Ultrasound Obstet Gynecol 2004; 23: 247–253

Published online 17 February 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.974

Cesarean scar pregnancy: issues in management

K.-M. SEOW*‡§, L.-W. HUANG*, Y.-H. LIN*‡, M. YAN-SHENG LIN¶, Y.-L. TSAI*
and J.-L. HWANG*†
*Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital and †Taipei Medical University, Taipei, ‡School of
Medicine, Fu-Jen Catholic University, Hsinchuang, Taipei Hsien, §Department of Obstetrics and Gynecology, Li Shin Hospital, Pingjen,
Taoyuan County and ¶Department of Obstetrics and Gynecology, Chi-Mei Hospital, Tainan, Taiwan

K E Y W O R D S: Cesarean scar pregnancy; methotrexate; transvaginal color Doppler imaging

ABSTRACT Conclusion Ultrasound-guided methotrexate injection

Objective To evaluate our experience with the diagnosis
and treatment of Cesarean scar pregnancy.
Methods During a 6-year period, 12 cases of Cesarean
scar pregnancy were diagnosed using transvaginal color
Doppler sonography and treated conservatively to
preserve fertility. Incidence, gestational age, sonographic
findings, β-human chorionic gonadotropin (β-hCG) levels,
flow profiles of transvaginal color Doppler ultrasound,
and methods of treatment were recorded.
Results The incidence of Cesarean scar pregnancy was
1 : 2216 and its rate was 6.1% in women with an
ectopic pregnancy and at least one previous Cesarean
section. Gestational age at diagnosis ranged from 5 + 0
to 12 + 4 weeks. The time interval from the last Cesarean
section to the diagnosis of Cesarean scar pregnancy
ranged from 6 months to 12 years. High-velocity and
low-impedance subtrophoblastic flow (resistance index,
0.38) persisted until β-hCG declined to normal. Patients
were treated as follows: transvaginal ultrasound-guided
injection of methotrexate into the embryo or gestational
sac (n = 3), transabdominal ultrasound-guided injection
of methotrexate (n = 2), transabdominal ultrasound-
guided injection of methotrexate followed by systemic
methotrexate administration (n = 2), systemic methotrex-
ate administration alone (n = 2), dilatation and curettage
(n = 2), or local resection of the gestation mass (n = 1).
Eleven of the 12 patients preserved their reproductive
capacity; the remaining patient, treated by dilatation and
curettage, underwent a hysterectomy because of profuse
vaginal bleeding. The Cesarean scar mass regressed from
2 months to as long as 1 year after treatment. Uterine
rupture occurred in one patient during the following
pregnancy at 38 + 3 weeks’ gestational age.
emerges as the treatment of choice to terminate Cesarean
scar pregnancy. Surgical or invasive techniques, including
dilatation and curettage are not recommended for
Cesarean scar pregnancy due to high morbidity and
poor prognosis. Copyright  2004 ISUOG. Published
by John Wiley & Sons, Ltd.
INTRODUCTION
Cesarean scar pregnancy is defined as an ectopic
pregnancy embedded in the myometrium of a previous
Cesarean scar1 . The incidence of Cesarean scar pregnancy
is extremely low. A review of the published literature from
January 1966 to October 2001 was performed by means
of a computerized database search of MEDLINE. Medical
subject heading search words used were ‘Cesarean scar’
+ ‘ectopic pregnancy’ and the search was limited to the
English language. This was supplemented by a manual
search of the reference lists of the articles for additional
relevant case reports. Our search produced only 15
articles1 – 15 .
Ultrasound permits earlier and accurate diagno-
sis of Cesarean scar pregnancy, allowing successful
preservation of the uterus without causing maternal
complications2,8,12,13 . Treatments include local resection
of the ectopic gestational mass, dilatation and curet-
tage (D&C), and systemic or local administration of
methotrexate. We present our experience with 12 patients
with Cesarean scar pregnancy diagnosed using transvagi-
nal color Doppler ultrasound during a 6-year period and
treated conservatively to preserve the uterus.
METHODS
From January 1995 to December 2000, a total of 642
ectopic pregnancies was diagnosed in Shin Kong Wu

Correspondence to: Dr Y.-L. Tsai, Department of Obstetrics and Gynecology, Shin-Kong Wu Ho-Su Memorial Hospital, No. 95, Wen
Chang Road, Shin Lin District, Taipei, Taiwan, R.O.C (e-mail: M002249@ms.skh.org.tw)
Accepted: 20 May 2003

Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
248
Ho-Su Memorial Medical Referral Center. Among these,
198 patients had a previous Cesarean section before
the ectopic pregnancy; 12 of these were diagnosed with
Cesarean scar pregnancy using transvaginal ultrasound.
During this 6-year period, a total of 26 596 newborns was
delivered in our hospital; 7980 of these deliveries were via
Cesarean section. The Cesarean section rate was 30%.
The diagnosis of Cesarean scar pregnancy was
confirmed if all of the following sonographic criteria were
met: (1) the uterus was empty, with clearly demonstrated
endometrium; (2) the cervical canal was empty, without
a gestational sac or ballooning at the early diagnosis;
(3) the gestational sac showed the ‘double ring’ sign in
the anterior part of the isthmic portion of the uterus;
(4) the gestational sac, with or without cardiac activity,
was embedded and surrounded by the myometrium, the
fibrous tissue of the scar, and it was separated from
the endometrial cavity or Fallopian tube (Figure 1). This
is different from a normally eccentric lower segment
implantation in which the main gestational sac is located
in the endometrial canal.
After counseling about the risk of hysterectomy,
all patients underwent conservative treatment including
methotrexate injection, D&C, or wedge resection of the
ectopic pregnancy, because preservation of fertility was
desired.
The method of treatment was according to the decision
made by the individual physicians. This study was
reviewed and approved by the institutional review board
of Shin Kong Wu Ho-Su Memorial Medical Center. All
patients gave informed consent before treatment.
Local methotrexate injection under transabdominal
ultrasound guidance was performed using a 22-gauge long
needle (Tokyo Co., Tokyo, Japan). Using a needle guide,
1 mg/kg methotrexate was injected into the chorionic
Figure 1 Transvaginal ultrasound image of a Cesarean scar
pregnancy at 6 + 1 weeks, with cardiac activity (Case 10;
crown–rump length, 6.3 mm). A sac is visible within the
myometrium of the retroverted uterus with the endometrial and
cervical canals both empty (arrows). The bladder wall
(arrowheads) is seen anterior to the gestational sac.
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
Seow et al.
Figure 2 Image of puncture line for transvaginal ultrasound-guided
local methotrexate injection in Case 12.
sac or embryo. This procedure was performed without
anesthesia. Just prior to methotrexate injection, the
chorionic sac cavity, amniotic fluid and gestational tissues
were aspirated. Penetration of the bladder by the needle
was avoided during the procedure.
To reduce the patient’s discomfort and anxiety, local
methotrexate injection under transvaginal ultrasound
guidance was performed under general anesthesia with
the patient in the lithotomy position. The gestational sac
was punctured and aspirated under transvaginal sono-
graphic guidance using a double-lumen ovum aspiration
needle (ECHO-Tip, Cook, Sydney, Australia) (Figure 2).
Afterwards, 1 mg/kg methotrexate was injected slowly,
resulting in a hyperechogenic area in the region of the
former gestational sac.
β-hCG testing was performed daily during hospital-
ization and weekly thereafter, until the level returned to
< 5 mIU/mL.
Transvaginal sonography using a Toshiba SSA-270A
scanner (Toshiba Co., Tokyo, Japan) equipped with a
6.25-MHz vaginal probe with color and pulsed wave
Doppler was used to monitor subtrophoblastic blood flow
velocity. Vascular pattern, vascular waveform, pulsatility
index, resistance index and peak systolic velocities were
checked weekly until no subtrophoblastic blood flow
velocity could be detected. The diameter of the Cesarean
scar ectopic pregnancy mass was measured in centimeters
if it persisted.
RESULTS
Data are presented in Table 1. The mean age of the
patients was 32 (range, 27–41) years. The time interval
between the current Cesarean scar pregnancy and the
previous Cesarean section ranged from 6 months to
12 years. Gestational age at diagnosis ranged from
5 + 0 weeks to 12 + 4 weeks. Five gestational sacs
showed cardiac activity. With the exception of Case
5, in which the pregnancy was the result of in-vitro
Ultrasound Obstet Gynecol 2004; 23: 247–253.
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.

