Hysteroscopic Morcellation Offers Minimally Invasive Option for Cesarean Scar Ectopic Pregnancy: Study
A 30-year-old woman with a prior lower-segment cesarean section was successfully treated for cesarean scar ectopic pregnancy using systemic methotrexate followed by hysteroscopic retrieval with a morcellator. The uneventful procedure highlights the value of early imaging, planned intervention, and readiness for hemorrhage control in this high-risk implantation disorder.
Cesarean scar ectopic pregnancy is an uncommon but potentially life-threatening form of ectopic pregnancy in which the gestational tissue implants within the scar of a previous cesarean delivery. The condition is increasingly relevant to obstetricians and gynecologists as cesarean delivery rates rise, and it may be asymptomatic or present with minimal symptoms despite a risk of severe hemorrhage, uterine rupture, placenta accreta spectrum, and hysterectomy.
The patient, a 30-year-old woman, gravida 4 para 1 living 1 abortion 2, had undergone a lower-segment cesarean section 9 years earlier, followed by dilatation and evacuation for two unwanted pregnancies. She presented to the institute after a positive urine pregnancy test and an outside pelvic ultrasonography report suggestive of a lesion at the previous cesarean scar site.
Ultrasonography showed a heterogeneous hyperechoic lesion measuring approximately 4.5 × 4.5 cm in the lower uterine segment at the lower-segment cesarean scar, with thinning of the overlying myometrium. On admission, the patient was hemodynamically stable, had no active bleeding on per-speculum examination, and had a bulky uterus corresponding to 8–10 weeks on per-vaginal examination. Her baseline beta-human chorionic gonadotropin level was 263.14.
Magnetic resonance imaging was performed to confirm the diagnosis and supported the ultrasound findings. The uterus was retroverted, and a heterogeneous T2-weighted hyperintense area measuring 4.4 × 4.6 × 4.5 cm was noted in the lower uterine segment at the previous cesarean scar site. The lesion communicated with the endometrial cavity, with thinning of the overlying myometrium and increased surrounding flow voids. There was no obvious extension beyond the serosa and no intraendometrial gestational sac.
After written informed consent, the patient received systemic methotrexate at 1 mg/kg. Serial beta-human chorionic gonadotropin monitoring showed a value of 300.59 on day 4 and 201.8 on day 7. She was subsequently taken up for hysteroscopic retrieval of the scar ectopic pregnancy after high-risk consent, with blood and blood products reserved because of the risk of hemorrhage.
Intraoperatively, chorionic tissue was identified, along with an isthmocele in the lower uterine segment on the anterior uterine wall. The chorionic tissue was retrieved using a morcellator, and the specimen was sent for histopathology, which confirmed the diagnosis. The procedure was uneventful, and the patient was discharged the following day.
Cesarean scar ectopic pregnancy remains a diagnostic and therapeutic challenge. Transvaginal ultrasonography is the primary imaging modality, but magnetic resonance imaging may help clarify anatomy and surgical planning when ultrasound findings require confirmation. Key diagnostic features include an empty uterine cavity, an empty endocervical canal, trophoblastic tissue or a gestational sac implanted anteriorly at the level of the internal os within the previous cesarean scar, a thin or absent myometrial layer between the gestation and bladder, and prominent trophoblastic or placental vascularity on Doppler examination.
Management is individualized and may include medical therapy, ultrasound-guided aspiration, hysteroscopic or laparoscopic resection, or combined approaches. This case supports the practical role of a planned minimally invasive hysteroscopic approach after medical priming in a stable patient, provided that the team is prepared for bleeding and has access to blood products and surgical backup.
For clinicians, the case underscores three priorities: maintain suspicion for cesarean scar ectopic pregnancy in any early pregnancy after cesarean delivery; use targeted imaging promptly when implantation appears low in the uterus; and select definitive management early to reduce the risk of catastrophic hemorrhage and uterine rupture. In carefully selected patients, hysteroscopic retrieval after methotrexate can offer a minimally invasive, fertility-sparing treatment pathway.
Source: Negi et al. Indian Journal of Obstetrics and Gynecology Research. 2026;13(2):442–445.
