This document discusses two cases of high risk obstetrics. Case 1 involves a woman at 34 weeks gestation presenting with abdominal pain and bleeding. Her examination and investigations indicate signs of placental abruption. Case 2 involves a woman at 34.5 weeks gestation with a history of two previous cesarean sections and placenta previa diagnosed at 21 weeks. Her examination and ultrasound confirm placenta previa and possible placenta accreta. The document then discusses various questions related to the differential diagnosis, risk factors, complications, management, and delivery approach for conditions like placental abruption and placenta previa.

1. HIGH RISK OBSTETRICS

3. CASE 1: HISTORY
 A G3P2L2 B/D 34.4 Weeks B/S 33.5 Weeks Previous LSCS came
with complaints with pain in abdomen in emergency.
 Patient gave history of Previous LSCS done at 8 months of
pregnancy as she had started bleeding.
 C/O bleeding P/V for 1 hour
 No C/O decreased foetal Movement
 No other medical or surgical illness

4. CASE 1: EXAMINATION
On examination,
Pallor +, No icterus, No oedema
Pulse : 110/min
BP 100/60
Per abdomen: Uterus 34 week size, FHS +/144/Regular, Breech presentation,
Uterus was tonically contracted
Per Vagina: OS 3cm dilated, Cervix 40% effaced, mid posterior, Membranes
intact, Bleeding ++, Breech presentation, Pelvis adequate

5. CASE 1: INVESTIGATION
 Hb 7.2g/dl, WBC 9200/cu mm Platelets 98000/cu mm
 Liver function test
1. Total Bili : 1.8
2. Direct Bili :0.6
3. SGPT : 65
4. SGOT: 40
5. Alkaline phosphatase : 540
 BUN 8, Creatinine 0.6
 PT 18.3 INR 1.5

6. CASE 1: SONOGRAPHY
PREVIOUS USG SHOWS , Single
Live Intrauterine gestation of
30weeks, with foetal weight of
2098 gram, AFI 28cm with a
posterior placenta.

7.  What are the differential diagnosis?
 Labour with bloody show
 Vasa previa
 Placenta Praevia
 Vaginal trauma
 Malignancy (rare)
 Vaginitis

8.  What are the risk factors of Abruptio Placentae?
 Abruption in a previous pregnancy
 Pre-eclampsia
 Foetal growth restriction
 Non-vertex presentations
 Polyhydramnios
 Advanced maternal age
 Multiparity
 Maternal thrombophilia

9.  What are the risk factors of Abruptio
Placentae?
 Low body mass index (BMI)
 Pregnancy following assisted reproductive techniques
 Intrauterine infection
 Premature rupture of membranes
 Abdominal trauma (both accidental and resulting from domestic
violence)
 Smoking
 Drug misuse (cocaine and amphetamines)

10.  What are the maternal complications of Abruptio
placentae?
 Anaemia
 Infection
 Maternal shock
 Renal tubular necrosis
 Consumptive coagulopathy
 Postpartum haemorrhage
 Prolonged hospital stay
 Psychological sequelae
 Complications of blood transfusion

11.  What are the foetal complication of Abruptio
Placentae?
 Foetal hypoxia
 Small for gestational age and foetal growth restriction
 Prematurity (iatrogenic and spontaneous)
 Foetal death

12.  What is the role of clinical assessment in women
presenting with APH?
 The role of clinical assessment in women presenting with APH is
first to establish whether urgent intervention is required to
manage maternal or foetal compromise.
 The process of triage includes
1. History taking to assess coexisting symptoms such as pain,
2. An assessment of the extent of vaginal bleeding, the
cardiovascular condition of the mother, and
3. An assessment of foetal wellbeing.

13.  Role of USG in APH?
 Women presenting with APH should have an ultrasound scan
performed to confirm or exclude placenta praevia if the placental
site is not already known.
 The sensitivity of ultrasound for the detection of retroplacental
clot (abruption) is poor. Sensitivity is only 24% and specificity 96%.
 If the foetal heart rate cannot be heard on auscultation, then an
ultrasound scan should be performed to exclude an intrauterine
foetal death.

