Caesarean section scar pregnancy: a case series


  • Tan Ying An Department of Obstetrics and Gynaecology, Hospital Tuanku Jaafar, Jalan Rasah, Seremban, Malaysia
  • Kavitha Nagandla Department of Obstetrics and Gynaecology, IMU health Care, Associate Dean Academic affairs, International Medical University, 126, Jln Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur, Malaysia
  • Krishna Kumar Department of Obstetrics and Gynaecology, Fetal Medicine Specialist, Hospital Tuanku Jaafar, Jalan Rasah, Seremban, Malaysia
  • Akshatha Daniel West Middlesex University Hospital, Twickenham Rd, Isleworth, United Kingdom



Cesarean section, Scar pregnancy, Methotrexate, Serum β-hCG


Cesarean scar pregnancy is a rare type of ectopic pregnancy but potentially life threatening. The incidence of this ectopic pregnancy continues to rise due to global increase in cesarean sections rates as well as the diagnosis with wide use of transvaginal ultrasound. Delay or wrong diagnosis may result to uterine rupture and life-threatening bleeding with potential maternal morbidity and mortality.  Endo-vaginal ultrasound has a reported sensitivity of 85-90% for detection. In difficult cases, magnetic resonance imaging is often useful as second line imaging. Treatment may be ranging from conservative to medical therapy or surgery. We present a series of three illustrative cases successfully managed with medical management and sequential treatment of medical and surgical management. We discuss diagnostic challenges and review of literature on updates on management strategies.


Taran FA, Kagan KO, Hübner M, Hoopmann M, Wallwiener D, Brucker S. The Diagnosis and Treatment of Ectopic Pregnancy. Dtsch Arztebl Int. 2015;112(41):693-705.

Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Am Fam Physician. 2020;101(10):599-606.

Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. Ectopic pregnancies in a Caesarean scar: review of the medical approach to an iatrogenic complication. Hum Reprod Update. 2004;10(6):515-23.

Le Minh Tam TK, Linh TM, Thu PTM, Khanh TV, Anh NTK, Nguyen NTT, et al. Outcome of cesarean scar pregnancy treated with local methotrexate injection. Nagoya J Med Sci. 2020;82(1):15.

Timor-Tritsch IE, Monteagudo A, Cali G, El Refaey H, Kaelin Agten A, Arslan AA. Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester. Am J Obstet Gynecol. 2016;215(2):225.e1-7.

Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre NH. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril. 2016;105(4):958-67.

Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol. 2014;43(4):383-95.

Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean scar pregnancies: a systematic review of treatment options. J Minim Invasive Gynecol. 2017;24(6):915-25.

Kanat-Pektas M, Bodur S, Dundar O, Bakir VL. Systematic review: what is the best first-line approach for cesarean section ectopic pregnancy? Taiwan J Obstet Gynecol. 2016;55(2):263-9.

Wang H-Y, Zhang J, Li Y-N, Wei W, Zhang D-W, Lu Y-Q, et al. Laparoscopic management or laparoscopy combined with transvaginal management of type II cesarean scar pregnancy. JSLS. 2013;17(2):263-72.

Glenn TL, Bembry J, Findley AD, Yaklic JL, Bhagavath B, Gagneux P, et al. Cesarean scar ectopic pregnancy: current management strategies. Obstet Gynecol Surv. 2018;735(5):293-302.

Gonzalez N, Tulandi T. Cesarean scar pregnancy: a systematic review. J Minim Invasive Gynecol. 2017;24(5):731-8.

Hoffmann J, Exner M, Bremicker K, Grothoff M, Stumpp P, Schrey-Petersen S, et al. Cesarean section scar in 3T magnetic resonance imaging and ultrasound: image characteristics and comparison of the methods. Arch Gynecol Obstet. 2019;299(2):439-49.

Braileanu M, Wicks JM, Saindane AM. Appearance of an unusual ring enhancing brain capillary telangiectasia on 3.0T MRI with dynamic susceptibility contrast perfusion. Radiol Case Rep. 2020;15(8):1331-4.

Guo S, Wang H, Yu X, Yu Y, Wang C. The diagnostic value of 3.0T MRI in cesarean scar pregnancy. Am J Transl Res. 2021;13(6):6229-35.

Pristavu A, Vinturache A, Mihalceanu E, Pintilie R, Onofriescu M, Socolov D. Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series. BMC Pregnancy Childbirth. 2020;20(1):1-10.

Levin G, Zigron R, Dior UP, Gilad R, Shushan A, Benshushan A, et al. Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes. Reprod Biomed Online. 2019;39(5):827-34.

Bodur S, Özdamar Ö, Kılıç S, Gün I. The efficacy of the systemic methotrexate treatment in caesarean scar ectopic pregnancy: a quantitative review of English literature. J Obstet Gynaecol. 2015;35(3):290-6.

Wang S, Beejadhursing R, Ma X, Li Y. Management of Caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes. BMC Pregnancy Childbirth. 2018;18(1):289.

Jayaram PM, Okunoye GO, Konje J. Cesarean scar ectopic pregnancy diagnostic challenges and management options. Obstet Gynaecol. 2017;19(1):13-20.

Hoffman T, Lin J. Cesarean Scar Ectopic Pregnancy: Diagnosis with Ultrasound. Clin Pract Cases Emerg Med. 2020;4(1):65-8.

Heidar Z, Zadeh Modarres S, Abediasl Z, Khaghani A, Salehi E, Esfidani T. Cesarean scar pregnancy treatment: a case series. J Med Case Rep. 2021;15(1):506.

Jiang T, Liu G, Huang L, Ma H, Zhang S. Methotrexate therapy followed by suction curettage followed by Foley tamponade for caesarean scar pregnancy. Eur J Obstet Gynecol Reprod Biol. 2011;156:209-11.

Keung JJ, Spies JB, Caridi TM. Uterine artery embolization: A review of current concepts. Best Pract Res Clin Obstet Gynaecol. 2018;46:66-73.

Deans R, Abbott J. Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril. 2009;93(6):1735-40.

Maymon R, Svirsky R, Smorgick N, Mendlovic S, Halperin R, Gilad K, et al. Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy. J Ultrasound Med. 2011;30(9):1179-84.






Case Series