Cesarean scar pregnancy

Table 1 Clinical data of patients with conservative treatment of Cesarean scar pregnancy

Gestational Cardiac Time after Time after

Time interval age at activity Initial treatment for treatment for
Age from last diagnosis in gestational β-hCG level β-hCG to reach flow* to disappear
Case (years) C/S (years) (weeks) sac (Yes/No) (mIU/mL) Type of treatment normal level (days) (days) Pertinent follow-up information

1 29 3 7+6 No 35 927 D&C 36 — Hysterectomy due to massive bleeding during

D&C. Microscopic findings: chorionic villi
and trophoblastic tissue inside the dense and
fibrotic myometrium.
2 35 13 & 10 7+4 Yes 19 755 Wedge resection 21 — No residual tissue. Microscopic findings: the
myometrium adjacent to the chorionic villi
showed dense interstitial fibrosis.
3 31 7 7+3 No 36 023 TAS local MTX + 188 117 Disappearance of ectopic mass after 8 months.
systemic MTX
4 30 7&4 5+0 No 3 217 Systemic MTX 30 14 Disappearance of ectopic mass after 2 months.
5† 41 12 6+1 No 23 328 TAS local MTX + 76 90 IVF treatment. Disappearance of ectopic mass
systemic MTX after 1 year.
6 28 5 6+0 Yes 16 628 TAS local MTX 56 70 Disappearance of ectopic mass after 6 months.
7 35 5&3 6+4 Yes 19 086 TAS local MTX 75 85 Disappearance of ectopic mass after 4 months
8 31 1.5 12 + 4 No 58 400 D&C + cervical balloon 63 58 Blood loss 1000 mL during D&C; 3 months
tamponade later patient was pregnant again but died
due to uterine rupture at 38 + 3 weeks.
9 30 0.5 8+4 Yes 47 752 TVS local MTX 117 130 Persistent ectopic mass for 5 months
Ultrasound Obstet Gynecol 2004; 23: 247–253.

(4.5 × 3.82 cm).

10 27 4 6+1 Yes 24 195 TVS local MTX 78 92 Persistent ectopic mass for 4.5 months
(2.24 × 1.75).
11 36 2 5+2 No 4 280 Systemic MTX 36 45 Persistent ectopic mass for 10 months
(2.11 × 1.51 cm).
12 32 8 6+2 No 20 122 TVS local MTX 76 85 Resolution of ectopic mass after 1 year.

*Subtrophoblastic flow. †This pregnancy was induced by in-vitro fertilization and embryo transfer. C/S, Cesarean section; D&C, dilatation and curettage, IVF, in-vitro fertilization; MTX,
methotrexate; TAS, transabdominal ultrasound guidance; TVS, transvaginal ultrasound guidance.

