Volume 57, Number 8

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2002
by Lippincott Williams & Wilkins, Inc. CME REVIEWARTICLE 24
CHIEF EDITOR’S NOTE: This article is the 24th of 36 that will be published in 2002 for which a total of up to 36 Category 1
CME credits can be earned. Instructions for how credits can be earned appear on the last page of the Table of Contents.

Ectopic Pregnancy Within a Cesarean

Scar: A Review
Donald L. Fylstra, MD
Associate Professor of Obstetrics and Gynecology, Medical University of South Carolina, Charleston,
South Carolina

Implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of
ectopic pregnancy locations. Only 19 cases have been reported in the English medical literature
since 1966. If diagnosed early, treatment options are capable of preserving the uterus and subse-
quent fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture,
hysterectomy, and significant maternal morbidity. Although expectant and medical managements
have been reported, termination of a cesarean scar pregnancy by laparotomy and hysterotomy,
with repair of the accompanying uterine scar dehiscence, may be the best treatment option.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader will be able to define the entity of an
ectopic pregnancy within a cesarean delivery scar, to list the ultrasound findings used to make the
diagnosis of an ectopic pregnancy within a cesarean delivery scar, and to outline a potential management
plan for a patient with an ectopic pregnancy within a cesarean delivery scar.

