THE IMPORTANCE_Cignini

A 36-year-old woman (gravida 2, para 1) come to the Prenatal Diagnosis Center, Artemisia, in Rome referred by another institution for evaluating the presence of a Cesarean Scar Pregnancy (CSP). Woman came at our institution with no symptoms. She had a caesarean section a term of gestation 3 years prior. She was at 9 weeks gestation calculated from the first day of the last menstrual period. Physical examination was negative and no bleeding from the vagina was observed. Serum human corionic gonadotropin level was 7500 mIU/ml. Both transabdominal and transvaginal ultrasound revealed a CSP according to the Jurkovic criteria (6). The gestational sac, containing a yolc sac and a embryonic pole with cardiac motion, was located in the anterior isthmus, in the location of the previous caesarean scar (Fig. 1A). Within the endometrial cavity, above the gestational sac, a fluid collection was observed, but no communications were observed between this collection and the gestational sac. Also sonographic examination with color-flow Doppler imaging was performed to determine whether the pregnancy was implanted in the uterus or was ectopic (Fig. 1B). No normal myometrium was visualized between the bladder and the gestational sac; only 3 mm of thickness separated the sac from the urinary bladder (Fig. 1). Termination of pregnancy was suggested and the patient was carefully counselled with the therapeutic options, including laparotomy, laparoscopy, suction evacuation and medical treatment with methotrexate. After a written informed consent was obtained an exploratory laparotomy was performed. When the peritoneal cavity was opened after the mobilization of the bladder, the lower uterine myometrial implantation was confirmed. A hysterotomy was performed but a severe hemorrage ensued and could not be contained by uterotonics and conservative surgical measures; therefore, a decision was made to perform an emergency subtotal hysterectomy. The estimated blood loss was 1500 The importance of early diagnosis in cesarean scar pregnancy