Caesarean Scar Pregnancy

Caesarean Scar Pregnancy

What does Caesarean scar pregnancy mean?

A Caesarean scar pregnancy (CSP) is a rare type of pregnancy that develops in the scar left on the womb (uterus) from a previous caesarean birth.
Instead of growing inside the main part of the womb, the pregnancy grows in the scar itself. It happens in about 1 in every 2000 pregnancies and can happen even if you’ve had only one previous caesarean section.

It is becoming a little more common because more people are giving birth by caesarean.

Why does it happen?

We don’t always know why CSP occurs, but it may happen if the scar from a previous caesarean section doesn’t fully heal, leaving a small space where a pregnancy can start to grow.

Is there subtypes for CSP?

Yes , there are 2 types

Type 1 :

The pregnancy grows towards the womb’s cavity.

The pregnancy may continue to the second or third trimester with a high risk of adherent placenta

Type 2 :

 The pregnancy grows towards the bladder with

 higher risk of rupture in the first trimester.

Is treatment needed?

A CSP can cause serious bleeding and, in rare cases, may cause rupture of the womb.
Early diagnosis and treatment reduce these risks and help preserve your future fertility. Because it can behave unpredictably, early treatment is usually advised rather than waiting to see what happens.

What symptoms might I have?

30% of women have no symptoms and the condition is found during a routine scan.
Others may notice:

• Light painless vaginal bleeding (common)
• Mild lower tummy (abdominal) discomfort or pain
  In more serious cases, there may be:
• Heavy vaginal bleeding
• Severe abdominal pain
• Dizziness or fainting (which can be a sign of internal bleeding)

If you are experiencing sudden pain or heavy bleeding, please seek emergency medical help straight away.

How is it diagnosed?

The main way to diagnose CSP is with an ultrasound scan.

• A transvaginal scan (where a small probe is gently inserted into the vagina) gives the clearest view.
• Sometimes a transabdominal scan (over the tummy) is used as well.
• MRI scan may be recommended if the vaginal ultrasound doesn’t give clear answers.

These scans can show where the pregnancy is growing in relation to your previous caesarean scar and the urinary bladder. In some cases a repeat US may be needed.

What are my treatment options?

There isn’t enough strong evidence to say that one treatment is clearly better than another, but overall, surgery seems to work better than medication. Because there is a high risk of serious health complications for the mother, simply waiting to see what happens (expectant management) is not recommended when a caesarean scar pregnancy is diagnosed.

We will discuss the best treatment for you based on your health, symptoms, and how far along the pregnancy is.

1. Medical treatment by Methotrexate

• This medicine helps to stop the pregnancy from growing so your body can absorb it naturally over time. It may be suitable if the pregnancy is less than 8 weeks with HCG (pregnancy hormone level) below 5000 IU/l
• It may be given as:
  • An injection into a muscle (like a vaccination),
  • A small injection directly into the pregnancy under ultrasound guidance, or
  • A combination of both.
• You will need to do some blood tests before and after taking this medication, to check that pregnancy hormone levels are falling.
• Side effects are usually mild but can include tiredness, nausea, or mild tummy discomfort.
• You’ll be advised to wait at least 3 months before trying to get pregnant again.

2. Surgical treatment

Surgery is recommended if:

• You have heavy bleeding or severe pain,
• You prefer a quicker resolution,
• High pregnancy hormone level ,
• Contraindication medical treatment  or
• Medical treatment hasn’t worked

There are several surgical approaches and you will be asleep with a general anaesthetic:

• Gentle suction through the cervix to remove the pregnancy. This is done under ultrasound guidance in theatre.
• Keyhole (laparoscopic) surgery to remove the pregnancy and repair the scar.
• Hysteroscopy, where a small camera is inserted through the cervix to remove the pregnancy under direct vision and repair the womb from inside.
• Open surgery (laparotomy) in rare cases or emergencies.

Your team will choose with you the safest option for you and take steps to reduce blood loss during and after the procedure.  

3. Expectant (watch-and-wait) management

This is not usually recommended because of the risk of heavy bleeding or rupture.
It may be considered only if:

• The pregnancy is no longer growing, and
• The pregnancy hormone (hCG) is already falling.

You would need very close monitoring as it can take several months for the pregnancy to resolve, and sometimes further treatment is still required. This also, carries a risk of severe vaginal bleeding.

4. Sequential management

This means using more than one type of treatment. Usually, medication is tried first, and then surgery is done to remove the remaining pregnancy tissue growing in the caesarean scar. The idea is that this might lower the risk of heavy bleeding during surgery and help with a faster recovery. However, research so far has not shown clear benefits to this approach.

Uterine artery embolisation (UAE) is a procedure to reduce blood flow to the pregnancy area. Although, it is not a treatment for the CSP on its own, it is sometimes used in combination with the medical or surgical treatment to help prevent heavy bleeding.

What are the risks of CSP and its treatment?

All treatment options carry a small risk of:

• Heavy bleeding
• Needing a hysterectomy (removal of the womb) in an emergency
• Infection
• Formation of scar tissue inside the womb

We will take every precaution to reduce these risks.

Will I be able to have children in the future?

Many women go on to have successful pregnancies after CSP treatment.
Studies show that around 8 out of 10 women conceive again, and over half have a live birth.

If you have medical treatment you should avoid pregnancy for 12 weeks after the injection. However, if you have had keyhole surgery, you should postpone pregnancy for 3-6 months after the procedure .

Future pregnancies will need early ultrasound scans to check that the pregnancy is developing in the right place.
Most women will be advised to have another caesarean birth, and close attention will be paid to the scar / incision during the next pregnancy.

Can CSP happen again?

It can happen again, but the risk is between 7 % -40 %
Repairing the scar during surgery can help to reduce this risk.

Emotional support

CSP can be a very emotional and stressful experience.
You are not alone — support and information are available through:

• The Ectopic Pregnancy Trust (www.ectopic.org.uk)
• Local hospital bereavement or counselling services
• Talking to your GP or specialist nurse

Relaxation techniques such as breathing or muscle relaxation exercises can also help reduce anxiety during medical treatment.

What are the next steps?

• You will have regular blood tests until pregnancy hormone levels return to normal.
• It can take several months for the scar area to completely heal.
• Avoid becoming pregnant again for at least 3 months after methotrexate treatment.
• If your blood type is resus negative, you will be offered an anti-D injection to protect future pregnancies.

Further information and support

Contact the Emergency Gynae Assessment Unit on 01905761489 . This is 24/7 emergency service. You will talk to one of our experienced staff  who will be able to advise you and answer your questions.

Go to A&E or call emergency services111 or 999 if you experience:

• Heavy vaginal bleeding
• Severe abdominal pain
• Dizziness, fainting, or feeling unwell

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Summary

• CSP is a rare complication of a previous caesarean birth.
• Early diagnosis and treatment are important for your safety and future fertility.
• There are several safe treatment options, which your doctor will discuss with you.
• Most women recover well and can have healthy pregnancies in the future.

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience

We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback

Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)

If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:

Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:

The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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