14.  Foetal monitoring in APH?
 CTG monitoring as it influences the timing and mode of
delivery.
 An abnormal CTG is associated with poor foetal outcome
and delivery should be expedited to save the foetus.
 ‘If active obstetric intervention in the interests of the foetus
is not planned, for example at gestations less than 26+0
weeks, continuous monitoring of the foetal heart rate is not
advised.

15.  Should corticosteroids be administered to
women who present with APH before term?
 Clinicians should offer a single course of antenatal
corticosteroids to women between 24+0 and 34+6 weeks
of gestation at risk of preterm birth.
 In women presenting with spotting, where the most likely
cause is lower genital tract bleeding, where imminent
delivery is unlikely, corticosteroids are unlikely to be of
benefit, but could still be considered

16.  Should Tocolytic therapy be used in women
presenting with APH who have uterine
activity?
 Tocolysis should not be used to delay delivery in a woman presenting with a
major APH, or who is haemodynamically unstable, or if there is evidence of
foetal compromise.
 RCOG Green-top Guideline No. 1b states that tocolytic therapy is
contraindicated in placental abruption and is ‘relatively contraindicated’ in ‘mild
haemorrhage’ due to placenta praevia.

17. When should women with APH be delivered?
What mode of delivery should be employed in
women whose pregnancies have been complicated
by APH?

18.  If foetal death is diagnosed, vaginal birth is the
recommended mode of delivery
 If the foetus is compromised, a caesarean
section is the appropriate method of delivery
with concurrent resuscitation of the mother.
 Women with APH and associated maternal
and/or foetal compromise are required to be
delivered immediately.

19.  What is the optimal mode of anaesthesia for
women who have experienced APH?
 Regional anaesthetic is recommended for operative delivery unless
there is a specific contraindication.
 Specific contraindications to regional anaesthesia relevant to APH
include maternal cardiovascular instability and coagulopathy
 In a case of APH where maternal or foetal condition is
compromised and caesarean section required, a general
anaesthetic should be considered to facilitate control of maternal
resuscitation and to expedite delivery.

20.  How should the woman presenting with an APH
who develops a coagulopathy be managed?
 Clotting studies and a platelet count should be urgently requested
 Advice from a haematologist sought.
 Up to 4 units of FFP and 10 units of cryoprecipitate may be given
whilst awaiting the results of the coagulation studies.

21.  How should the woman with an extremely
preterm pregnancy (24+0 to 26+0 weeks of
gestation) and APH be managed?
 Regardless of the gestation, the mother’s life
should take priority. She should be resuscitated
and stabilised before any decision is made
regarding delivery of the baby.
 Conservative management is usually appropriate
when APH occurs in the extremely preterm
pregnancy (less than 26+0 weeks of gestation)
and the mother’s condition is stable.

22.  When the bleeding is considered life-threatening
for the woman or there is evidence of
cardiovascular compromise that fails to respond
to resuscitation, consideration should be given to
delivery of the foetus.
 If foetal death is diagnosed, vaginal birth is the
recommended mode of delivery for most women.
 If the foetus is compromised, a caesarean section
is the appropriate method of delivery with
concurrent resuscitation of the mother.

23. Case 2: HISTORY
 A G4P2L2A1 Previous 2 LSCS B/D 34.5 WKS B/S 33.2 WKS Came
for routine antenatal check up.
 Patient gives history of being admitted at 21 weeks of pregnancy
for bleeding P/V.
 Patient has no complaints.
 No complaints of bleeding P/V.
 No history of any medical or surgical illness.

24. CASE 2: EXAMINATION
 General examination: No Pallor, No icterus or oedema
 Pulse 80/min
 BP 120/70
 Per abdomen : uterus 32 weeks size, transverse lie , FHS +/R/148
 Per Vagina: not done as scan done at 21 week suggestive of low lying
placenta.

