Site Of Cesarean Scar Research Articles

Pouch of sorrow: Undiagnosed isthmocele – presenting as secondary infertility of 11 years in a middle age female

In the past decade, the rate of cesarean sections has doubled leading to the more frequent occurrence of cesarean-related complications. Cesarean scar site diverticulum or isthmocele is one such complication that is defined as an outpouching of the anterior uterine wall at the cesarean scar site in continuity with the endometrial cavity, creating a wedge-shaped defect of variable depth. We report a case of a middle-aged female with secondary infertility for the last 11 years with one live issue 12 years back through a cesarean section at term. She had undergone an array of investigations for infertility for the past 5 years. She was diagnosed as having an isthmocele and managed with surgical repair of the defect at our hospital with subsequent assisted conception 8-month post-surgical repair. The importance of diagnosing a cesarean scar diverticulum cannot be understated not only because it is a surgically treatable cause of infertility but also because if such patients conceive, they may land in uterine rupture, placenta accreta, or scar ectopic pregnancy which can complicate into life-threatening situations.

Emergency Bilateral Internal Iliac Artery Ligation in Antepartum Haemorrhage with Complete Placenta Previa and Placenta Accreta at Previous Caesarean Scar Site: A Case Report

Implantation and placentation at the normal site are critical for a successful pregnancy. Many complications associated with pregnancy, which manifest late in pregnancy, such as preeclampsia and preterm labour, have been reported to have origins early during pregnancy with abnormalities in implantation and placental development. Placental abnormalities result from impaired embedding of the placenta in the endometrium, encompassing a wide range of placental pathologies associated with high maternal morbidity and mortality. Pregnancy-related complications such as Postpartum Haemorrhage (PPH) and hysterectomy have been closely linked to the Placenta Accreta Spectrum (PAS). PAS refers to the aberrant and invasive implantation of the placenta into the myometrium. Invasiveness in placenta accreta is marginal, followed by placenta increta (partial), placenta percreta (total), and placenta previa (covering the cervix). Here, the authors present a unique case report of an antenatal woman with antepartum haemorrhage, placenta previa, and placenta accreta at the previous Lower Segment Caesarean Section (LSCS) scar site, with massive PPH at 35 weeks, who benefited from an emergency LSCS with bilateral uterine and internal iliac artery ligation procedure, resulting in a life-saving outcome. The most common risk factors for PAS include prior caesarean section and curettage. The adhered placenta can lead to pelvic bleeding and necessitate an emergency hysterectomy. Therefore, it poses unique diagnostic and treatment issues, with the majority of cases requiring preterm termination of pregnancy.

A RARE CASE OF SCAR ENDOMETRIOSIS WITH UTEROCUTANEOUS FISTULA

Utero-cutaneous fistula is a rare condition which is characterized by an abnormal communication between the anterior wall of the uterus and the abdominal wall. The causes are multiple caesarean sections, abortions, uterine cavity revision, retention of placental material after delivery, endometriosis, use of drains, post-operative infections, or injuries. Blood discharge from the caesarean scar during menstruation is a prominent feature as in our case. Here we present a case of para 2 living 1 lady, with previous 2 caesarean section presented to our Gynecology outpatient department with bleeding from the classical caesarean scar site cyclically during menses. Elective laparotomy with excision of uterocutaneous tract was done. Histopathology showed scar endometriosis.

Conservative management of Caesarean scar site ectopic pregnancy with morbidly adherent placenta: a challenging scenario

Conservative management of Caesarean scar site ectopic pregnancy with morbidly adherent placenta: a challenging scenario

The association between acute lower abdominal pain over a previous caesarean scar and uterine rupture

Pregnant women with previous caesarean delivery might suffer from acute lower abdominal pain located at the site of previous caesarean scar (CS). The association between this complaint and uterine rupture (UR) is not fully understood. Therefore, we aimed to examine the risk of UR in women with acute persistent abdominal pain (APAP) over a previous CS and to investigate all the women with UR, with or without APAP and with or without previous CS, in order to determine risk factors, clinical presentation and management. We performed a retrospective analysis on two study groups: women who had APAP over previous CS and women who had UR. We found an incidence of UR in patients with APAP over the previous CS was 0.7%; which doubled the total UR rate among women with previous caesarean in our medical centre (0.35%). Forty percent of the women with APAP over a previous CS had preterm delivery. Twenty percent of the cases of UR occurred in preterm weeks. To conclude, APAP over a previous CS is associated with a doubled risk of UR. Considering this symptom as a preliminary sign of UR might lead to elevated rate of iatrogenic preterm deliveries. Impact statement What is already known on this subject? Women with UR may present with abdominal pain which may vary from non-specific mild discomfort to severe acute abdominal pain. Additionally, these women may suffer from acute persistent abdominal pain (APAP) located over the previous caesarean scar. The clinical significance of APAP in these women has not been fully investigated. What do the results of this study add? Lower abdominal pain located at the site of previous CS is associated with a doubled risk of UR. Considering this complaint as a major sign of UR might lead to an elevated rate of iatrogenic preterm deliveries. What are the implications of these findings for clinical practice and/or further research? Further studies are needed to explore whether women with a single complaint of APAP over CS could be managed expectantly and even offered a trial of labour after caesarean delivery (CD).

