Case notes
A 36-year-old G4P2012 at 6 weeks by last menstrual period presented to the emergency department with abdominal pain and vaginal bleeding. On examination, she had normal vital signs with mild suprapubic tenderness without rebound or guarding. Her medical history was notable for 2 uncomplicated cesarean deliveries.
Ultrasound imaging showed implantation of a 7-week gestation within the endometrium overlying the prior cesarean delivery scar with thin adjacent myometrium. The serum human chorionic gonadotropin (hCG) was 155,009 mIU/mL. Due to the rare nature of cesarean delivery scar implantation pregnancies, there are no standardized guidelines for management. After extensive counseling regarding surgical management vs medical management with intraamniotic KCl injection and multidose methotrexate, the patient opted for medical management. She was admitted to the gynecology service after undergoing intraamniotic KCl 6-mEq injection under ultrasound guidance with confirmed cessation of the fetal heartbeat. The patient then received 4 doses of methotrexate (1 mg/kg intramuscularly) with a 5-mg leucovorin ‘rescue’ on alternating days. Following an initial decline in serial hCGs, the hCG plateaued and never fell below 131,000 mIU/mL. Dilation and curettage was not offered after reviewing the imaging given concern for perforation in the setting of minimal myometrium separating the implantation and the bladder ( Figure 1 ).
The patient was offered excision of the cesarean delivery scar implantation with wedge resection vs total laparoscopic hysterectomy (TLH). This was an undesired pregnancy and she did not desire future fertility, thus she opted for definitive surgical management with a TLH. She underwent an uncomplicated TLH and was discharged on postoperative day 1 ( Figure 2 ).
