EARLY SECOND TRIMESTER CESAREAN SCAR ECTOPIC PREGNANCY: UTERINE RUPTURE AFTER ASPIRATION

Problem statement
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, which incidence is estimated at between 0,05 to 0,4% of all pregnancies.
The pathophysiology of CSP is not fully understood. A possible mechanism is that trauma caused by a caesarean section creates microscopic tracts through which an implanting blastocyst abnormally invades the affected myometrium. The uterine rupture and massive hemorrhage are the major complications.

Methods
We present a case of CSP diagnosed in the second trimester with uterine rupture during aspiration.

Results
A 27-year-old woman, gravida 2 para 2 (cesarean section and eutocic delivery), was referred to the gynecology emergency department with a complaint of a vaginal bleeding with pelvic discomfort, with 3 months of amenorrhea.
Vaginal examination shown an active vaginal bleeding and on bimanual palpation there was tenderness at the anterior fornix.
Transvaginal ultrasound confirmed the presence of a gestational sac containing a live fetus implanted at the location of the previous caesarean scar. The head circumference corresponded to 15 weeks and 6 days of gestation with the presence of cardiac activity.
Dilatation and ultrasound-guided vacuum aspiration was performed under general anesthesia. A silicone balloon was inserted in lower segment of the uterus with 60 ml of normal saline.
Two hours after surgery, she became hemodynamic unstable with signs of hypovolemic shock, and was immediately prepared for an emergency laparotomy with fluid and blood resuscitation.
The perioperative findings included a retroperitoneal hematoma close to the right ovary extending to the lower segment of the anterior wall of the uterus, without active bleeding. Abdominal packing was performed in the pelvic cavity and in the right flank. On day 3, abdominal packing was removed. On day 9, the transvaginal ultrasound showed the retroperitoneal hematoma was 71*30mm and the patient was discharged.

Conclusion
Late diagnosis of CSP can be associated with serious life-threatening obstetric complications.
The uterine rupture after the aspiration should be immediately suspected when faced with hemodynamic instability. In this case, it was possible to treat without hysterectomy.