25. CASE 2: INVESTIGATIONS
 Hb 9.8 g/dl, WBC 9200/cu mm Platelets2 98000/cu mm
 Blood Group AB negative
 ICT negative
 BUN 8, Creatinine 0.6
 PT 11.3
 INR 1.05

26. CASE 2: SONOGRAPHY
Sonography done on admission suggestive of:
 Single live intra uterine gestation of 33.5 weeks
 Transverse lie with foetal head to maternal right
 Placenta completely covering internal OS with
accreta
 Foetal weight : 2765g
 AFI : 10cm
 Scar thickness: 3.2mm

27.  Can we diagnose placenta praevia clinically?
Clinical suspicion should be raised in all women with:
 Vaginal bleeding after 20 weeks of gestation
 A high presenting part
 An abnormal lie
 Painless or provoked bleeding
 The definitive diagnosis of most low-lying placentas is with
ultrasound imaging

28.  How and when should we screen for Placenta
Previa?
 Routine ultrasound scanning at 20 weeks of
gestation should include placental localisation.
 Transvaginal scans improve the accuracy of
placental localisation and are safe, so the
suspected diagnosis of placenta praevia at 20
weeks of gestation by abdominal scan should be
confirmed by transvaginal scan.

29.  How can a morbidly adherent placenta be
diagnosed?
 3D power Doppler with greyscale is most
accurate in diagnosing adherent placenta.
 MRI can be used in equivocal cases.

30. How and when should we screen for
Placenta Previa?
 In cases of asymptomatic women with suspected minor praevia,
follow-up imaging can be left until 36 weeks of gestation.
 In cases with asymptomatic suspected major placenta praevia or a
question of placenta accrete as in Previous LSCS with anterior
Placenta, imaging should be performed at around 32 weeks of
gestation to clarify the diagnosis

31.  Where should women with placenta praevia be
cared for in the late third trimester?
 Women with placenta praevia in the third trimester should be counselled
about the risks of preterm delivery and obstetric haemorrhage, and
should be managed in hospital.
 Any home-based care requires close proximity to the hospital, the
constant presence of a companion and full informed consent by the
woman.
 It should be made clear to any woman being managed at home that she
should attend immediately she experiences any bleeding, contractions or
pain (including vague suprapubic period-like aches).

32.  Is there a place for tocolytics in women who
bleed?
 The aetiology of bleeding in placenta praevia is due to the
dynamics of the development of the lower uterine segment, but
may also be triggered by uterine activity.
 May prolong the interval from admission to delivery and increase
baby weight.
 No role of prophylactic tocolysis.

33.  In what situations can vaginal delivery be
contemplated for women with a low-lying placenta?
 The mode of delivery should be based on clinical judgement
supplemented by sonographic information.
 A woman with a placental edge less than 2 cm from the internal
OS in the third trimester is likely to need delivery by caesarean
section

34.  At what gestation should elective delivery occur?
 Elective delivery by caesarean section in asymptomatic women is
not recommended before 38 weeks of gestation for placenta
praevia, or before 36–37 weeks of gestation for suspected
placenta accreta.

35.  What preparations should be made before
surgery?
 The six elements considered to be reflective of good care were:
● consultant obstetrician planned and directly supervising delivery
● consultant anaesthetist planned and directly supervising anaesthetic at
delivery
● blood and blood products available
● multidisciplinary involvement in pre-op planning
● discussion and consent includes possible interventions (such as
hysterectomy, leaving the placenta in place, cell salvage and intervention
radiology)
● local availability of a level 2 critical care bed.

36.  When is interventional radiology indicated?
 Uterine artery embolization in cases of
uncontrolled haemorrhage can be life saving and
uterus sparing and should be considered.
 The place of prophylactic catheter placement for
balloon occlusion or in readiness for
embolization if bleeding ensues requires further
evaluation.

37.  What should be included in the consent form for
caesarean section?
 Any woman giving consent for caesarean section
should understand the risks associated with caesarean
section in general and the specific risks of placenta
praevia in terms of massive obstetric haemorrhage, the
need for blood transfusion and the chance of
hysterectomy.

