment was challenging, necessitating reliance on magnetic resonance imaging (MRI). The patient desired to continue the pregnancy, but due to pain and concerns about uterine rupture she consented to a laparotomy to potentially terminate the pregnancy. Findings during the laparotomy were reassuring, leading to the decision not to terminate the pregnancy. The patient remained hospitalised until delivery by caesarean-hysterectomy at 33⁺⁶ weeks. Histopathology confirmed the PAS diagnosis.

This case highlights the importance of achieving early diagnosis and obtaining clear sonographic findings. It emphasises the pitfalls of relying on MRI due to its tendency to over-diagnose severity. It emphasises the urgency for improved training in this domain. Early sonographic diagnosis allows safer performance of termination of pregnancy. It also provides women who continue with the pregnancy useful prognostic signs to facilitate decisions on the optimal gestation for delivery.

Determining optimal conservative management for CSP remains an ongoing challenge. This case emphasises the importance of multidisciplinary discussion, comprehensive patient counselling and involving patients in their care planning, to create an individualised and adaptable treatment plan.