A Dangerous Implantation: Cesarean Scar Ectopic Pregnancy and the Role of Definitive Surgery

Introduction: Cesarean scar ectopic pregnancy (CSEP) is a rare but increasingly encountered complication of cesarean sections, driven by increasing global cesarean rates and improved detection methods. Management strategies vary from medical management to fertility-sparing surgical options, but optimal treatment remains unknown. We present a complex CSEP case highlighting the importance of multidisciplinary planning and definitive surgical management. Case: A 43-year-old G6P3033 with a history of one cesarean section and two dilation and curettage procedures presented for an initial prenatal visit at 10 weeks, where bedside ultrasound was suspicious for a failing intrauterine pregnancy. Formal ultrasound at this time demonstrated an anterior myometrial defect at the cesarean scar with endometrial contents protruding through the defect. Subsequent MRI revealed lobular soft tissue extending into the cesarean-scar site that was concerning for placenta accreta spectrum, cesarean scar ectopic pregnancy, and/or uterine dehiscence with retained products of conception. The patient was transferred to a tertiary referral center with a multidisciplinary surgical team. Multidisciplinary subspeciality collaboration (Generalist OB/GYN, Maternal Fetal Medicine, Gynecologic Oncology, Interventional Radiology (IR), Urology) together proposed a treatment plan involving uterine artery embolization by IR, systemic methotrexate administration, and bilateral ureteral stent placement by Urology. Given the lesion’s proximity to the bladder and the patient’s lack of desire for future fertility, the decision was made to proceed with total abdominal hysterectomy (TAH). This plan was successfully implemented and TAH was performed without complication. Pathology confirmed placenta percreta. Gynecologic oncology was available for surgical backup but ultimately was not required. After two days postoperatively and five days in the hospital total, the patient was discharged home in stable condition. Discussion: Although optimal guidelines for CSEPs remain uncertain, this case illustrates a deviation from typical management for a more advanced case at a later gestational age. Generally, medical management can be pursued with intra-gestational sac methotrexate administration. Surgical management includes operative resection (with transvaginal or laparoscopic approaches when possible), ultrasound guided uterine aspiration, or, less commonly, hysterectomy. This case is unique due to the use of several different modalities, most notably definitive treatment with an open surgery involving a multidisciplinary team. Conclusion: CSEP remains a rare and potentially life-threatening condition. This case highlights the value of a multidisciplinary approach and demonstrates that hysterectomy may serve as a safe and effective treatment strategy when patient and clinical circumstances favor definitive management.