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Abnormal placentation in caesarean scar ectopic pregnancy Melissa J Chen, 1 Eric C Huang, 2 Melody Y Hou 1 1 Department of Obstetrics and Gynecology, University of California, Davis School of Medicine, Sacramento, California, USA 2 Department of Pathology, University of California, Davis, Sacramento, California, USA Correspondence to Dr Melody Y Hou, [email protected] Accepted 17 October 2016 To cite: Chen MJ, Huang EC, Hou MY. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/bcr-2016- 217311 DESCRIPTION A multiparous woman aged 34 years with a prior low transverse caesarean delivery presented at 12 weeks gestation for nuchal translucency screen- ing. She had an unremarkable ultrasound study at 8 weeks gestation. Although asymptomatic at her screening, the patient had imaging findings suspi- cious for a caesarean scar ectopic, including loss of myometrial border between the placenta and uterine serosa on her ultrasound ( figure 1A) and MRI examinations ( figure 1B). The patient was counselled on her options, including continuing the pregnancy with further interventions at the time of delivery, medical management with intra-amniotic potassium chloride and systemic methotrexate, and hysterectomy. Since she had completed child bearing, she chose surgical treatment. A total abdominal hysterectomy was performed without complication. Intraoperative findings included a 14-week sized uterus with placenta implanting and penetrating the lower uterine segment ( figure 2). Histology revealed placenta increta with villi extending to 0.5 mm from the uterine serosa ( figure 3). Her recovery was uneventful. Caesarean delivery is associated with various complications, including abnormal placentation and caesarean scar pregnancies in subsequent gesta- tions. 1 A theory exists that caesarean scar pregnan- cies and abnormal placentation may be manifestations of the same disease process. 23 Our case provides further histological evidence of pla- cental increta after ultrasound diagnosis of caesar- ean scar pregnancy. With this knowledge, patient counselling regarding caesarean scar pregnancies should reflect that expectant management will likely result in abnormal placentation and its Figure 1 Loss of the myometrial border (M) between the placenta (P) and uterine serosa indicated with white arrowheads on ultrasonography (A) and black arrowheads on MRI (B), with uterine serosa and bladder (Bl) interface intact. Figure 2 Bivalved uterus with caesarean scar pregnancy. Note the placental implantation and thinning of the anterior lower uterine segment (white star). Chen MJ, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-217311 1 Images in …
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Abnormal placentation in caesarean scar ectopicpregnancyMelissa J Chen,1 Eric C Huang,2 Melody Y Hou1
1Department of Obstetrics andGynecology, University ofCalifornia, Davis School ofMedicine, Sacramento,California, USA2Department of Pathology,University of California, Davis,Sacramento, California, USA
Correspondence toDr Melody Y Hou,[email protected]
Accepted 17 October 2016
To cite: Chen MJ,Huang EC, Hou MY. BMJCase Rep Published online:[please include Day MonthYear] doi:10.1136/bcr-2016-217311
DESCRIPTIONA multiparous woman aged 34 years with a priorlow transverse caesarean delivery presented at12 weeks gestation for nuchal translucency screen-ing. She had an unremarkable ultrasound study at8 weeks gestation. Although asymptomatic at herscreening, the patient had imaging findings suspi-cious for a caesarean scar ectopic, including loss ofmyometrial border between the placenta anduterine serosa on her ultrasound (figure 1A) andMRI examinations (figure 1B). The patient wascounselled on her options, including continuing thepregnancy with further interventions at the time ofdelivery, medical management with intra-amnioticpotassium chloride and systemic methotrexate, andhysterectomy. Since she had completed childbearing, she chose surgical treatment. A totalabdominal hysterectomy was performed withoutcomplication. Intraoperative findings included a14-week sized uterus with placenta implanting andpenetrating the lower uterine segment (figure 2).Histology revealed placenta increta with villiextending to 0.5 mm from the uterine serosa(figure 3). Her recovery was uneventful.Caesarean delivery is associated with various
complications, including abnormal placentation andcaesarean scar pregnancies in subsequent gesta-tions.1 A theory exists that caesarean scar pregnan-cies and abnormal placentation may bemanifestations of the same disease process.2 3 Ourcase provides further histological evidence of pla-cental increta after ultrasound diagnosis of caesar-ean scar pregnancy. With this knowledge, patient
counselling regarding caesarean scar pregnanciesshould reflect that expectant management willlikely result in abnormal placentation and its
Figure 1 Loss of the myometrial border (M) between the placenta (P) and uterine serosa indicated with whitearrowheads on ultrasonography (A) and black arrowheads on MRI (B), with uterine serosa and bladder (Bl) interfaceintact.
Figure 2 Bivalved uterus with caesarean scarpregnancy. Note the placental implantation and thinningof the anterior lower uterine segment (white star).
Chen MJ, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-217311 1
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associated complications at the time of delivery. Prompt diagno-sis and treatment of caesarean scar pregnancies can minimisematernal morbidity and mortality.
Contributors MJC wrote and revised the manuscript. ECH created the pathologyimages, wrote the pathology description and revised the manuscript. MYH conceivedand revised the manuscript.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES1 Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of
cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review.Am J Obstet Gynecol 2012;207:14–29.
2 Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar pregnancy is a precursorof morbidly adherent placenta. Ultrasound Obstet Gynecol 2014;44:246–53.
3 Sinha P, Mishra M. Caesarean scar pregnancy: a precursor of placenta percreta/accreta. J Obstet Gynaecol 2012;32:621–3.
Figure 3 Placental villi (black arrows) penetrating the myometriumand extending to 0.5 mm from the serosa (inked black).
Learning points
▸ Caesarean scar pregnancies and abnormal placentation arelikely manifestations of the same disease process;accordingly, patients should be counselled that expectantmanagement will likely result in complications related toabnormal placentation, such as hysterectomy, at the time ofdelivery.
▸ Prompt diagnosis of caesarean scar pregnancy is importantfor early treatment to minimise maternal morbidity.
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2 Chen MJ, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-217311
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