38.  What surgical approach should be used for
suspected placenta praevia accreta?
Surgeons delivering the baby by caesarean section in the presence of
a suspected placenta praevia accreta should consider:
 Opening the uterus at a site distant from the placenta
 Delivering the baby without disturbing the placenta,
 Elective hysterectomy to be performed if the accreta is confirmed

39.  Conservative management of placenta accreta when the woman is
already bleeding is unlikely to be successful and risks wasting
valuable time.
 A low transverse skin incision allows access to the lower half of the
uterus and is reasonable if the upper margin of the anterior aspect
of the placenta does not rise into the upper segment of the uterus.
 If, however, the placenta is anterior and extending towards the level
of the umbilicus, a midline skin incision may be needed to allow for
a high upper-segment longitudinal uterine incision.
 What surgical approach should be used for
suspected placenta praevia accreta?

40.  What should be done if the placenta does not
separate after delivery of the baby?
 If the placenta fails to separate with the usual
measures, leaving it in place, closing the uterus
and proceeding to a hysterectomy is associated
with less blood loss than trying to separate it.

41.  How should the woman be managed after
placental retention?
 The woman should be warned of the risks of bleeding
and infection postoperatively and prophylactic
antibiotics may be helpful in the immediate postpartum
period to reduce this risk.
 Neither methotrexate nor arterial embolization reduces
these risks and neither is recommended routinely.
 Follow-up of the woman using ultrasound should
supplement serum beta-human chorionic
gonadotrophin measurements.

42. CASE 3: HISTORY
 Primigravida 35.4 weeks B/D , 34 weeks B/S came with h/o one
Generalised Tonic Clonic convulsion 1 hour back
 Patient had complaints of headache, blurring of vision and pain in
abdomen for the convulsion.
 No C/O leaking or bleeding P?V
 No C/O decreased foetal movement
 Patient gives history of taking Labetalol 100mg BD for one month in view
raised BP
 No other medical or surgical illness

43. CASE 3 : EXAMINATION
 General condition : fair, no pallor or icterus , B/L pedal oedema ++, DTR
normal
 Pulse 78/min
 BP: 170/100
 U/A +2
 Per Abdomen: UT 30 week size, Cephalic floating, FHS +/R/ 138, relaxed
 Per Vagina: OS closed, cervix tubular and posterior, No show or leak

44. CASE 3 : INVESTIGATIONS
 Hb 10.2g/dl, WBC 9200/cu mm Platelets 98000/cu mm
 Liver function test
1. Total Bili : 3.8
2. Direct Bili :1.6
3. SGPT : 165
4. SGOT: 40
5. Alkaline phosphatase : 540
 BUN 7, Creatinine 0.6
 PT 16.3 INR 1.3

45. CASE 3 : SONOGRAPHY
USG Obs done on admission suggestive of:
 Single live intra uterine gestation of 3o.5 weeks
 Cephal presentation
 Placenta fundoposterior
 Foetal weight : 1800g.
 AFI : 10cm

46.  Definitions
 Chronic hypertension is hypertension that is present at the booking
visit or before 20 weeks or if the woman is already taking
antihypertensive medication when referred to maternity services. It
can be primary or secondary in aetiology.
 Gestational hypertension is new hypertension presenting after 20
weeks without significant proteinuria.
 Pre-eclampsia is new hypertension presenting after 20 weeks with
significant proteinuria.
 Eclampsia is a convulsive condition associated with pre-eclampsia.
 HELLP syndrome is haemolysis, elevated liver enzymes and low
platelet count.

47.  What is significant proteinuria?
 If an automated reagent-strip reading device is used to
detect proteinuria and a result of 1+ or more is obtained,
use a spot urinary protein: creatinine ratio or 24-hour
urine collection to quantify proteinuria.
 Diagnose significant proteinuria if the urinary protein:
creatinine ratio is greater than 30 mg/mmol or a
validated 24-hour urine collection result shows greater
than 300 mg protein.