Implantation of a pregnancy within the scar of a
previous cesarean delivery is the rarest form of ec-
topic pregnancy. Including a case treated by the
author, a computer MEDLINE and bibliography
search has yielded only 19 cases reported in the
English language from 1966 through January 2002.
The natural history of such a condition is unknown,
but uterine scar rupture and hemorrhage, even in the
first trimester, seems likely if the pregnancy is al-
lowed to continue, with possible serious maternal
morbidity and the possible need for hysterectomy
and loss of subsequent fertility. Presented are a re-
view of the reported cases, an analysis of etiologic
factors, and an appraisal of treatment options.
Endometrial and myometrial disruption or scarring
can predispose to abnormal pregnancy implantation.
When the placenta is implanted over the scar of a
Reprint requests to: Donald L. Fylstra, MD, Associate Professor
of Obstetrics and Gynecology, Medical University of South Caro-
lina, CSB 634F, 96 Jonathan Lucas Street, Charleston, South
Carolina 29425. Email: fylstrad@musc.edu
The author has disclosed no significant financial or other rela-
tionship with any commercial entity.
537
previous cesarean delivery, the risk of placenta ac-
creta is significantly increased (1–3). Trophoblast
adherence or invasion is enhanced when the scant
decidualization of the lower uterine segment is im-
paired further by previous myometrial disruption.
Cesarean delivery increases five-fold the incidence
of future placenta previa accreta, and the incidence
further increases with multiple previous cesarean de-
liveries (1, 2).
Implantation of a pregnancy within the uterine scar
of a prior cesarean delivery is different from an
intrauterine pregnancy with placenta accreta. Cesar-
ean scar implantation is a gestation completely sur-
rounded by myometrium, and the fibrous tissue of
the scar, and separated from the endometrial cavity
or fallopian tube. The mechanism that most probably
explains scar implantation, like intramural implanta-
tion, is invasion of the myometrium through a mi-
croscopic tract. With intramural pregnancy, such a
tract is believed to develop from the trauma of pre-
vious uterine surgery, such as curettage, cesarean
delivery, myomectomy, metroplasty, hysteroscopy,
538 Obstetrical and Gynecological Survey
and even manual removal of the placenta (1, 4, 5).
The time interval between such trauma and a subse-
quent pregnancy may impact upon implantation
events. Some of the reported cases were diagnosed
and treated within a few months of a prior cesarean
delivery (6, 7), suggesting that incomplete healing of
the uterine scar may contribute to scar implantation.
Early diagnosis with ultrasound can offer treatment
options capable of avoiding uterine rupture and hem-
orrhage and, thereby, preserve the uterus. The differ-
ential diagnosis between spontaneous abortion in
progress, cervico-isthmic pregnancy, and implanta-
tion within a cesarean cesarean scar can be difficult.
Strict ultrasound imaging criteria must be used to
assess the diagnosis of cesarean scar pregnancy. Ul-
trasound should reveal an empty uterine cavity, an
empty cervical canal, development of the gestational
sac in the anterior part of the uterine isthmus, and an
absence of healthy myometrium between the bladder
and sac, this last criterion allowing differentiation
from cervico-isthmic implantation (8).
REVIEW OF THE LITERATURE
The 19 reported cases of cesarean scar pregnancy
are summarized in Table 1. Larsen and Solomon (9)
reported the first case of a cesarean scar pregnancy in
1978, and successfully treated this case with laparot-
omy, hysterotomy resection, and uterine scar dehis-
cence repair. Five other case reports reveal primary
treatment success with laparotomy and hysterotomy
(10–14).
Systemic methotrexate as primary treatment for
cervical scar ectopic pregnancy has had some degree
of success. Ayoubi and colleagues (15) successfully
resolved a 10-week cesarean scar pregnancy with a
single dose of systemic methotrexate 10 days after a
failed attempted evacuation by curettage. Shufaro
and Nadjari (16) successfully treated a 7-week cesar-
ean scar pregnancy with a multidose methotrexate
protocol (1 mg/kg) with alternate day folinic acid
rescue.
Ravhon and colleagues (17) unsuccessfully treated
a living 8-week cesarean scar gestation with a single
dose of 50 mg/m2 of intramuscular methotrexate.
Despite declining hCG values, the patient continued
to have a bloody vaginal discharge, and ultrasound
revealed persistence of the gestational sac containing
amorphous tissue debris. Nine weeks after metho-
trexate, 10 ml of straw-colored fluid was aspirated
from the gestational sac by a transvaginal ultrasound-
guided needle, and the sac disappeared on ultrasound
3 months later.
Nawroth et al. (18) claim to have successfully
treated a 9-week cesarean scar pregnancy with a
combination of multidose systemic and direct injec-
tions of methotrexate. However, 105 days after the
methotrexate treatment, associated with heavy vagi-
nal bleeding, an embryo-like structure was passed.
The passage of such tissue suggests that the preg-
nancy communicated with the uterine cavity and may
have been, instead, a cervico-isthmic implantation.
Padavan and colleagues (19) reported successfully
terminating a 7-week cesarean scar pregnancy with
oral methotrexate after curettage. These authors ad-
mit that an accurate preoperative ultrasound exami-
nation was not possible because of the urgent need
for surgical intervention, and a true cervical or cer-
vico-isthmic implantation could not have been
excluded.
Limited success has also been achieved with a
direct injection of methotrexate or hyperosmolar glu-
cose into the cesarean scar pregnancy. Godin and
colleagues (8) reported the first case of cesarean scar
pregnancy diagnosed at 9 weeks of gestation with
ultrasound and magnetic resonance imaging (MRI)
and achieved primary treatment success with endo-
vaginal sonographic-guided local injection alone:
first 8 mEq of KCL injected into the embryo to stop
cardiac activity, followed by 60 mg of methotrexate
injected into the gestational sac. hCG levels fell
progressively to an undetectable level by 82 days,
with disappearance of any residual sac structure de-
tected on ultrasound by 96 days. Recognizing the
extremely slow absorption of the pregnancy after
systemic methotrexate reported by others (17), com-
menting in an editorial, these same authors believe
that direct sac injection more rapidly interrupts the
pregnancy (20). Because the cesarean scar pregnancy
is surrounded by fibrous scar rather than normally
vascularized myometrium, potentially limiting sys-
temic access, KCL and methotrexate injected directly
into the gestational sac may be more effective (20).
Seow and colleagues (21) reported the first case of
cesarean scar pregnancy after in vitro fertilization
and embryo transfer. Two weeks after uterine curet-
tage for a suspected inevitable abortion with pathol-
ogy containing chorionic villi, a 4-cm uterine saccu-
lus located within the isthmic area of the lower
anterior wall of the uterus, separated from the blad-
der by a 7.1 mm thickness, was observed on ultra-
sound with a serum hCG still greater than 23,000
mIU/ml. The sacculus was in the anatomical location
of the previous cesarean scar. With ultrasound guid-
ance, local injection of 50 mg of methotrexate into
TABLE 1 Case reports of Cesarean scar pregnancies
Treatment Subsequent
Weeks’ Gestation Pregnancy
Author(s) Year Presenting Symptoms Primary Diagnostic Tool at Diagnosis Primary Secondary Uterus Preserved Reported

