Purpose: To report a rare case of cesarean scar ectopic pregnancy (CSEP) complicated by placenta accreta spectrum (PAS), managed expectantly, culminating in cesarean hysterectomy at 32 weeks of gestation. Methods: Case Report. Results: A 40-year-old G5P3013 with three prior cesarean deliveries presented with spotting and pelvic cramping. Transvaginal ultrasound suggested a 6-week CSEP. She was hemodynamically stable, with minimal vaginal bleeding and a closed cervix. Her body mass index (BMI) was 40 kg/m², and she had a 15-pack-year smoking history. Maternal-fetal medicine (MFM) confirmed the diagnosis and counseled her extensively on risks, benefits, and alternatives, recommending management via termination or hysterectomy. Risks of significant hemorrhage, cesarean hysterectomy, bladder injury, uterine rupture, miscarriage, and other serious maternal morbidities were discussed thoroughly. The patient chose expectant management and close MFM follow-up. At 15 weeks, her ultrasound raised concerns for placenta accreta spectrum (PAS). She also had several blood pressures around 140/90 mmHg and was started on 81 mg of daily aspirin for preeclampsia prevention in the setting of her chronic hypertension. She failed both the 1-hour and 3-hour glucose tolerance tests, despite an early first-trimester A1c of 4.9%. She met with a diabetes educator and began logging her blood sugar levels. At 24 weeks, ultrasound confirmed placenta increta. Risks of hemorrhage, invasion of surrounding structures, cesarean hysterectomy, blood transfusion, and maternal and fetal death were again extensively discussed. Gynecologic Oncology was consulted and noted definitive need for hysterectomy and the possibility of leaving the placenta in situ to avoid life-threatening hemorrhage. This would be a decision at time of cesarean delivery, regardless of imaging. Magnetic resonance imaging was negative for placenta percreta. At 32 weeks, she was admitted from high-risk clinic due to ultrasound findings of extreme thinning of the lower uterine segment, with much of the pregnancy either bulging or extrauterine. Betamethasone was administered for fetal lung maturation, which lead to hyperglycemia. The decision was made to deliver within the week. Four units of type and crossmatched packed red blood cells (pRBCs) were made available. The day prior to delivery, the patient became hypoxic, and a chest x-ray revealed pulmonary edema and/or atelectasis. She was placed on an IV insulin drip for 24 hours preoperatively, and tight glucose control was achieved. At 32 weeks and 4 days, she underwent cesarean delivery via vertical midline and vertical uterine incisions. The infant had APGARs of 8 and 9 and weighed 5 lbs 14 oz. Gynecology oncology then performed an exploratory laparotomy, cesarean hysterectomy, and lysis of adhesions. Estimated blood loss was 2,300 mL. She received 2 units of pRBCs, 1 unit of fresh frozen plasma, and 4.6 L of crystalloids intraoperatively. Placental vessels were visualized invading the bladder dome serosa anteriorly. Pathology confirmed placenta increta, maternal and fetal vascular malperfusion, and a 3-vessel cord with marginal insertion. On postoperative day (POD) 0, she was diagnosed with chronic hypertension with superimposed severe preeclampsia. On POD 1, she again developed hypoxia and pulmonary edema. One MFM specialist suggested her hypertension and pulmonary edema were likely due to volume overload rather than severe preeclampsia. She was discharged home on POD 4. Her baby was doing well in the NICU. On POD 9, the patient returned with a 1 cm area of superficial wound dehiscence, serosanguineous discharge, induration, erythema, and a leukocytosis of 17,000 cells/µL. Wound culture grew Serratia marcescens, and she was treated with antibiotics. At her six-week postpartum visit, her wound was closed and the visit was unremarkable. Conclusions: CSEP is rare type of ectopic pregnancy with significant maternal morbidity and mortality risk. Scar tissue from a prior cesarean delivery is weaker and less vascular than the surrounding uterine wall. In rare cases, a CSEP embryo may have a heartbeat, leading to a difficult decision to either terminate the pregnancy or accept serious risks including hemorrhage, uterine rupture, PAS, cesarean hysterectomy. If expectant management is chosen, a multimodal team is essential to ensure the patient is receiving appropriate management.
Poiroux et al. (Sat,) studied this question.