CESAREAN SCAR

PREGNANCY
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history of
three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-lying
gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
 A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER) with
complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
https://www.who.int/news/item/16-06-2021-caesarean-
section-rates-continue-to-rise-amid-growing-
inequalities-in-access
 Klasifikasi
Berdasarkan Risiko CSP

Risky Stable
CSP CSP

Type I Type II Type II

Thin Myometrium < 3mm Thick Myometrium >3mm Gestasional Sac Deviation

Type Ia Type Ib
Type Ic
Caesarean scar Caesarean scar
Giant
on lower on upper
protruding mass
uterine segment uterine segment
Klasifikasi
Berdasarkan Risiko
Tipe I Tipe III
Dinding tipis (<3mm) • Kandung kehamilan
• Ia : luka SC rendah terletak Sebagian
• Ib : luka SC tinggi pada luka SC
• Ic : terdapat massa • Berisiko perdarahan
menonjol hebat

Tipe II
Dinding tebal (3mm)
Klasifikasi
Berdasarkan Temuan Pencitraan

Endogen

Eksogen Cross over sign

Klasifikasi
Family Plan Group, Chinese Medical Society of Obsgyn Expert Consensus on Diagnosis and Treatment of CSP

Tipe Standar Diagnosis

I • Jaringan gestasional tertanam sebagian di dalam jaringan parut, sebagian/sebagian besar di rongga rahim
bahkan ada yang sampai ke dasar rongga rahim.
• Kantung kehamilan secara jelas mengalami kerusakan, memanjang dan ujung bawah lancip
• Myometrium antara kantung kehamilan dan kandung kemih > 3mm
• CDFI : aliran darah resistensi rendah terlihat di bekas luka
II • Jaringan gestasional tertanam sebagian di dalam jaringan parut, sebagian/sebagian besar di rongga rahim
bahkan ada yang sampai ke dasar rongga rahim.
• Kantung kehamilan secara jelas mengalami kerusakan, memanjang dan ujung bawah lancip
• Myometrium antara kantung kehamilan dan kandung kemih < 3mm
• CDFI : aliran darah resistensi rendah terlihat di bekas luka
III • Jaringan gestasional tertanam seluruhnya di lapisan muscular dari bekas luka uteri dan menonjol
keluar ke kandung kemih
• Kekosongan kavum uteri dan kanal serviks
• Myometrium antara kantung kehamilan dan kandung kemih sangat tipis, atau bahkan hilang, ketebalannya
< 3mm
• CDFI : aliran darah resistensi rendah terlihat di bekas luka
Manifestasi Klinis Pemeriksaan Penunjang
• Asimptomatis – nyeri • USG
• Tidak khas, biasanya • TVUS
ditemui saat USG • MRI
• Histeroskopi
• Laparaskopi
Kriteria RCOG untuk
Mendiagnosis CSP
menggunakan TVUS
A. Rongga rahim kosong
B. Kantung kehamilan atau massa padat trofoblas yang tertanam di
lokasi bekas luka caesar
C. Kanal endoserviks kosong
D. Lapisan miometrium tipis atau tidak ada antara kantung
kehamilan dan kandung kemih / dinding rahim anterior
E. Bukti adanya sirkulasi yang menonjol pada pemeriksaan Doppler
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history of
three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-lying
gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-lying
gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-lying
gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-lying
gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-
lying gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-
lying gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-
lying gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-
lying gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six weeks and history
of three previous cesarean sections presented with pervaginal spotting.

(A) TVS showing retroverted uterus with empty endometrial cavity and low-
lying gestational sac containing fetal pole, close to the scar site.
(B) Increased vascularity was noted around the gestational sac on Doppler
(arrow). This gestational sac was appearing to grow towards the cervico-
isthmic cavity, and it was likely representing type 1 or endogenic CSP
A 28-year-old female, G6 with gestational amenorrhea of six
weeks and history of three previous cesarean sections
presented with pervaginal spotting.

Injection MTX was given for medical

(A) TVS showing retroverted uterus with empty
endometrial cavity and low-lying gestational sac
termination of pregnancy with serial beta
containing fetal pole, close to the scar site. human chorionic gonadotropin (hCG)
(B) Increased vascularity was noted around the
gestational sac on Doppler (arrow). This gestational sac
monitoring. She subsequently underwent
was appearing to grow towards the cervico-isthmic hysteroscopy and uterine evacuation.
cavity, and it was likely representing type 1 or Post-operative period was unremarkable
endogenic CSP
and post-procedural ultrasound showed
no evidence of retained products of
conception (RPOC). She was discharged
in a stable state.
 A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER) with
complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
 A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER) with
complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER)
with complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER)
with complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER)
with complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER)
with complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER)
with complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this was
representing type 2, or exogenic CSP
A 32-year-old female, G4 with ten weeks gestational amenorrhea and history of
three previous cesarean sections, was admitted to the emergency room (ER)
with complaints of left lumbar pain for two days.

(A) Transabdominal scan images showing empty endometrial cavity and

eccentrically placed gestational sac in the lower anterior uterine segment
(asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm
(arrowhead). The gestational sac was growing towards the bladder, this
was representing type 2, or exogenic CSP
 A 32-year-old female, G4 with ten weeks gestational
amenorrhea and history of three previous cesarean
sections, was admitted to the emergency room (ER) with
complaints of left lumbar pain for two days.
(A) Transabdominal scan images showing empty endometrial cavity and eccentrically placed
gestational sac in the lower anterior uterine segment (asterisk).
(B) TVS confirmed thin rim of myometrium anteriorly measuring 2.4 mm (arrowhead). The
gestational sac was growing towards the bladder, this was representing type 2, or
exogenic CSP

The patient was initially managed medically with injection methotrexate

(MTX); however, due to non-progress and hemodynamic instability, surgery
was planned. Preoperatively, bilateral uterine arteries were embolized.
Laparotomy was done. Intraoperative findings included adhesions between the
anterior abdominal wall and omentum. The urinary bladder was closely attached
to the uterine surface. Due to excessive bleeding and fragile tissue, total
abdominal hysterectomy was carried out.
Terima Kasih