Larson and Soloman (9) 1978 Hemorrhage after None Unknown Laparotomy/Hysterotomy None Yes
SAB curettagea
Rempen and Albert (10) 1990 Unknown Ultrasound 7 Laparotomy/Hysterotomy None Yes
Lai et al. (23) 1995 None Ultrasound (considered 7 Direct injection MTX (failed) Laparotomy/Hysterotomy Yes Yes
tubal ectopic)
Herman et al. (26) 1995 Vaginal bleeding Ultrasound 6 Expectant management Emergent laparotomy at 35 weeks No
Cesarean hysterectomy massive
blood loss
Ravhon et al. (17) 1997 Vaginal bleeding Ultrasound 8 Systemic MTX, 50 mg/m2 Aspiration of persistent sac Yes Yes
Godin et al. (8) 1997 Vaginal bleeding Ultrasound 9 Direct injection KCL, MTX None Yes
Roberts et al. (22) 1998 Vaginal bleeding Ultrasound, laparoscopy, 7 Direct injection 50% glucose plus oral None Yes
hysteroscopy MTX ⫻ 5 days
Valley et al. (12) 1998 Patient requested Ultrasound, laparoscopy 10 Laparotomy, Hysterotomy post-op None Yes
pregnancy single-dose MTX
interruption
Neiger et al. (13) 1998 Pain and vaginal Ultrasound, suction 8 Laparotomy/Hysterotomy None Yes Yes
bleeding curettage, laparoscopy
Huang et al. (6) 1998 Vaginal bleeding Ultrasound, curettage Unknown 3 months after cesar- Laparotomy/Hysterectomy None No
ean delivery
Padavan et al. (19) 1998 Pain and vaginal Ultrasound 7 Curettage and oral methotrexate ⫻ 3 None Yes
bleeding days
Marcus et al. (7) 1999 Pain and vaginal Ultrasound 13 Uterine artery embolization, Single-dose None No
bleeding MTX 4 days later,
Laparotomy/Hysterectomy
Lee et al. (24) 1999 Profuse bleeding Ultrasound, Unknown Operative Laparoscopy None Yes
after pregnancy hysteroscopy
interruption
Seow et al. (21) 2000 IVF-ET, D & C for Ultrasound 7 Direct injection MTX None Yes
inevitable abortion,
Persistent vaginal
Cesarean Scar Pregnancy Y CME Review Article

bleeding
Vial et al. (11) 2000 Pain and vaginal Ultrasound 6 Laparotomy/Hysterotomy None Yes Yes
bleeding
Ayoubi et al. (15) 2001 Vaginal bleeding Ultrasound 10 Curettage Systemic Methotrexate 1 mg/kg IM Yes
10 days after curettage
Shufaro and Nadjari (16) 2001 None Ultrasound, MRI 7 Multidose systemic MTX 1 mg/kg None Yes
alternate day folinic acid
Nawroth et al. (18) 2001 None Ultrasound 9 Systemic and local injection MTX None Yes
Fylstra et al. (14) 2002 Vaginal bleeding Ultrasound 8 Laparoscopy, laparotomy, hysterotomy None Yes
a
SAB ⫽ spontaneous abortion; IVF-ET ⫽ in vitro fertilization and embryo transfer; MTX ⫽ methotrexate; D & C ⫽ dilatation and curettage.
539
540 Obstetrical and Gynecological Survey