Preventing Isthmocele after Cesarean Section (PICS): A Pilot Randomized Controlled Trial

<h3>Study Objective</h3> An isthmocele is a cesarean scar site defect with a depth of >2mm and can lead to both obstetric and gynecologic complications. The primary objective was to evaluate the feasibility of a study protocol comparing different cesarean section closure techniques amongst our own patients/physicians, with the ultimate goal of a larger scale randomized controlled trial (RCT). Secondary objectives included isthmocele incidence, measurements on postoperative ultrasound, and adverse surgical outcomes related to suture technique. <h3>Design</h3> A single-center parallel-group pilot RCT comparing locked vs. unlocked first-layer uterine closure. Outpatient transvaginal ultrasound to evaluate isthmocele formation was performed at least six months postoperatively. <h3>Setting</h3> Operating room and outpatient ultrasound clinic. <h3>Patients or Participants</h3> All term pregnant patients >18 years old undergoing a primary caesarean section were eligible. Exclusion criteria included previous uterine hysterotomy, known uterine anomalies, active labour, and maternal bleeding and/or connective tissue disorders. <h3>Interventions</h3> Locked or unlocked closure of the first uterine layer. <h3>Measurements and Main Results</h3> Forty-one subjects were randomized, and 23 completed the follow-up ultrasound, with 12 in the locked group and 11 in the unlocked group. Barriers to feasibility included hesitance to participate in research during pregnancy, difficulty attending follow-up ultrasound with a newborn, and mainly Covid-19 pandemic related delays in study activities and fear of potential exposures. Isthmocele was present in 10/12 patients receiving locked closure, and in 11/11 of the unlocked group. Mean sagittal depth was 0.36 cm and 0.40 cm in the locked vs. unlocked groups, respectively. Sagittal adjacent myometrial thickness was 1.03 cm in the locked group, and 1.12 cm in the unlocked group. No adverse outcomes were noted with either surgical technique. <h3>Conclusion</h3> The study design is feasible outside of the pandemic setting. A larger trial is needed to determine differences regarding isthmocele rates and measurements between groups.

Uterine Rupture at a Site Distant From Old Scar: An Unusual Presentation

Uterine rupture is a rare life threatening emergency with severe obstetric consequences. Most ruptures occur in a scarred uterus at the site of previous transmyometrial surgical incision. However, rupture on site distant from previous scar is a very rare entity. It is associated with major maternal and neonatal morbidity than rupture at a scarred area. Index case describes a scenario where uterine rupture occurred at the fundal region, far away from previous caesarean scar site leading to fetal demise. Till now, only a very few cases with uterine rupture away from the site of previous caesarean scar have been reported.&#x0D; Keywords: uterine rupture, unscarred uterus, acute abdomen, hemoperitoneum

Choriocarcinoma in Cesarean Scar Site: A Case Report

Background & aim: Cesarean scar pregnancy is an ectopic pregnancy implanted in the myometrium at the site of a previous cesarean section scar and is the rarest kind of ectopic pregnancy. The present study present a case of choriocarcinoma (CC) in the cesarean scar. The clinical course, findings, and treatment plan are discussed. Case report: A 41-years old multi-gravid woman with a history of one previous cesarean section and three subsequent abortions was admitted to the hospital. She suffered from an unknown abnormal vaginal bleeding for two months. Β-HCG titer was 1,000 IU/L and the report of sonography showed no gestational sac. Accordingly, the patient was diagnosed with ectopic pregnancy in the cesarean scar site and, therefore, weekly usage of methotrexate was prescribed for her. Since she did not respond to the treatment, she was referred to our department in the Faculty of Medicine. The evaluation showed mass invasion through the entire uterine wall. The uterus preservation was not possible, therefore, total hysterectomy was performed. The pathology report confirmed CC in the cesarean scar. Conclusion: Based on previous studies, as the number of cesarean sections increases, the possibility of complications rises, as well. Cesarean scars implantation of CC is one of the rare complications of caesarean section. The probability of a gestational trophoblastic disease should be considered in any woman during her pregnancy. Early detection and proper management of the complications can result in a decrease in morbidity and mortality.

