Pregnant Woman With Abnormal Ultrasound.

A 28-year-old gravida 3, para 2 female at approximately 6 weeks gestation with 2 prior cesarean deliveries presented to the emergency department for evaluation of an abnormal obstetrical ultrasound. Her blood pressure was 106/73 mmHg, with a pulse rate of 89 beats/min. She was well-appearing and asymptomatic with an unremarkable physical examination. Quantitative beta-human chorionic gonadotropin was 51,915 mIU/mL. Transabdominal ultrasound performed by the emergency physician revealed a gestational sac outside the uterine cavity without free fluid (Figure 1 and Video E1, available at http://www.annemergmed.com). Radiologic transvaginal ultrasound confirmed its location in the anterior myometrium of the lower uterine segment, consistent with the area of the cesarean section scar (Figure 2 and Video E2, available at http://www.annemergmed.com.) The obstetrician performed a dilation and curettage followed by 2 total doses of methotrexate, leading to an uneventful recovery.Figure 2Endocavitary ultrasound demonstrated ectopic pregnancy (arrow) within the anterior myometrium (plus sign). Endometrial stripe (triangle).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Cesarean scar ectopic pregnancy. Cesarean scar ectopic pregnancies occur when blastocysts implant in myometrial uterine scars outside of the uterine cavity.1Timor-Tritsch I.E. Monteagudo A. Calì G. D'Antonio F. et al.Cesarean scar pregnancy: diagnosis and pathogenesis.Obstet Gynecol Clin North Am. 2019 Dec; 46: 797-811Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Although this is the rarest form of ectopic implantation, the increasing incidence of cesarean deliveries has resulted in a corresponding increase in this abnormality.1Timor-Tritsch I.E. Monteagudo A. Calì G. D'Antonio F. et al.Cesarean scar pregnancy: diagnosis and pathogenesis.Obstet Gynecol Clin North Am. 2019 Dec; 46: 797-811Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar,2Rotas M.A. Haberman S. Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management.Obstet Gynecol. 2006; 107: 1373-1381Crossref PubMed Scopus (501) Google Scholar Patients typically present asymptomatically or with painless vaginal bleeding.2Rotas M.A. Haberman S. Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management.Obstet Gynecol. 2006; 107: 1373-1381Crossref PubMed Scopus (501) Google Scholar Early diagnosis and intervention are critical as missed cesarean scar ectopic pregnancies can cause uterine rupture, hemorrhage, infertility, and maternal death.1Timor-Tritsch I.E. Monteagudo A. Calì G. D'Antonio F. et al.Cesarean scar pregnancy: diagnosis and pathogenesis.Obstet Gynecol Clin North Am. 2019 Dec; 46: 797-811Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 2Rotas M.A. Haberman S. Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management.Obstet Gynecol. 2006; 107: 1373-1381Crossref PubMed Scopus (501) Google Scholar, 3Birch Petersen K. Hoffmann E. Rifbjerg Larsen C. et al.Cesarean scar pregnancy: a systematic review of treatment studies.Fertil Steril. 2016; 105: 958-967Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar, 4Timor-Tritsch I.E. Monteagudo A. Calì G. et al.Cesarean scar pregnancy: patient counseling and management.Obstet Gynecol Clin North Am. 2019; 46: 813-828Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Diagnosis is made with pelvic ultrasound depicting a gestational sac in the lower anterior uterine segment with less than 5mm of intervening myometrium between it and the bladder, an empty uterine cavity, and Doppler imaging showing increased surrounding blood flow.1Timor-Tritsch I.E. Monteagudo A. Calì G. D'Antonio F. et al.Cesarean scar pregnancy: diagnosis and pathogenesis.Obstet Gynecol Clin North Am. 2019 Dec; 46: 797-811Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzMjM1YjVlZjlmMTVmMDcxNTFjNTU5NTY0YWE2MTliYiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MzE1MDMyfQ.nQaN4XGnzjIv_ZxcMwkWRGx4jmsWaJNcXq_HolykmyvSOtFEp72pTbtaQsAHY76Z8wNC4NaBY8AsZH9sLehy-mIJWCv1CHhBe-EkiTmL1Ys3h_rG4V_hrn1jUEetVoPCMweb2NSYqNoyeBcHy1MTbh1zn2qFy3kJmPIB5xV75gSuJsdY9zUm1Q8qQbX84c07Cxlu_aNX4NMy9OcTkk6mymbl1uGNycDBGzTBsY1mpSgpvFqK-ytjp7leNj2Q2t8hfKhf9A9z3j3DimZdNp88aqgW7b0DAByZiC0_UfkTSdGBtey2t9G-PkRI3WOZa0iN7uI-odzCWuu8o9xdgazplg Download .mp4 (6.49 MB) Help with .mp4 files Video E1Transabdominal ultrasound in longitudinal orientation showed gestational sac (arrow) outside of the uterine cavity. Fundus (angle bracket), endometrial stripe (triangle), bladder (asterisk).eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiYWYzZTE1NmZlOTM4MTkzM2RlMWVlMGExMjU5ODEyNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MzE1MDMyfQ.mPYLVAC3fXP5LjUBj5-znRAa4PBhEkfkqs5KSu2nac-iSamzeZ25g_29iyf78hjdxNctrKbeCVqBPH7esrLW1swmD89AMafNJB0aP4PabnnzuBbegYJA9UXjAOZQ470oNM8y48QjdDtXtxEABj1aQgmK2S-G_1pA6mTWBch0vHBN2CaHnv6Z4Xb3jbk_efzh75oLaH5LGf2yLCaheHdkbF4cBQhNx33KvwYluqryINTSDkJ597PO_672dru7bs8UZbhqMClKUCm_e-DbMvYUKWI7PDJnLKCMzKlbY0_yZWBQzOIbRHuQThlAmX6Xa9iYoxixbsCM1zC1q9ScNG77gg Download .mp4 (5.67 MB) Help with .mp4 files Video E2Endocavitary ultrasound of ectopic pregnancy (arrow) within the anterior myometrium (plus sign). Endometrial stripe (triangle).