Fig. 1. Transvaginal ultrasound of early first trimester pregnancy implanted at the anatomical location of a previous cesarean section
scar.

the sac was performed. The gestational mass progres-
sively disappeared, with a gradual fall of hCG.
Roberts et al. (22) reported success with treating a
cesarean scar pregnancy with the direct injection of
hyperosmolar glucose followed by oral methotrexate.
Suspected on ultrasound examination at 7 weeks,
these authors decided to confirm the diagnosis with
laparoscopy and hysteroscopy. Laparoscopy revealed
no evidence of tubal ectopic pregnancy and the lower
uterine segment seemed normal. Hysteroscopy re-
vealed a normal uterine cavity except for a “salmon
red” appearance of the anterior lower uterine seg-
ment. With transvaginal ultrasound guidance, 3 ml of
50% glucose was injected directly into the gesta-
tional sac, followed by 2.5 mg of oral methotrexate
three times a day for 5 days. hCG levels fell to an
undetectable level within 6 weeks, with no evidence
of a residual sac on ultrasound.
Mistakenly diagnosing the condition as a tubal
ectopic pregnancy, Lai et al. (23) unsuccessfully
treated a living 7-week cesarean scar pregnancy with
50 mg of methotrexate injected directly into the
gestational sac. Despite the disappearance of cardiac
motion and declining hCG levels, 2 weeks after pri-
mary treatment, an emergency laparotomy was re-
quired because of severe pain and active vaginal
bleeding. Laparotomy revealed normal fallopian
tubes and ovaries, no intraperitoneal blood, and a
 Cesarean Scar Pregnancy Y CME Review Article 541

Fig. 2. Photograph of anterior view of uterus at laparotomy, revealing gestational sac within the uterine wall.