249
250
fertilization–embryo transfer, the patients conceived
naturally. All patients complained of vaginal bleeding,
and six had accompanying abdominal pain at the time of
diagnosis; this is the reason these patients were referred
to our medical center.
The patient in Case 1 underwent a D&C for
suspected incomplete miscarriage, since the gestational
sac was located in the lower segment of the uterus.
Uncontrolled bleeding of about 1000 mL occurred
during the procedure, and an emergency hysterectomy
was performed. During the hysterectomy, inadvertent
perforation occurred during bladder separation. The
microscopic findings revealed many chorionic villi and
trophoblastic tissue inside the dense, interstitial, fibrotic
myometrium.
A D&C was also performed in Case 8. This woman
was only diagnosed with Cesarean scar pregnancy at
12 + 4 weeks of gestation due to the misdiagnosis of
inevitable miscarriage. The gestational sac measured
6.37 cm in diameter and was located within the isthmus
area. Profuse bleeding estimated to be 1000 mL occurred
within a 10-min period during the D&C. A Foley catheter
balloon filled with 50 mL normal saline was used for
tamponade, and the uterus was successfully preserved.
Transvaginal color Doppler imaging of the patient
in Case 8 demonstrated a complex vascular mass with
an area of neovascularization surrounding the placental
area in the lower uterine segment. A high peak systolic
velocity of 65.2 cm/s and low impedance (mean resistance
index, 0.38) were observed at the time of diagnosis
(Figure 3). This low impedance and high subtrophoblastic
flow velocity was consistent with a normal intrauterine
pregnancy and remained unchanged until the serum β-
hCG declined to normal. Thereafter, this unique area
of vascular flow decreased progressively and disappeared
within 2 weeks.
The residual ectopic Cesarean scar persisted in-situ for
several months after conservative treatment even though
β-hCG had declined to a normal limit (Figure 4). The
mass regressed from 2 months to as long as 1 year after
the treatment.
Figure 3 Doppler velocimetry demonstrated (Case 8) that
high-velocity (peak systolic velocity, 65.2 cm/s) and low-impedance
(resistance index, 0.38) turbulent blood flow was prominent and
surrounded the Cesarean scar gestational mass.
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
Seow et al.
Figure 4 Ultrasound image showing a persistent Cesarean scar
mass (Case 3) with a diameter of 1.79 × 2.13 cm found during
follow-up 3 months after treatment.
The uterus was preserved in 11 of the 12 patients,
and the patient in Case 8 had a subsequent intrauterine
pregnancy 3 months later, with normal implantation of
the gestational sac. She was followed up regularly during
the pregnancy. She refused an early Cesarean section at
36 weeks because the fetus would have had a low birth
weight. Unfortunately, this patient had a uterine rupture
at 38 + 3 weeks of gestation. Despite resuscitation she
died due to hypovolemic shock secondary to internal
bleeding and the fetus was stillborn.
DISCUSSION
Cesarean scar pregnancy is a rare form of ectopic
pregnancy, and its incidence in our institution may
have been increased because of the increased rate of
Cesarean sections performed. The incidence of Cesarean
scar pregnancy was 1 : 2216 (12/26 596) in this study
and its rate was 6.1% (12/198) for women with an
ectopic pregnancy and at least one previous Cesarean
section; the incidence of Cesarean scar pregnancy in
women with a previous Cesarean section was 0.15%
(12/7980). There are two reasons why the incidence of
Cesarean scar pregnancy is high in our hospital. First,
our hospital is a tertiary referral medical center in a
local district to where many women who have abnormal
or ectopic pregnancies are referred for further diagnosis
and treatment. Second, the high frequency with which
transvaginal ultrasound is used early in pregnancy leads
to early diagnosis of abnormal pregnancies. If we exclude
two patients referred from another hospital, the incidence
of Cesarean scar pregnancy was 1 : 2656 (10/26 596) and
its rate was 5.05% (10/198) for women with an ectopic
pregnancy and at least one previous Cesarean section; the
incidence of Cesarean scar pregnancy in women with a
previous Cesarean section was 0.13% (10/7980).
The exact cause of Cesarean scar pregnancy is still
unknown. Nonetheless, its occurrence may be linked to
Ultrasound Obstet Gynecol 2004; 23: 247–253.
Cesarean scar pregnancy
an existing scar defect or microscopic dehiscent tract
generated between the prior Cesarean scar and the
endometrial canal4 . Such tracts or wedge defects, likely
resulting from previous Cesarean sections, can be detected
with transvaginal sonography even several years following
