Window to the Womb: Pregnancy Following Extensive Preconception Cesarean Scar Dehiscence

Background: Evidence-based recommendations for the management of pregnancy following preconception diagnosis of extensive cesarean scar dehiscence are lacking. We present a case of successful pregnancy after spontaneous conception occurred before planned surgical repair of a large lower uterine segment defect. Case: A 33-year-old G5P2022 underwent suction dilation and curettage under ultrasound guidance for management of an early pregnancy loss. During the procedure, a defect within the prior cesarean scar was identified. Pelvic MRI subsequently confirmed a 10-mm cesarean scar dehiscence involving the full width of the lower uterine segment/isthmus. Given the extent of the defect and concern for uterine rupture in a future pregnancy, interval surgical repair was recommended prior to conception. Before repair could be performed, the patient conceived spontaneously after a short interpregnancy interval. Following confirmation of an ongoing pregnancy, she received extensive counseling regarding the uncertain risk of uterine rupture, potential maternal morbidity, and the absence of data to guide management. Management options, including pregnancy termination, were reviewed in detail. After counseling, the patient elected to continue the pregnancy. Serial sonographic surveillance was performed throughout gestation. At the detailed anatomic survey at 22 weeks, the dehiscence measured 17 mm. Given concern for progressive scar separation and uterine rupture with advancing gestation, her care was coordinated by a multidisciplinary team including Maternal-Fetal Medicine, her primary obstetric provider, and Neonatology. The patient was admitted at 26 weeks and 1 day of gestation for inpatient antepartum surveillance and remained hospitalized through delivery. Repeat cesarean delivery was performed at 34 weeks’ gestation because of concerns regarding continued pregnancy in the setting of extensive lower uterine segment dehiscence. Maternal and neonatal outcomes were favorable, and both were discharged without major complications. Conclusion: Pregnancy following extensive preconception cesarean scar dehiscence involving the full width of the lower uterine segment presents a rare clinical challenge for which management recommendations are not established. This case highlights the complexities of counseling patients who conceive before planned repair and demonstrates that individualized multidisciplinary care, intensive surveillance, and planned preterm delivery can result in favorable maternal and neonatal outcomes. Further study is needed to guide surveillance strategies and delivery planning in similar cases.