2.  Cesarean scar pregnancy (CSP): Rare  High index of suspicion  No universal treatment guidelines  Controversies in management  Delay: Catastrophic hemorrhage/uterine rupture  Objectives of management: Prevention of massive blood loss, preserve fertility and women’s health

3.  Twenty two years old  Gravida 3 para 1+1  No live issue  Six weeks amenorrhea  Lower abdominal pain.

4.  Haemodynamically stable.  Closed cervical os  Six weeks sized uterus  No adnexal tenderness.  Serum beta-hCG level 12,040mIU/ml.

5.  15.9 mm gestational sac,  Regular yolk sac, live fetus in previous scar line in myometrium  Endometrial cavity empty  Diminished myometrium between bladder and sac (Figure 1a, b, c,d).  No adnexal mass or fluid in Pouch of Douglas.

10. In view of:  Previous bad obstetric history  Desire to avoid surgery  Stable condition Offered and agreed for medical management with systemic Methotrexate (MTX).

11. DayBhCG levelUltrasound pictureManagement 012,040mIU/mL15.9 mm GS, regular yolk sac with live fetus (Fig 1a,b,c) First dose of systemic MTX 82mg. according to 50mg/kg body surface area 524,618mIU/mLGS 28.8 mm with live fetus of 10.2mm at 7.2 weeks Second dose of MTX 82 mg given 1030,699mIU/mLOffered hysteroscopic aspiration but declined Given 3 doses of MTX 82 mg on alternate days with folinic acid rescue 1521,303mIU/mLGS of 9 weeks entering into endometrial cavity(Fig 2) Ultrasound guided suction evacuation successfully performed without damage to uterus or heavy bleeding

12. On day 15, her BhCG level was 21,303mIU/mL US showed GS of 9 weeks entering into endometrial cavity(Fig 2)

14.  Patient was counseled  Ultrasound guided suction evacuation was successfully performed without damage to uterus and minimal bleeding.

15.  Beta hCG 5 days after procedure was 412 mIU/ml  Negative after 10 days.  Normal menstrual cycles 34 days after evacuation  Conceived spontaneously after two years and recently delivered a healthy baby boy of 2800gm by Elective LSCS.

17.  Rare form of ectopic pregnancy  Incidence 1/1800–1/2500 of all caesarian deliveries  6.1% of all ectopic pregnancies with at least one caesarian section. Litwicka K. Curr Opin Obstet Gynecol 2013 Timor-Tritsch IE et al. Am J Obstet Gynecol 2012 Ash A et al. BJOG 2007

18.  Passage of embryo through tract between uterus and old caesarean scar  Rising caesarean deliveries increase chances of pathologically adherent placenta and CSP Al-Hashmi S et. al. BMJ case reports 2012 Timor-Tritsch IE et al. Am J Obstet Gynecol 2012

19.  Empty uterine cavity and cervix  GS anteriorly at level of internal os covering previous LSCS scar site  Increased peri-trophoblastic or peri- placental vascularity on colour Doppler  High-velocity, low-impedance flow velocity waveforms on pulsed Doppler Jurkovic D et al. Ultrasound in Obstetrics and Gynecology 2003

20. May present between 5-16 weeks as:  Painless vaginal bleeding(39%)  Mild to moderate pain (16%)  Abdominal pain (9%)  Incidental ultrasound finding (37%)  Severe acute pain with profuse bleeding or hemodynamic instability indicates impending or ruptured CSP Al-Hashmi S et al. BMJ case reports 2012 Rotas M et al.Obstet Gynecol 2006

21.  Towards serosal layer or uterine cavity.  Former needs immediate intervention due to high risk of life-threatening bleeding and uterine rupture.  In the latter, conservative management, till viability has been attempted Ash A et al. BJOG 2007 Litwicka K et al. Curr Opin Obstet Gynecol 2011

22.  This resulted in uterine rupture, severe hemorrhage and DIC in 3 out of 6 patients, mandating hysterectomy  Severe bleeding complicated remaining three cases, which needed control with salvage treatments. Rotas M et al AJOG 2006

23.  Systemic MTX is the standard management for ectopic pregnancies less than 9 weeks gestation, with fetal pole less than 10mm, absent fetal heart activity and serum beta-hCG less than 10,000mIU/ml Rotas M et al Obstet Gynecol 2006

24. Of the 16 cases:  Five with ß-hCG less than 5000mIU/ml had complete resolution within a few months.  Another five received multiple doses of MTX alternating with folinic acid.  Of these, two needed additional laparotomy and hysterectomy Al-Hashmi S et al. BMJ case reports 2012

25.  Due to fibrous scar tissue leading to limited absorption of systemic MTX, intra- gestational sac MTX has also been used especially in women with higher BhCG levels Godin PA et al Fertil Steril 1997 Jurkovic D et al Ultrasound Obstet Gynecol 2003

26.  Other local embryocides like hyperosmolar glucose, potassium chloride and crystalline trichosanthin have been tried Fylstra DL Obstet Gynecol Surv 2002 Godin PA et al Fertil Steril 1997 Maymon R et al Hum Reprod Update 2004

27.  Hysteroscopic coagulation of vessels at implantation site  Laparoscopic removal of gestational mass  Laparotomy with wedge resection of the pregnancy  Ultrasound guided suction evacuation Maymon R et al Hum Reprod Update 2004

28.  Uterine artery embolization along with local or systemic MTX  Blind uterine curettage is contraindicated due to high chances of uterine rupture and severe hemorrhage Maymon R et al Hum Reprod Update 2004 Ash A et al BJOG 2007 Flystra D Obstetrical And Gynecological Survey 2002

29.  CSP is a potentially serious condition despite advances in many diagnostic techniques and therapeutic measures.  As it is a relatively rare entity and there are no definite guidelines, its management needs to be tailored according to the patient.