the Cesarean section16 and their depth or size can be
measured with saline infusion sonohysterography17 . The
conceptus enters and implants in the myometrium through
this ‘ectopic tract’. We are not sure whether the risk of
Cesarean scar pregnancy is related to the number of
previous Cesarean sections. Nine of the patients had only
one prior Cesarean section and the other three (25%)
had two prior Cesarean sections, and two of the women
had a history of intrauterine device (IUD) use, whereas
three others had a history of previous pelvic inflammatory
disease. Nonetheless, we did not find a close relationship
between these factors and the risk of Cesarean scar
pregnancy due to the small number of patients in this
study. Further study is required to assess the risk of IUD
use and pelvic inflammatory disease in Cesarean section
ectopic pregnancy.
Clinical history can aid in differentiating Cesarean
scar pregnancy from a failed chorionic sac and non-
live embryo passing through the lower uterine segment
and the cervix. All our patients complained of vaginal
bleeding but only half of the patients had accompanying
mild to moderate abdominal pain at the time of diagnosis.
Cesarean scar pregnancy differs from a spontaneous or
inevitable miscarriage in which the volume of bleeding is
often greater due to detachment of a failed chorionic sac
in the lower uterine segment and the cervix. Moreover,
most patients with inevitable abortion will have cramp-
like lower abdominal pain and some have cervical motion
or adnexal tenderness18 .
Sonography is the first-line diagnostic tool for Cesarean
scar pregnancy. Transvaginal ultrasound equipped with
color Doppler imaging may serve as an additional tool to
augment the diagnostic capabilities of transvaginal ultra-
sound; high-velocity, prominent, low-impedance blood
flow can be detected surrounding an ectopic gestational
sac, consistent with normal early pregnancy19 . With
pulsed Doppler functions, more physiological informa-
tion such as flow pattern and resistance and pulsatility
indices can be obtained on the peritrophoblastic vascula-
ture. This information can help to confirm or exclude the
diagnosis of an ectopic pregnancy.
The early diagnosis of Cesarean scar pregnancy led
to a high success rate of conservative treatment with
local methotrexate administration alone6,7,20,21 . Direct
local injection of methotrexate into the amniotic cavity of
a Cesarean scar pregnancy using either transabdominal
or transvaginal ultrasound-guided injection showed
excellent outcomes4,13 . In our experience, the transvaginal
approach is preferable for treating Cesarean scar ectopic
pregnancy because it allows for a shorter distance to
the gestational sac, approaching from the vagina rather
than through the abdomen. The transabdominal route
was used only in the first four patients due to insufficient
experience with transvaginal procedures. Moreover, the
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
251
thin 22-gauge needle used in abdominal puncture made
the process of aspiration of gestation tissue difficult.
In contrast, the transvaginal approach with the thick
double-lumen IVF needle made the process of aspiration
easier. Local methotrexate administration increases the
success rate due to the high concentration of methotrexate
deposited in the lesion, avoiding the side effects produced
with systemic administration22 . The same treatment
principles of local methotrexate injection that we used
in our patients with Cesarean scar ectopic pregnancy have
been used in other ectopic pregnancies, such as cornual
or cervical pregnancies, with similar outcomes23,24 .
Side effects associated with methotrexate treatment,
such as pneumonitis, alopecia, nausea or stomatitis, were
not experienced by our patients because each patient
received no more than two doses of methotrexate25 .
Systemic methotrexate injection seemed to be effective
for patients with β-hCG levels less than 5000 IU/mL.
Surgical or invasive techniques, including D&C, were not
recommended for Cesarean scar pregnancy due to high
morbidity and poor prognosis, except for cases of failure
of conservative treatment1 or rupture of the uterus due
to delayed diagnosis. The surgical methods were used
only in Cases 1, 2 and 8, but the outcome was dismal.
Although some authors26,27 have advocated expectant
management of selected ectopic pregnancies, we do not
believe that this approach should be used for Cesarean
scar pregnancies, which are prone to catastrophic rupture
and high β-hCG levels (3217–58 400 mIU/mL in our
study). Expectant management achieved a high success
rate (60%) in ectopic pregnancies when the starting
β-hCG level was < 2000 mIU/mL, whereas in 93.3%
of patients with an initial β-hCG level > 2000 mIU/mL