A Case Report of Cesarean Scar Site Endometriosis: Diagnosis and Management

Endometriosis is a frequent clinical problem in women of reproductive age, which means the presence and proliferation of endometrial glands and stroma outside the uterus, the most common site of endometriosis is in the pelvic cavity, extra pelvic endometriosis as on the surgical scar (as caesarean section, laparoscopic incision, episiotomy, and hysterectomy scars) which is relatively rare, it is clinically presented by chronic pelvic pain, dysmenorrhea, dyspareunia, subfertility, infertility, and poor both maternal & fetal outcomes and even stillbirth. Caesarean section endometriosis is presented with cyclic pain and bleeding from the scar site. Our 33- year case presented with a scar site endometriosis after the third Cesarean section. MRI was done to exclude uterine fistula and a definite diagnosis has been made by histopathology. Management involved different modalities of treatment including medical management, Mirena coil insertion. However, the definite treatment was surgical excision of the endometriotic lesion and reclosure of the skin incision.

AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days.

AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days.

Pregnancy at the Cesarean Section Scar: Successful Management and Review of Current Literature

AbstractWhen implantation of the early embryo occurs at the scar of previous cesarean, it is called cesarean scar pregnancy. Though in uterus, it behaves like an ectopic pregnancy with risk of rupture and hemoperitoneum. A 37-year-old woman came with missed period and vague abdominal discomfort; she had a positive pregnancy test. She had previous two cesarean sections. The last cesarean section was 12 years ago and the patient was not using any contraception. Her ultrasonography (USG) was inconclusive; β human chorionic gonadotropin was 2,980 mIU/mL. Her repeat USG showed a hypoechoic area at the cesarean scar site, behind the reflection of bladder, separated from bladder by a thin layer of myometrium. She was counseled regarding the management options and prognosis. She was managed with two doses of injection. Methotrexate on day 1 and day 4. β human chorionic gonadotropin was repeated until it was close to normal. USG was also repeated. Cesarean scar pregnancy can be managed by many ways; the one most suitable to the patient with least side effects should be adopted, after adequate counseling of the patient.

Medical Management of Cesarean Scar Pregnancy at Latifa Hospital Dubai Health Authority, Dubai, UAE

Introduction: Cesarean scar pregnancy (CSP) is defined as implantation of gestational sac at the site of cesarean scar. It’s a serious diagnosis that has become more prevalent in recent years and related to the increasing rate of cesarean sections reported worldwide. Identifying these cases and treating them is challenging, with no agreed upon universal protocol for successful treatment. We aim to evaluate the success rate and outcome of medical management for Cesarean scar pregnancy. Methods: It was a retrospective descriptive study of all cesarean scar pregnancies managed at fetal medicine unit at Latifa Hospital in Dubai, UAE the main obstetrics & Gynecology tertiary hospital in Dubai Emirate, UAE from 2015 to 2017. Certainly, a set of diagnostic criteria were implemented to confirm the diagnosis of CSP. The cases were then offered our proposed management which is systemic methotrexate injections ± KCL. Follow up made by serial βhcg and ultrasound scan. The data were collected used specified data collection sheet for this purpose then analyzed and presented using statistical package for social sciences (SPSS) version 26. Results: 33 cases of cesarean scar pregnancies are confirmed and medically managed during the study period. The study subjects composed of a group of patients who had a viable CSP and received local KCL injection + systemic methotrexate, a second group who had non-viable CSP and received systemic methotrexate 20 cases were viable pregnancies who received combined local potassium chloride plus systemic methotrexate, and 13 were non-viable received systemic methotrexate only. The mean gestational age at diagnosis was 8 weeks (SD ± 1.8). On average our cases had a history of 3 previous cesarean sections (range 1 - 6). Overall, the success rate calculated from our study population for medical management of CSP was 77.8%; this varied between viable CSP which had a success rate of 66.7% and non-viable CSP which had a success rate of 100%. The average period of outpatient follow-up for the patients to achieve complete resolution was 14 weeks (SD ± 7.5). Conclusions: Medical management of CSP in the form of systemic methotrexate ± local KCL injections proves to have acceptability and a good success rate especially for non-viable CSP, low complications rate and with the benefit of preserving future fertility.

