Causes, Assessment and Management of Cesarean Scar Pregnancy

Cesarean scar pregnancy is rare but potentially life threatening type of ectopic pregnancy. It is a condition in which the concepts implants in an iatrogenic cesarean scar in the uterus and is surrounded by uterine muscular fiber, scar tissue, and thin myometrium adjacent to the bladder. It can occur in women with a single previous cesarean delivery. CSP was first described by [1]. The incidence of CSP has been reported to be 1:1800-1:2216 of normal pregnancies and accounts for 6.1% of all ectopic pregnancies [2-5]. This rate is expected to rise in the future worldwide owing to increasing rates of cesarean deliveries and awareness of its pathology. During the last two decades ultrasonography diagnosis have improved and the techniques for uterine surgery has changed .In recent time the uterus is often closed in one layer, compared with the previous twolayer technique. These factors may play a role in the increasing prevalence of CSP. Vial et al. [6] proposed two different types of CSPs; Endogenous CSP (CSP type I) and Exogenous CSP (CSP type II). CSP type I is a superficial implantation of the embryo on the cesarean scar (CS) which develop towards the cervicoisthmic space or the uterine cavity. CSP type II is a deep implantation of the embryo into a CS defect growing towards the bladder, infiltrating the uterine myometrium, and bulging from the uterine serosa. CSP type II may result in uterine rupture and hemorrhage during the first trimester of pregnancy. The above two types of CSP are easily differentiated by ultrasound or MRI examination. Due to the high risk of life-threatening complications including massive hemorrhages/shock, uterine rupture with the potential necessity for hysterectomy in worst case scenario and maternal death, CSP needs a prompt accurate and proper diagnosis and management. However, termination of pregnancy is generally recommended. Routine transvaginal ultrasonography has been recommended in early pregnancy for patients who have previously undergone a cesarean delivery [7-9].