Complications and Management in a Case of Missed Abortion with Cesarean Scar Pregnancy

Background Cesarean scar pregnancy (CSP) is a first-trimester pregnancy in which the gestational sac implants within the myometrial defect of a prior cesarean section scar. Placenta accreta spectrum (PAS) refers to a range of disorders characterized by abnormal placental adherence and invasion, and is most often diagnosed later in pregnancy. CSP and PAS likely represent a continuum of the same underlying process occurring at different stages of gestation, with CSP considered an early precursor to PAS. Both conditions are strongly associated with a history of uterine surgery—such as cesarean delivery, myomectomy, or dilation and curettage (D&C)—which can result in focal defects in the decidua basalis. These defects create an environment that permits abnormal trophoblastic invasion into the myometrium, leading to deeply anchoring placental villi and progressive placental infiltration. Such pathologic invasion significantly increases the risk of severe hemorrhage and associated maternal morbidity and mortality. Objective To present a rare case of first-trimester placenta accreta spectrum versus cesarean ectopic pregnancy culminating in pregnancy loss managed by dilatation and curettage (d&c). Significant hemorrhage was experienced during the d&c. This was eventually controlled with assistance from our interventional radiology colleagues in a way that preserved the patient’s future fertility prospects. Through presenting this case, we hope to highlight the importance of multidisciplinary preparedness in dealing with pathologies of placental attachment – even in early gestation. Study Design This case report details the clinical presentation, intraoperative findings, and multidisciplinary management of a patient with suspected cesarean scar pregnancy who experienced severe hemorrhage during a first-trimester dilatation and curettage. The patient’s clinical course, interventions performed, and recovery trajectory were retrospectively reviewed. Results A 31-year-old gravida 2 para 1 with a history of term cesarean section presented for elective dilatation and curettage following a diagnosis of missed abortion at approximately 13 weeks’ gestation. Prenatal imaging raised concern for abnormal placentation; several first-trimester ultrasounds prior to the pregnancy loss noted a 5-centimeter subchorionic hemorrhage versus involuting second gestational sac and concern for placenta accreta spectrum (PAS) versus cesarean scar pregnancy (CSP). Given these concerns for placental pathology, shared decision-making between patient and provider concluded that surgical evacuation of the products of conception would be the safest way to manage the missed abortion. During the procedure, brisk hemorrhage occurred following initial suction curettage. Despite administration of intramuscular methergine and uterotonics, hemorrhage persisted. Intraprocedural ultrasound was used to evaluate the situation and revealed a possible clot in the lower uterine segment, as well as a large uterine niche at the site of the prior cesarean scar. A Foley balloon was placed for attempted intrauterine tamponade, but bleeding continued around the catheter. With an estimated blood loss exceeding 1000cc, tranexamic acid and intrauterine methergine injections were administered and vaginal packing was placed. However, the patient became hemodynamically unstable and the decision to perform an emergent exploratory laparotomy was made to evaluate for injury of the uterus and surrounding structures. No uterine rupture or extrauterine bleeding was identified. The source of hemorrhage was determined to be intrauterine, likely related to the cesarean niche. The patient was stabilized and the abdomen was closed. She was transferred to interventional radiology where she underwent successful uterine artery embolization. Postoperative recovery was uneventful. Discussion This case illustrates the clinical challenges of managing a cesarean scar pregnancy versus early placenta accreta spectrum. It also accentuates the importance of careful surgical coordination in all cases of suspected abnormal placentation – even first-trimester pregnancy losses – as the extent of placental invasion and resultant bleeding can be unpredictable. In this case, high clinical suspicion for placental pathology, timely recognition of bleeding complications, and access to multidisciplinary care were essential to preserving uterine integrity and preventing maternal morbidity. Conclusion First trimester dilation and curettage complicated by hemorrhage due to placental pathology is a rare but potentially devastating complication with profound profound maternal morbidity and mortality risks. This case highlights the importance of preoperative risk assessment, interdepartmental planning, and provider preparedness to escalate care. Further research and clinical guidelines are needed to assist providers in managing CSP versus early PAS in order to further improve maternal outcomes.