Clear Cell Carcinoma Arising from Endometriosis at the Cesarean Scar Site: A Case Report

The association of endometriosis with ovarian cancer has been a rare but well-documented phenomenon since 1925, when Sampson first described clear cell carcinoma arising from endometriosis. Here, we report the case of a woman who underwent staging laparotomy including total abdominal hysterectomy and bilateral salpingo-oophorectomy with the excision of an abdominal wall mass at the site of her cesarean section scar. Although the abdominal wall mass and lymph node was proven to be clear cell carcinoma, the patient’s ovaries were free of carcinoma. This case provides important etiological evidence because it is a clear example of endometriosis that has transitioned to clear cell carcinoma. We report this case for review.

Cеsarean section scar endometrosis

Endometriosis is defined as a functional endometrial tissue outside the uterine cavity. The ectopic endometrial tissue has been identified after gynecologic laparoscopy or laparotomy procedures in the skin, subcutaneous tissues, abdominal and pelvic wall musculature, and it represents amayor cause of acute or chronic recurrent abdominal or pelvic pain resembling the menstrual cycle. The frequency of abdominal wall endometriosis is approximately 1% of all women who had a cesarean delivery. A 39-year-old patient with a history of one prior Cesarean section, presented with continuous cyclical focal pain at the left part of cesarean scar site for the past 16 months, 23 months after Cesarean section. The patient underwent a mini laparotomy, when endometrioma was completely removed surgically. The PH diagnosis of endometriosis was based on the presence of all elements of the endometrial mucosa (glands, stroma and signs of fresh and old hemorrhage) in an inadequate place (anterior abdominal wall). Endometriosis is difficult to diagnose and it is often mistaken for other conditions such as a suture granuloma, incisional hernia, primary or metastatic cancer. Endometriosis can be prevented only with good surgical techniques and clinical practice as well as the proper care during primary surgery.

When a cesarean section scar is more than an innocent bystander in a subsequent pregnancy: Ultrasound to the rescue.

Over the years, cesarean section has played a pivotal role in reducing maternal and perinatal morbidity and mortality. With the rising trend of this surgery, a substantial number of pregnant women have a cesarean section scar. The scar can serve as the abode of grave conditions in subsequent pregnancies, namely cesarean scar pregnancy, morbidly adherent placenta, and scar dehiscence. Sonography has emerged as a robust tool for the diagnosis of these potentially life-threatening conditions. This review highlights the key sonographic features of various complications that can occur at the cesarean scar site in subsequent pregnancies. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:319-327, 2017.

Embryo Implantation in the Region of a Previous Caesarean Section Scar and Scar Dehiscence in Second Trimester: A Rare Case Report.

The first case of a Caesarean scar site ectopic pregnancy was reported in 1978 [1]. Implantation of a pregnancy within a caesarean fibrous tissue scar is considered to be the rarest form of ectopic pregnancy and a life-threatening condition. This is because of the very high risk of uterine rupture and the maternal complications related to it. The most probable mechanism that can explain scar implantation is that there is invasion of the myometrium through a microtubular tract between the caesarean section scar and the endometrial canal. A recent case series estimates an incidence of 1:2226 of all pregnancies, with a rate of 0.15 % in women with a previous caesarean section and a rate of 6.1 % of all ectopic pregnancies in women who had at least one caesarean delivery [2].Although expectant and medical management have been reported in early pregnancy, termination of a caesarean scar pregnancy by laparotomy and hysterotomy, with repair of the accompanying uterine scar dehiscence, may be the best treatment option in later weeks of pregnancy.

Feasibility of treatment of cesarean scar pregnancy with dilatation and curettage under ultrasound guidance