48.  What is the role of aspirin in preventing pre
eclampsia?
 women at high risk of pre-eclampsia to take 75 mg of aspirin*
daily from 12 weeks until the birth of the baby may reduce the
incidence of complication and IUGR

49.  When should aspirin be prescribed?
Women at high risk are those with any of the following:
 Hypertensive disease during a previous pregnancy
 Chronic kidney disease
 Autoimmune disease such as systemic lupus erythematosis
or antiphospholipid syndrome
 Type 1 or type 2 diabetes
 Chronic hypertension.

50. Advise women with more than one moderate risk factor for pre-
eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth
of the baby. Factors indicating moderate risk are:
 First pregnancy
 Age 40 years or older
 Pregnancy interval of more than 10 years
 Body mass index (BMI) of 35 kg/m2 or more at first visit
 Family history of pre-eclampsia
 Multiple pregnancy.
 When should aspirin be prescribed?

51.  Management of pregnancy with chronic
hypertension
 In pregnant women with uncomplicated chronic hypertension
aim to keep blood pressure lower than 150/100 mmHg.
 Offer pregnant women with target-organ damage secondary to
chronic hypertension (for example, kidney disease) treatment
with the aim of keeping blood pressure lower than 140/90
mmHg
 Do not offer birth to women with chronic hypertension whose
blood pressure is lower than 160/110 mmHg, with or without
antihypertensive treatment, before 37 weeks.

52.  Management of pregnancy with pre-eclampsia
DEGREE OF
Mild hypertension
to 149/ 99 mmHg)
Moderate hypertension (150/100 to
109 mmHg)
Severe hypertension (160/110 mmHg
higher)
Admit to hospital YES YES YES
TREAT With oral labetalol† as first-line treatment
to keep: diastolic blood pressure
between 80–100 mmHg systolic blood
pressure less than 150 mmHg
With oral labetalol† as first-line treatment
to keep: diastolic blood pressure between
80–100 mmHg systolic blood pressure less
than 150 mmHg
Measure blood pressure At least four times a day At least four times a day More than four times a day, depending on
clinical circumstances
Test for proteinuria Do not repeat
quantification of
proteinuria
Do not repeat quantification of
proteinuria
Do not repeat quantification of
proteinuria
Blood tests Monitor using the
following tests twice a
week: kidney function,
electrolytes, full blood
count, transaminases,
bilirubin
Monitor using the following tests three
times a week: kidney function,
electrolytes, full blood count,
transaminases, bilirubin
Monitor using the following tests three
times a week: kidney function, electrolytes,
full blood count, transaminases, bilirubin

53.  Timing of birth
 Manage pregnancy in women with pre-eclampsia conservatively
until 34 weeks, Preferably after a course of corticosteroids have
been given.

54. Foetal monitoring
 Carry out ultrasound foetal growth and amniotic fluid volume assessment
and umbilical artery doppler velocimetry starting at between 28 and 30
weeks (or at least 2 weeks before previous gestational age of onset if earlier
than 28 weeks) and repeating 4 weeks later in women with previous:
1. severe pre-eclampsia pre-eclampsia that needed birth before 34
weeks
2. pre-eclampsia with a baby whose birth weight was less than the 10th
centile
3. intrauterine death
4. placental abruption.

55. Anticonvulsants: when to use??
 If a woman in a critical care setting who has severe
hypertension or severe preeclampsia has or
previously had an eclamptic fit, give intravenous
magnesium sulphate*.
 Consider giving intravenous magnesium sulphate*
to women with severe preeclampsia who are in a
critical care setting if birth is planned within 24
hours.

56. Anticonvulsants: when to use??
 Mild or moderate hypertension and proteinuria with one or more of the
following:
1. Symptoms of severe headache
2. Problems with vision, such as blurring or flashing before the eyes
3. Severe pain just below the ribs or vomiting
4. Papilledema
5. Signs of clonus (≥3 beats)
6. Liver tenderness
7. HELLP syndrome platelet count falling to below 100 x 109 per litre
abnormal liver enzymes (ALT or AST rising to above 70 iu/litre).