expectant management failed27 . The ectopic mass grows
progressively without spontaneous resolution if the
ectopic scar pregnancy is left untreated or incompletely
treated, whether or not there is cardiac activity3,11,13 .
Serial transvaginal color Doppler ultrasound examina-
tion was useful in monitoring Cesarean scar pregnancies
and appeared to correlate well with serum β-hCG lev-
els. The high-velocity, low-impedance, turbulent flow
remained prominent without much change during the
course of the follow-up, until the β-hCG level returned
to normal. Those patients with such flow characteristics
should be advised of the risk of uterine rupture with
internal bleeding1,28 due to the high-velocity flow, even
if β-hCG progressively declines during follow-up28 . Fur-
thermore, the high peak systolic velocity of the patient in
Case 8 should have been a clear warning to the physician
not to perform D&C to terminate the ectopic pregnancy
due to the danger of profuse bleeding from such an area
of high-flow velocity.
Spontaneous uterine rupture has been reported in
patients with prior Cesarean section29 . Women with prior
Cesarean section were 17 times more likely to experience
uterine rupture than were those with an unscarred
uterus30 . The risk of uterine rupture may be higher
after the implantation of a pregnancy in the thin uterine
scar5 . It is also unpredictable as to which kind of uterine
Ultrasound Obstet Gynecol 2004; 23: 247–253.
252
scar is prone to complications in such a situation and
when they might occur. Uterine rupture still unfortunately
occurred in Case 8 despite the fact that weekly ultrasound
examination of the uterine scar thickness was performed
on the patient during the third trimester, and the
thickness of the uterine scar remained 1.5 cm in diameter
1 week before the occurrence of the rupture. Uterine
scar thickness is not the only risk factor for uterine
rupture in women with prior Cesarean sections5,31 .
Fertile patients in whom Cesarean scar pregnancy has
occurred should be advised of the risk of uterine rupture
when there is a sudden onset of lower abdominal
pain during the course of pregnancy, especially in the
mid-third trimester. Some authors have recommended
surgical repair of the scar before the next conception
following methotrexate treatment5,12 . However, reports
of pregnancy outcome after such an occurrence are
rare. Furthermore, repair of the uterine laparotomy scar
may not prevent the occurrence of uterine rupture in
the subsequent pregnancy32 . In fact, in the absence of
further reports on similar complications, we do not advise
laparotomy for suturing the scar or arrange an emergency
hysterectomy to terminate an ectopic pregnancy in
favor of conservative treatment. However, a subsequent
pregnancy should be avoided for more than 3 months
and probably 1 or 2 years. For the pregnancy following
a Cesarean scar pregnancy, we prefer an early Cesarean
section be done as soon as the fetal lungs become mature,
to avoid the possibility of spontaneous uterine rupture.
We cannot predict when the Cesarean scar mass
completely resolves after conservative treatment; we
found that some masses persisted for several months. One
possible explanation for this is that the scanty venous flow
within the fibrous scar tissue made the reabsorption of
residual gestational tissue difficult. A second mechanism
might be related to the proliferation of collagen fiber
or fibrous tissue in the isthmic portion of the uterus in
response to myometrial injury induced by placental villi
invasion.
In summary, Cesarean scar pregnancy is a very unusual
and possibly life-threatening complication of pregnancy.
We hope that we have demonstrated that transvaginal
color flow Doppler ultrasound can contribute to a clear,
early diagnosis and effective non-surgical management
and follow-up of Cesarean scar pregnancy. This helps
to preserve fertility and avoid catastrophic complications
because of delayed treatment. Uterine rupture is a possible
but rare complication in the subsequent pregnancy. Early
Cesarean section is recommended as soon as maturity of
the fetal lungs is achieved.
REFERENCES
1. Lai YM, Lee JD, Lee CJ, Chen TC, Soong YK. An ectopic
pregnancy embedded in the myometrium of a previous cesarean
section. Acta Obstet Gynecol Scand 1995; 75: 573–576.
2. Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R,
Bukovsky Y. Follow up and outcome of isthmic pregnancy
located in a previous caesarean section scar. Br J Obstet
Gynaecol 1995; 102: 839–841.
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
Seow et al.
3. Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus:
an unusual cause of postabortal hemorrhage. S Afr Med J 1978;
53: 142–143.
4. Godin PA, Bassil S, Donnez J. An ectopic pregnancy developing