The present study sought to investigate the predictors of successful dilatation and curettage (D&C) in treatment of cesarean scar pregnancy (CSP). Retrospective analysis was conducted in 84 CSP patients undergoing D&C from January 2013 to December 2014. Failure was defined as D&C followed by transcatheter uterine arterial embolization due to uncontrolled hemorrhage. Sub-stratification of success group as residue group or non-residue group was performed according to the residues at the site of cesarean scar after D&C. The univariate logistic regression and linear regression were used to assess the predictors of the failure and residues. ROC curve was used to assess the cut-off values of the predictors. D&C under ultrasound guidance succeeded in 75 patients (89.3%) and 36 patients had residues at the site of cesarean scar among them (48%), 9 patients failed in D&C (10.7%). High Serum human chorionic-gonadotropin (hCG), small gestation sac (GS), thin cesarean scar myometrium thickness (CSM) and low peritrophoblastic flow resistance index (RI) were risk factors of D&C failure in treatment of CSP. That serum hCG>97 006 U/L was prime predictor of failure (predictive value 100%, 95% CI 94.9%-100%). High success ratio was observed in patients with serum hCG<58 076 U/L, GS≤19 mm, CSM>2.7 mm, and RI>0.25. And days of menopause≤41 d, GS≤15 mm, CSM>3.7 mm, RI>0.4 and serum hCG<3 935 U/L were predictors of complete success of D&C. The postponed restoration of menstruation was observed in patients with residues, which did not induce amenorrhea and disappeared in 1-3 months after procedures. Early diagnosis and treatment is associated with successful D&C in treatment of CSP. HCG, GS, CSM and RI are valuable in predicting the prognosis of D&C in treatment of CSP.

P25.01: Sonographic evaluation of uterine scar 4 and 12 weeks after Caesarean section

The aim of the study was to evaluate uterine scar 4 and 12 weeks after delivery using transvaginal ultrasound. The study group consisted of 108 women who underwent Caesarean section (CS) from September 2011 until September 2012 and reported for the transvaginal ultrasound examination. There were 108 women evaluated 4 weeks and 58 of them 12 weeks after delivery. The lower uterine segment was assessed and the presence of the Caesarean scar, scar defect and defect's dimensions were noted and analyzed. The scar defect was defined as hypoechoic area within the myometrium at the site of CS. 12 weeks after CS there was also external defect evaluated. External defect was defined as the loss of myometrium in the anterior wall under the bladder. Defect was measured in three dimensions: width and depth (sagital plane), and length (transverse plane). The external defect and residual myometrial thickness (RMT) were measured on sagital plane. The uterine scar was visible in all patients. The uterine scar defect was found in 58(49%) and 15(26%) of women 4 and 12 weeks after delivery respectively. External defect was found in 6(10%) cases. The mean width of the defect 4 weeks after CS was 8,7±3,7 mm; depth 7,6±4,1 mm; length 11,9±5,2 mm. The same measurements 12 weeks after CS were: 4,6±2,3 mm; 4,0±1,9 mm; 5,8±2,3 mm. The external defect width was 3,9±11,3 mm and depth 4,7±1,5 mm. RMT 4 weeks after Caesarean section was 8,1±4,4 mm in the defect group versus 13,1±3,8 mm in non-defect group. 12 weeks after Caesarean section the same values were: 5,3±3,0 mm and 8,1±2,7 mm respectively. The ultrasound's sign of successful recovery of the uterus defined as non-defect visualisation can be observed as early as 4 weeks after CS in half of women. As the postpartum evolution of uterus is ending the prevalence of uterine scar defect decreases 12 weeks after CS. There is significant difference in RMT between women with and without uterine scar defect. In women with uterine scar defect myometrium at the site of Caesarean scar is 35-37% thinner compared to those without defect.

Caesarean scar site complete molar pregnancy

<p style="margin-bottom: 0in;"><span style="color: #231f20;"><span style="font-family: Helvetica-Narrow,sans-serif;"><span style="font-size: x-small;">A 40 year old multiparous asymptomatic woman presented at 9+ weeks with a finding of rising serum beta-HCG over 3500 IU without ultrasonically detectable intra-uterine pregnancy. First diagnostic laparoscopy was performed on 3rd day of admission and found to be normal. Because of rising serum beta-HCG second laparoscopy was performed and it was converted to a laparotomy as a caesarean scar site pregnancy was suspected. Sub-total hysterectomy was performed in order to remove suspected caesarean scar molar pregnancy. Patient recovered completely with normal beta-HCG on 20th post day. Pieces of tissue obtained from between the anterior abdominal wall and the previous caesarean section scar revealed diagnosis of complete hydatidiform mole.</span></span></span> <p style="margin-bottom: 0in;"><span style="color: #231f20;"><span style="font-family: Helvetica-Narrow-BoldOblique,sans-serif;"><span style="font-size: x-small;"><em><strong>Background: </strong></em></span></span></span><span style="color: #231f20;"><span style="font-family: Helvetica-Narrow,sans-serif;"><span style="font-size: x-small;">Implantation at the caesarian scar site can lead to first trimester miscarriages, placenta previa, placenta accreta or ectopic pregnancy. While caesarean scar site ectopic pregnancy is a rare occurrence; caesarian scar site molar pregnancy is extremely rare. We report this case to highlight the importance of high index of suspicion and proper monitoring in diagnosing this condition.</span></span></span> <p style="margin-bottom: 0in;"><span style="color: #231f20;"><span style="font-family: Helvetica-Narrow,sans-serif;"><span style="font-size: x-small;">DOI: <a href="http://dx.doi.org/10.4038/sljog.v35i2.6162">http://dx.doi.org/10.4038/sljog.v35i2.6162</a></span></span></span> <p style="margin-bottom: 0in;"><span style="color: #231f20;"><span style="font-family: Helvetica-Narrow-Bold,sans-serif;"><span style="font-size: x-small;"><em><span style="font-weight: normal;">Sri Lanka Journal of Obstetrics and Gynaecology</span></em><strong> </strong><span style="font-family: Helvetica-Narrow,sans-serif;">2013; 35: 62-64</span></span></span></span> <p style="margin-bottom: 0in;">

