1. Role of Ultrasound Imaging and Management option for Caesarean scar Ectopic Pregnancy Shah. Fatima, Vaithilingam. N Queen Alexandra Hospital, Southwick Hill Road. Cosham Portsmouth PO6 3LY, England Background Case Histories & ManagementConclusions Discussion Implantation of pregnancy within a scar is a rare occurrence with only 50 reported cases Due to its rarity optimal management is yet to be established Imaging plays an important role as a diagnostic modality in skilled hands Increase in incidence is anticipated as number of caesarean delivery is increasing Implantation of a pregnancy within scar is a life threatening condition It should be part of differential diagnosis Women who had a scar pregnancy and are planning future pregnancy should be counselled to have early scan to confirm location Introduction Caesarean scar ectopic pregnancy is a rare condition which poses challenges for optimal management. Even though different modalities are available for the treatment early diagnosis improves the outcome and future fertility. Background It has an estimated incidence of 1: 1800 - 2200 pregnancies. The etiology of caesarean scar pregnancy is unclear. Previous cesarean section, myomectomy, adenomyosis, IVF, previous dilation and curettage, and manual removal of the placenta have been linked as risk factors. The overall incidence is however thought to be increasing as result of increasing caesarean section rate and assessment of early pregnancy complication using transvaginal scan. Diagnosis All four cases the diagnosis of scar pregnancy was made from transvaginal scan. All the cases demonstrate empty endometrial canal, empty endocervical canal, gestational sac developed in anterior part of lower uterine segment and very thin myometrium in between the bladder and gestational sac. In addition we used Doppler study. Gestational sac above the uterine artery entry differentiated the scar ectopic from cervical pregnancy where the gestational sac is below the uterine artery. Management Methotrexate was used in all cases to suppress the trophoblastic activity. All patients responded to single dose methotrexate. Case 1 had evacuation following the methotrexate and KCl. Cervical cerclage was used to minimize blood loss. Careful counselling and patient compliance are important to achieve a successful clinical outcome with medical treatment Follow up Monitoring next pregnancy in early stage is important to exclude recurrent scar pregnancy 1 patient had successful normal intrauterine pregnancy and uncomplicated C-section. Methods Ultrasound Imaging Criteria An empty uterine cavity & empty cervical canal Development of the gestational sac in the anterior part of the uterine isthmus An absence of healthy myometrium between the bladder and sac Sac should be above the uterine artery Transvaginal ultrasound image of scar ectopic Sagittal section of uterus showing c-section scar pregnancy Transverse section of uterus showing c-section scar Retrospective analysis of Caesarean scar pregnancy and its outcome during the period of three years. OPTIONAL LOGO HERE Empty endometrial cavity Gestational Sac with Yolk sac Empty Cervical Canal Gestational sac growing towards bladder CasesHistorySymptomsDiagnosisOutcomes Case 1 34 yr Two previous section Asymptomatic BHCG 43681 IU 10 weeks POA US: Confirmed single viable pregnancy of 9wks and I day, Situated very low in the uterine wall possibly located in previous LSCS scar KCl and Methorexate Evacuation with cervical cerclage Two units blood transfusion Had successful pregnancy in 2010 Delivered by C - section & recovery uneventful Case 2 39yrs old Two previous section salpingectomy for tubal ectopic pregnancy in the past Left iliac fossa pain Right t shoulder tip pain and Six weeks amenorrhea BHCG 8431 US: 11x4x8 mm gestational sac with yolk sac at previous scar Trace amount free fluid Treated with methotrexate D4 – BHCG 8431 D35 – BHCG 14 Case 3 Case 2 Presented after one year with seven weeks amenorrhea to exclude ectopic pregnancy Asymptomatic BHCG 20543 US: Gestational sac in the scar live embryo at 6weeks 6 days Fetocide with KCl followed with methotrexate D4 – BHCG 20543 D40 – BHCG 10 Case 4 42 yrs old Two previous section Eight week amenorrhea Vaginal spotting Lower abdominal pain Patient declined to undergo any treatment readmitted 9 days later with severe lower abdominal pain US: Gestational sac at scar with live embryo at 6weeks 3days Repeat scan showed no cardiac pulsation Agreed for methotrexate on second admission Had two units blood transfusion D4 – BHCG 27706 D17 – BHCG 1820 BHCG monitoring was not possible due non compliance