PMC3747996_01
Findings in initial cesarean scar pregnancy. (A) Transvaginal ultrasonography showing the gestational sac at the previous cesarean section scar (arrow) at 7 weeks of gestation before dilatation and curettage performed under the diagnosis of missed abortion. (B) Transvaginal color Doppler ultrasonography showing the retained gestational products with prominent vascular flow at the previous cesarean section scar 7 weeks after dilatation and curettage, leading to the diagnosis of cesarean scar pregnancy. (C) Axial computerized tomographic image of hemorrhagic cesarean scar pregnancy showing the prominent extravasation (arrow) of iodine-contrast media from the left uterine artery (arrowhead). (D) Angiographic finding of cesarean scar pregnancy after intra-arterial infusion of dactinomycin followed by left arterial embolization by platinum coils (arrow).
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Although retrospective evaluation of the ultrasonographic image indicated the presence of a gestational sac in the previous cesarean section scar (Fig. 1A, arrow), such a diagnosis was not made at that time. Prominent vascular flow was noted around the retained gestational products (Fig. 1B). On iodine-enhanced computerized tomographic image, active extravasation of contrast agent (Fig. 1C, arrow) originating from the left uterine artery (Fig. 1C, arrowhead) was identified. Station, NJ, USA), arterial embolization was performed with Tornado platinum coils (Cook, Bloomington, IN, USA) for left uterine arterial occlusion (Fig. 1D, arrow) and with gelatin sponge particles (Gelpart, Nippon Kayaku, Tokyo, Japan) for right uterine arterial occlusion. With successful hemostasis, further conservative management was chosen and systemic intramuscular administration of MTX (50 mg/m2/day) was additionally performed 3 times. Subsequently, gestational products resolved without any further hemorrhagic complications, and first menstruation resumed 97 days after TACE.
Findings in a subsequent pregnancy after successful conservative management of cesarean scar pregnancy. (A) Transvaginal ultrasonography showing normal fetal growth with cardiac activity and low-lying placenta attached to the anterior wall of the uterus at 8 weeks of gestation. Lower segment of placenta attached to the cesarean section scar (arrow). (B) Sagittal magnetic resonance imaging showing attachment of the lower part of the placenta to the previous cesarean section scar (arrow) at 19 weeks of gestation. (C) Uterine scar showing slight decompression (arrow) at emergency cesarean section performed at 36 weeks and 5 days of gestation.
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At 8 weeks of gestation, normal fetal growth was identified (Fig. 2A). The lower segment of the placenta was attached to the cesarean section scar (Fig. 2A, arrow). Attachment of the lower part of the placenta to the previous cesarean section scar was confirmed (Fig. 2B, arrow). At laparotomy, the uterine scar from the previous cesarean section showed slight decompression, but scar dehiscence or rupture was not evident (Fig. 2C, arrow).