Caesarean scar pregnancy (CSP): a rare case of complete scar dehiscence due to scar ectopic pregnancy and its management

We present a rare case of Caesarean scar pregnancy (CSP) in which the embryo implants within the myometrium at the site of a previous caesarean scar with complete scar dehiscence and its distinctive management. A 38-year-old G8P1 woman presented with vaginal bleeding following 6 weeks of amenorrhoea following IVF. Serum b-human chorionic gonadotropin (HCG) level was 9166 mIU/mL and transvaginal ultrasound (TVS) revealed (Fig. 1) an inhomogeneous fixed mass, 5 cm in size within the myometrium at her previous caesarean scar site extending outside the uterus through the caesarean scar and adjacent to the bladder; on the basis of this diagnosis CSP was made. Systemic methotrexate (MTX) was administered, (1 mg/kg intramuscular) and b-HCG level fell to 18.0 mIU/mL over 3 months follow-up. However, the patient continued to have lower abdominal pain and a repeat TVS showed the mass had reduced in size to 3.5 cm. Because of drawn out recovery period and as she wanted to go for another IVF cycle, laparoscopy was undertaken. After reflection of the bladder peritoneum, it was noted that the previous caesarean section scar had dehisced completely (Fig. 2a, b). The CSP mass was thus excised and the edges of the defect approximated in two layers. Postoperative course was unremarkable, and her b-hCG levels were \5 mIU/mL. The histopathology report confirmed diagnosis of CSP with evidence of placenta percreta. The first ever case of CSP was reported in 1978, and since then only 19 cases were reported until 2001 [1, 2], followed by sudden increase to 751 cases by 2011 [3]. With no evident mechanism for CSP yet understood, the finding in most of the cases reflect that implantation occurs at the site of a micro or macroscopic defect in the scar [4]. Commonest presentation of CSP is abdominal pain and bleeding [5]. CSP is a diagnosis on ultrasound visualisation of gestational sac at the level of internal os, penetrating the anterior uterine wall approaching the bladder [6]. CSP is more challenging to diagnose if only inhomogeneous mass of products of conception is present such as in this case, where use of Doppler helps [3, 4]. Possibility of CSP should be considered in women who have had a previous caesarean [7], as delay in diagnosis can lead to uterine rupture causing serious maternal morbidity and loss of future fertility. There is no consensus on the preferred mode of treatment [3, 8]. After discussing the various treatment modalities in the literature [2, 3, 5], as per patients choice our management started with a single dose of systemic MTX. But later laparoscopy showed a silent complete scar dehiscence, which could have possibly resulted in rupture and intraperitoneal bleeding. There are no other published case reports of concomitant CSP and silent scar dehiscence. Our case brings to light the possibility of dehiscence after MTX therapy that could have implications for future fertility. It highlights the importance of post treatment long term surveillance following MTX and in cases where there is slow resolution of the CSP mass. The incidence of CSP is likely to rise substantially in the near future as caesarean delivery rates continue to increase. Setting up multicentre collaboration would encourage robust evidence-based studies essential for making recommendations for practice. Until then, one has to rely on N. Agarwal A. Shahid (&) F. Odejinmi Whipps Cross University Hospital, Barts Health NHS Trust, London, UK e-mail: anupamashahid@gmail.com; anupamashahid@yahoo.com