in a previous cesarean section scar. Fertil Steril 1997; 67:
398–400.
5. Ravhon A, Ben-Chetrit A, Rabinowitz R, Neuman M, Beller U.
Successful methotrexate treatment of a viable pregnancy within
a thin uterine scar. Br J Obstet Gynaecol 1997; 104: 628–629.
6. Rempen A. An ectopic pregnancy embedded in the myometrium
of a previous cesarean section scar. Acta Obstet Gynecol Scand
1997; 5: 492.
7. Valley MT, Pierce JG, Daniel TB, Kaunitz AM. Cesarean scar
pregnancy: imaging and treatment with conservative surgery.
Obstet Gynecol 1998; 91: 838–840.
8. Padovan P, Lauri F, Marcetti M. Intrauterine ectopic preg-
nancy. A case report. Clin Exp Obstet Gynecol 1998; 25:
79–80.
9. Neiger R, Weldon K, Means N. Intramural pregnancy in a
cesarean section scar: A case report. J Reprod Med 1998;
43: 999–1001.
10. Huang KH, Lee CL, Wang CJ, Soong YK, Lee KF. Pregnancy
in a previous cesarean section scar: Case report. Changgeng Yi
Xue Za Zhi 1998; 21: 323–327.
11. Lee CL, Wang CJ, Chao A, Yen CH, Soong YK. Laparoscopic
management of an ectopic pregnancy in a previous caesarean
section scar. Hum Reprod 1999; 14: 1234–1236.
12. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar.
Ultrasound Obstet Gynecol 2000; 16: 592–593.
13. Seow KM, Cheng WC, Chuang J, Lee C, Tsai YL, Hwang JL.
Methotrexate for cesarean scar pregnancy following in vitro
fertilization and embryo transfer: A case report. J Reprod Med
2000; 45: 754–757.
14. Nawroth F, Foth D, Wilhelm L, Schmidt T, Warm M, Romer T.
Conservative treatment of ectopic pregnancy in a cesarean sec-
tion scar with methotrexate: a case report. Eur J Obstet Gynecol
Biol 2001; 99: 135–137.
15. Ayuobi JM, Fanchin R, Meddoun M, Fermandez H, Pons JC.
Conservative treatment of complicated cesarean scar pregnancy.
Acta Obstet Gynecol Scand 2001; 80: 469–470.
16. Chen HY, Chen SJ, Hsieh FJ. Observation of cesarean section
scar by transvaginal ultrasonography. Ultrasound Med Biol
1990; 16: 443–447.
17. Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion
sonohysterography in nonpregnant women with previous
cesarean delivery: the ‘‘niche’’ in the scar. J Ultrasound Med
2001; 20: 1105–1115.
18. Farrell RG, Stonington DT, Ridgeway RA. Incomplete and
inevitable abortion: treatment by suction curettage in the
emergency department. Ann Emerg Med 1982; 11: 652–658.
19. Jurkovic D, Jauniaux E, Kurjak A, Hustin J, Campbell S, Nico-
laides KH. Transvaginal color Doppler assessment of the utero-
placental circulation in early pregnancy. Obstet Gynecol 1991;
77: 365–369.
20. Feichtinger W, Kemeter P. Conservative treatment of ectopic
pregnancy by transvaginal aspiration under sonographic control
and methotrexate injection. Lancet 1987; 1: 381–382.
21. Yankowitz J, Leake J, Huggins G, Gazaway P, Gates E. Cer-
vical ectopic pregnancy: Review of the literature and report
of a case treated by single dose methotrexate therapy. Obstet
Gynecol Surv 1990; 45: 405–414.
22. Schiff E, Shalev E, Bustan M, Tsabari M, Mashiach S, Weiner E.
Pharmacokinetics of methotrexate after local tubal injection for
conservative treatment of ectopic pregnancy. Fertil Steril 1992;
57: 688–690.
23. Timor-Tritsch IE, Monteagudo A, Matera C, Veit CR. Sono-
graphic evaluation of cornual pregnancies treated without
surgery. Obstet Gynecol 1992; 79: 1044–1049.
24. Palti Z, Rosenn B, Goshen R, Ben-Chitrit A, Yagel S. Successful
treatment of a viable cervical pregnancy with methotrexate. Am
J Obstet Gynecol 1989; 161: 1147–1148.
Ultrasound Obstet Gynecol 2004; 23: 247–253.
Cesarean scar pregnancy
25. Stovall TG. Medical management should be routinely used as
primary therapy for ectopic pregnancy. Clin Obstet Gynecol
1995; 38: 346–352.
26. Garcia AJ, Aubert JM, Sama J, Josimovich JB. Expectant man-
agement of presumed ectopic pregnancies. Fertil Steril 1987; 48:
395–400.
27. Shalev E, Peleg D, Tsabari A, Romano S, Bustan M. Sponta-
neous resolution of ectopic tubal pregnancy: natural history.
Fertil Steril 1995; 63: 15–19.
28. Montgomery Irvine L, Padwick ML. Serial serum HCG mea-
surements in a patient with an ectopic pregnancy: a case for
caution. Hum Reprod 2000; 15: 1646–1647.
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
253
29. Ozumba BC, Nwabue R. Spontaneous uterine rupture follow-
ing low upper segment transverse incision. Trop Doct 1997; 27:
111–112.
30. Gregory KD, Korst LM, Cane P, Platt LD, Kahn K. Vaginal
birth after cesarean and uterine rupture rates in California.
Obstet Gynecol 1999; 94: 985–989.
31. Rageth JC, Juzi C, Grossenbacher H. Delivery after previous
cesarean: A risk evaluation. Obstet Gynecol 1999; 93:
332–337.
32. Howe RS. Third trimester uterine rupture following hys-
teroscopic uterine perforation. Obstet Gynecol 1993; 81:
827–829.
Ultrasound Obstet Gynecol 2004; 23: 247–253.