bulging gestational sac within a previous cesarean
scar. The gestational sac was resected by hysterot-
omy and the uterine defect repaired.
A woman who became pregnant 6 months after a
cesarean delivery and who was mistakenly diagnosed
with an intrauterine pregnancy at 8 weeks of gesta-
tion, developed pain and vaginal bleeding at 13
weeks, and cesarean scar implantation was con-
firmed with repeat ultrasound and MRI. Marcus et al.
(7) reported this case, 4 days before a planned lapa-
rotomy, treated this patient with uterine artery em-
bolization and 50 mg/m2 of systemic methotrexate, in
hopes of decreasing intraoperative blood loss and
avoiding hysterectomy. However, hysterectomy was
necessary at laparotomy.
Lee and colleagues (24) claim to have performed
the first successful laparoscopic resection of a cesar-
ean scar pregnancy. This woman, 2 weeks after a
dilatation and curettage abortion at an unspecified
gestational age, developed profuse vaginal bleeding.
542 Obstetrical and Gynecological Survey
hCG was negative for pregnancy and an abdominal
ultrasound revealed a well-encapsulated 7 ⫻ 5 cm
heteroechoic mass over the anterior uterine wall.
Diagnostic hysteroscopy revealed retained gesta-
tional tissue in the lower uterus with an otherwise
normal cavity. Laparoscopy revealed normal fallo-
pian tubes and ovaries and a normal-sized anteverted
uterus, but with a 5-cm bulging mass arising from the
serosa of the previous cesarean scar. Operative lapa-
roscopy was performed, incising the mass, removing
dark-reddish tissue later confirmed pathologically to
be necrotic chorionic villi. Bleeding was limited and
controlled with bipolar cautery, and the uterine de-
fect closed with endoscopic suturing. Without gesta-
tional age information and an ultrasound evaluation
before the original curettage abortion, and without
details of the original procedure, the possibility of
uterine perforation at the old cesarean scar site at the
time of curettage, and, therefore the cause of the
mass, cannot be excluded in this case report. Placenta
accreta in a cesarean scar can lead to uterine perfo-
ration during curettage (25).
Herman et al. (26) expectantly managed a cesarean
scar implantation. Although suspected with ultra-
sound at 7 weeks of gestation, the diagnosis was
more certain at 14 weeks. But at 14 weeks, the sac
seemed to be bulging toward the uterine cavity, and,
with no symptoms, expectant management was con-
tinued. Elective repeat cesarean delivery was planned
for 36 weeks of gestation, but severe abdominal pain
developed at 35 weeks necessitating urgent delivery.
A healthy infant was delivered, but cesarean hyster-
ectomy was required because of massive blood loss,
with coagulopathy and a 16-unit blood transfusion.
Inasmuch as maternal well being is the first priority,
despite the delivery of a healthy newborn infant,
these authors questioned the prudence of allowing
this pregnancy to continue.
SUMMARY
Although cesarean delivery is a very common pro-
cedure, implantation of a pregnancy within a cesar-
ean scar is a very rare occurrence. However, without
a high index of suspicion and early diagnosis with
endovaginal sonography, like other ectopic pregnan-
cies, this abnormal implantation can lead to rupture
and produce significant maternal morbidity and loss
of future fertility. Rupture can occur early in gesta-
tion and a delay in diagnosis potentially limits con-
servative treatment options.
Clinical history and endovaginal ultrasound can aid
in differentiating cesarean scar pregnancy from in-
complete abortion and cervico-isthmic pregnancy.
Precise localization of the early pregnancy by trans-
vaginal ultrasound should be encouraged in all pa-
tients with threatening gestational pathology. A sag-
ittal ultrasound view along the long axis of the
uterus, through the gestational sac, can localize pre-
cisely a cesarean scar implantation (Fig. 1).
Because of the rarity of this ectopic implantation,
there are no universal treatment guidelines for cesar-
ean scar pregnancy. All reports are single cases and
there is no consensus on which treatment is pre-
ferred. Although expectant management with deliv-
ery of a near-term, live-born infant has been reported
in cesarean scar pregnancy (26), this mother’s life
was threatened, and it seems prudent to interrupt
such a pregnancy as soon as the diagnosis can be
made with certainty.
Evacuation by curettage alone has been attempted,
but secondary salvage treatments have already
proven necessary (6, 9, 12, 13, 15, 19, 21, 24). Cu-
rettage seems contraindicated because the tropho-
