# Diagnosis and Treatment of Ectopic Pregnancy in a Cesarean Section Scar—Case Report

## TL;DR

This case report describes a rare pregnancy implanted in a cesarean section scar, highlighting the use of MRI for diagnosis and the importance of early detection to avoid life-threatening complications.

## Contribution

The paper presents a novel case of scar niche pregnancy and emphasizes the role of MRI with contrast in guiding clinical decisions.

## Key findings

- MRI with contrast revealed chorionic adhesion to the cesarean scar and uterine wall insufficiency.
- Uterine artery embolization and laparoscopic procedures successfully managed the pregnancy without hysterectomy.
- Histological findings indicated inflammation in the affected scar tissue.

## Abstract

Background/Objectives: Post-cesarean section scar niche pregnancy is one of the rarest forms. It is characterized by implantation of the gestation sac within the scar niche and is often associated with chorionic villi adhesion into the thinned cesarean section scar. The increasing incidence of this condition is associated with the increasing frequency of cesarean sections and the widespread use of ultrasound in early pregnancy. The most significant clinical findings are the detection of chorionic villus invasion and uterine wall insufficiency, which may be detected using magnetic resonance imaging, including contrast, and are crucial for determining patient management. This pathology may be considered life-threatening due to complications such as early uterine rupture with bleeding, which, if not diagnosed promptly, can lead to hysterectomy and loss of the woman’s reproductive health. Early diagnosis allows for the use of conservative treatment methods, preserving the uterus. The aim of the study is to clarify the clinical practices to follow in cases where an MRI examination with contrast agent is indicated to be performed on a pregnant patient. Methods: Ultrasound and MRI examination with counter-rotation, as well as histological and immunohistochemical examination of the remnants of the gestational sac were performed. Results: A 36-year-old pregnant woman was hospitalized in her eighth week of pregnancy with complaints of vaginal bleeding and persistent abdominal pain. An ultrasound scan revealed a pregnancy of 8 weeks and 5 days, and a low-lying chorion in the isthmus of the uterus, along with thinning of the cesarean scar and the formation of a scar niche resembling a hernia. Early signs of chorionic invasion were not treated. An MRI revealed signs of superficial chorionic adhesion to the cesarean scar, both to the isthmus and the internal os. Given that the woman did not wish to continue the pregnancy, uterine artery embolization was performed to reduce potential blood loss. Subsequently, laparoscopy, adhesiolysis, vacuum aspiration of the gestational sac, uterine curettage, hysteroresectoscopy, and coagulation of the fetal bed were performed. Histological and immunohistochemical examination revealed signs of inflammation in the area of the suspected lesion. Conclusions: This case report shows the potential value of MRI in complex cases of ultrasound detection of a gestational sac within scar tissue. MRI was used to assess the location of the gestational sac and evaluate the thickness of the cesarean scar to detect its dysfunction. Furthermore, contrast enhancement of the MRI may be useful in the most complex cases but requires an informed consent discussion with the patient. However, the latter issue requires discussion and proof of its safety for the fetus.