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IMPLANTATION IN PREVIOUS CAESAREAN SECTION SCAR: A CASE REPORT

uterine rupture is a life threatening condition, and associated with high morbidity and mortality if not recognized early and managed properly. Here we are reporting a case of spontaneous rupture of uterus in early second trimester, where placenta had implanted on the previous uterine scar and perforating to uterine surface, resulting in spontaneous uterine rupture.

Procedure done: Uterovesical fold pushed down, myometrium on the scar region given away with minimal touching, with placenta just underneath. Placenta is separated from both edges of the scar. Dead fetus of around 14-16 weeks size removed from uterine cavity. Margins of the previous scar region is cleaned, edges are trimmed, and sutured with vicryl no1 in two layers. Abdomen is closed in layers after securing hemostasis. Tubal ligation not done as patient is not willing at that time. Two units of blood transfusion given and patient discharged on 9th post-operative day in a stable condition.
DISCUSSION: Implantation of the gestational sac on the uterine scar may progress towards the cervico-isthmic surface or towards the uterine cavity. Distance between implantation site and the scar influences the risk of spontaneous abortion, placenta praevia, adherent placenta and postpartum hemorrhage. 2 If progress towards uterine cavity, expectant management is justified since pregnancy may continue to a viable birth, but with increased risk of life-threatening bleeding from the site of implantation. Placenta percreta in the subsequent pregnancies, considered to be more aggressive than placenta previa or accreta. If there is a deep implantation into a post-Caesarean section defect, it will progress towards uterine surface, resulting in rupture during the first trimester of pregnancy. Risk of late first-trimester life-threatening bleeding is increased if immediate treatment is not undertaken.
Pathogenesis: Blastocyst enters into the myometrium through a microscopic dehiscent tract, created through a trauma of a previous Caesarean section, any other uterine surgery or following manual removal of the placenta. Another mechanism for intramural implantation is IVF and embryo transfer, even in the absence of any previous uterine surgery. 3 Role of USG: After Caesarean, sometimes uterus gets adherent anteriorly and pulled superiorly out of the focal range of the vaginal transducer, negating the higher resolution. Therefore, TAS, with its more panoramic field of view, can be more helpful in demonstrating the true nature of the pathology.
Sonographic diagnosis of pregnancy in scar: 4 I. An empty uterus; II. An empty cervical canal; III. On a sagittal view discontinuity in the anterior uterine wall while running through the amniotic sac. IV. The gestational sac on the anterior part of the isthmic portion of the uterus with a diminished myometrial layer between the bladder and the sac. V. Prominent peritrophoblastic flow on Doppler flow sonography.
Treatment options: currently, there is no consensus regarding the optimal management of patients with Caesarean scar ectopic pregnancies. 5 1. Methotrexate treatment if diagnosed early. A) sonographically guided intra-amniotic injection of 25 mg (MTX)/I.M. MTX only).B) (systemic) administration of (50 mg/m 2 ) on the basis of actual body weight. 6 2. combined potassium chloride (KCl) injections directly into the fetal thorax, with MTX being injected into the sac and the surrounding myometrium. 7 3. Tran's cervical aspiration of the gestational sac with advice of early pregnancy scans for future pregnancies. 4. Hysterectomy and excision of the pregnancy located in the scarred uterus. 5. Expecting line of management: It may progress to term with associate complications like rupture, placental adherence, and PPH. 6. A minimally invasive approach that has recently been described is endoscopic surgery (Lee et al., 1999), 8 includes hysteroscopy for visualizing the uterine cavity combined with incision and aspiration of the ectopic mass by operative laparoscopy.
CONCLUSION: Scar implantation in caesarean scar is relatively rare condition . With the advent of sonography and with the use of saline infusion, post-Caesarean section uterine wall integrity can be detected even in the non-pregnant state. Caesarean section scar defect, defined by the presence of fluid within the incision site or any filling defect ('niche'), defined as a triangular anechoic structure at the presumed site of the scar might alert for uterine scar complication in the subsequent pregnancy 9,10 Our patient did not undergone USG earlier and presented with early second trimester uterine rupture because of scar implantation. Timely intervention and surgery had saved her life.