blastic tissue is outside the uterine cavity unreachable
by the curette and curettage can potentially rupture
the uterine scar implantation and disrupt the myome-
trium leading to severe hemorrhage.
Nonsurgical treatment options, including systemic
and local methotrexate, KCL, and hyperosmolar glu-
cose, have been successful (8, 16, 18, 21, 22). How-
ever, because it is expected that a uterine scar dehis-
cence will accompany cesarean scar implantation
(Fig. 2) potentially affecting future pregnancies, only
surgical resection offers the opportunity to remove
the pregnancy and simultaneously repair the defect.
Such treatment has resulted in successful subsequent
pregnancies (11, 13, 23). Primary surgical treatment
by laparotomy and hysterotomy as soon as the diag-
nosis is confirmed may be the best treatment option.
REFERENCES
1. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for
placenta previa-placenta accreta. Am J Obstet Gynecol 1997;
177:210–4.
2. Chattopadhyay SK, Kharif H, Sherbeeni MM. Placenta praevia
and accreta after caesarean section. Eur J Obstet Gynecol
Reprod Biol 1993;52:151–6.
3. Chazotte C, Cohen WR. Catastrophic complications of previ-
ous cesarean section. Am J Obstet Gynecol 1990;163:738–
42.
4. McGowan L. Intramural pregnancy. JAMA 1965;192:637–638.
5. Fait G, Goyert G, Sundareson A et al. Intramural pregnancy
with fetal survival: Case history and discussion of etiologic
factors. Obstet Gynecol 1987;70:472–4.
6. Huang KH, Lee CL, Wang CJ et al. Pregnancy in a previous
cesarean section scar: Case report. Changgeng Yi Xue Za Zhi
1998;21:323–7.
 Cesarean Scar Pregnancy Y CME Review Article
7. Marcus S, Cheng E, Goff B. Extrauterine pregnancy resulting
from early uterine rupture. Obstet Gynecol 1999;94:804–5.
8. Godin PA, Bassil S, Donnez J. An ectopic pregnancy devel-
oping in a previous cesarian section scar. Fertil Steril 1997;
67:398–400.
9. Larsen JV, Solomon MH. Pregnancy in a uterine scar saccu-
lus—An unusual case of postabortal haemorrhage. A case
report. S Afr Med J 1978;28:142–3.
10. Rempen A, Albert P. Diagnosis and therapy of early preg-
nancy implanted in the scar of cesarean section. Z Geburt-
shilfe Perinatol 1990;194:46–8.
11. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar.
Ultrasound Obstet Gynecol 2000;16:592–3.
12. Valley MT, Pierce JG, Daniel TB et al. Cesarean scar preg-
nancy: imaging and treatment with conservative surgery. Ob-
stet Gynecol 1998;91:838–40.
13. Neiger R, Weldon K, Means N. Intramural pregnancy in a
cesarean section scar. A case report. J Reprod Med 1998;43:
999–1001.
14. Fylstra DL, Pound-Chang TD, Miller MG et al. Ectopic preg-
nancy within a cesarean section scar. A case report. Am J
Obstet Gynecol 2002. In press.
15. Ayoubi JM, Fanchin R, Meddoun M et al. Conservative treat-
ment of complicated cesarean scar pregnancy. Acta Obstet
Gynecol 2001;80:469–70.
16. Shufaro Y, Nadjari M. Implantation of a gestational sac in a
cesarean section scar. Fertil Steril 2001;75:1217.
17. Ravhon A, Ben-Chetrit A, Rabinowitz R et al. Successful
543
methotrexate treatment of a viable pregnancy within a thin
uterine scar. Br J Obstet Gynecol 1997;104:628–9.
18. Nawroth F, Foth D, Wilhelm L et al. Conservative treatment of
ectopic pregnancy in a cesarean section scar with methotrex-
ate: A case report. Eur J Obstet Gynecol 2001;99:135–37.
19. Padavan P. Lauri F, Marchetti M. Intrauterine ectopic preg-
nancy. A case report. Clin Exp Obstet Gynecol 1998;25:79–
80.
20. Donnez J, Godin PA, Bassil S. Successful methotrexate of a
viable pregnancy within a thin uterine scar (correspondence).
Br J Obstet Gynecol 1997;104:1216–7.
21. Seow KM, Cheng WC, Chuang J et al. Methotrexate for ce-
sarean scar pregnancy after in vitro fertilization and embryo
transfer. A case report. J Reprod Med 2000;45:754–7.
22. Roberts H, Kohlenber C, Lanzarone V et al. Ectopic pregnancy
in lower seg ment uterine scar. Aust N Z J Obstet Gynecol
1998;38:114–6.
23. Lai YM, Lee JD, Lee CL et al. An ectopic pregnancy embed-
ded in the myometrium of a previous cesarean section scar.
Acta Obstet Gynecol Scand 1995;74:573–6.
24. Lee CL, Wang CJ, Chao A et al. Laparoscopic management of
an ectopic pregnancy in a previous Caesarean section scar.
Hum Reprod 1999;14:1234–6.
25. Veridiano NP, Lopes J, Ohm HK et al. Placental percreta as a
cause of uterine perforation during abortion. J Reprod Med
1986;31:1049–50.
26. Herman A, Weinraub Z, Avrech O et al. Follow up and out-
come of isthmic pregnancy located in a previous caesarean
section scar. Br J Obstet Gynaecol 1995;102:839–41.