E2514. Scarred for Life: A Review of Cesarean Section Scar Pregnancy and Potential Pitfalls in Diagnosis
  1. Jennifer Huang; Vanderbilt University Medical Center
  2. Catherine Phillips; Vanderbilt University Medical Center
  3. Mariam Moshiri; Vanderbilt University Medical Center
Cesarean section scar pregnancy (CSSP), defined as implantation of a gestational sac on or in a previous cesarean section (CS) scar, is a rare form of ectopic pregnancy. Over the last several decades, the incidence of detection of CSSP has continued to increase, likely in part due to the growing rates of cesarean deliveries, and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated such as uterine rupture with severe hemorrhage, future infertility, and rarely maternal death.

Educational Goals / Teaching Points
This exhibit will provide a comprehensive review of this rare but important phenomenon, detailing the pathophysiology and types of CSSP, variations of imaging presentations, potential pitfalls in diagnosis, and management options.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Imaging plays a critical role in the diagnosis of CSSP as the clinical presentation is often nonspecific. Serum beta human chorionic gonadotropin (beta-hCG) levels should be checked in all patients with suspected CSSP, which can be used to help interpret imaging findings to distinguish CSSP from diagnoses with similar imaging appearances, such as miscarriage in progress. Pelvic ultrasound, using a combined transabdominal and transvaginal approach, is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful in cases when ultrasound findings are equivocal, or confirmation is requested prior to definitive intervention. Some important differential diagnoses to consider include cervical ectopic pregnancy, interstitial ectopic pregnancy, miscarriage in progress, and pregnancies with low implantation. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure.

Knowledge of the key differentiating clinical and imaging features of CSSP is critical for early and accurate diagnosis, allowing for prompt management to avoid severe complications, and the potential to preserve the uterus and future fertility.