57. Level of critical care in pre eclampsia
Level 3 Severe pre-eclampsia and needing ventilation
Level 2 Step-down from level 3 or severe pre-eclampsia with any of the following
complications:
– eclampsia
– HELLP syndrome
– haemorrhage
– hyperkalaemia
– severe oliguria
– coagulation support
– intravenous antihypertensive treatment
– initial stabilisation of severe hypertension
– evidence of cardiac failure
– abnormal neurology
Level 1 – Pre-eclampsia with mild or moderate hypertension
– Ongoing conservative antenatal management of severe preterm
hypertension
– Step-down treatment after the birth

58.  Advice regarding recurrence in future pregnancy
 Gestational hypertension in a future pregnancy ranges from about
1 in 8 (13%) pregnancies to about 1 in 2 (53%) pregnancies
 Pre-eclampsia in a future pregnancy is up to about 1 in 6 (16%)
pregnancies
 Pre-eclampsia in a future pregnancy is about 1 in 4 (25%)
pregnancies if their preeclampsia was complicated by severe pre-
eclampsia, HELLP syndrome or eclampsia and led to birth before
34 weeks, and about 1 in 2 (55%) pregnancies if it led to birth
before 28 weeks

59. CASE 4: HISTORY
 A 29 Years old G4P2L2A1 Previous LSCS (2 years back) B/d 7.4wks
presented with complains of pain in abdomen with mild vaginal
bleeding for 5 days
 Previous LSCS was done in view of Non Progress of labour 2years
back . She also gives history of a check curettage done 7 months
back in view of missed abortion.
 No history of fever chills or rigor
 No history of fall or trauma
 No history of any major medical or surgical illness

60. CASE 4: EXAMINATION
 General examination: Pallor +, no icterus , no oedema
 P 86/min
 BP 110/60
 Per Abdomen:
no distension, no rigidity , no guarding
pfannestial scar present, well healed
 P/S : minimal bleeding present
 Per Vagina : Uterus bulky

61. CASE 4: INVESTIGATIONS
 Hb 7.2g/dl,
 WBC 9200/cu mm
 Platelets 398000/cu mm
 BUN 8, Creatinine 0.6
 PT 14
 INR 1.0

62. CASE 4: SONOGRAPHY
 USG suggestive of single live
gestation of 10weeks at lower
anterior wall of the uterus.
 Endometrial cavity empty

63.  What is scar ectopic ?
What is the prevalence of scar ectopic?
 Caesarean scar pregnancy is defined as implantation
into the myometrial defect occurring at the site of
the previous uterine incision.
 The prevalence of caesarean scar pregnancy is
estimated to be approximately 1 in 2000 pregnancies
and these pregnancies may be ongoing potentially
viable pregnancies or miscarriages within the scar.
 It has been found that about 13% of CSP are missed
or misdiagnosed

64.  What are the differential diagnosis?
 Anterior cervical ectopic pregnancy
 Prominent C-section scar tissue
 Miscarriage in progress.

65.  What is the mechanism of scar ectopic
pregnancy?
 The most probable mechanism through which this can occur is
invasion of the myometrium through a microscopic tract.
 The tract is believed to develop from trauma due to previous
uterine surgeries like
1. Caesarean sections,
2. Dilatation and curettage,
3. Myomectomy,
4. Manual removal of the placenta,
5. Intra uterine contraceptive device (IUCD) insertions

66.  What is the mechanism of scar ectopic
pregnancy?
 There is no clear correlation between the risk of CSP and the
number of previous CS as most CSP occur after one previous CS.
 The risk of scar implantation might be proportional to the size of
the anterior uterine wall defect possibly due to larger surface area
induced by the scar.
 Elective CS for breech presentation in a previous pregnancy
appears to be most frequently associated with future risk of CSP.

67.  What are the types of scar ectopic?
Based on ultrasound scan findings and pregnancy progression, CSP is
classified into two types:
 Type one or endogenic CSP, is where implantation occurs on the
scar and the gestational sac grows towards the cervico-isthmic or
uterine cavity
 Type two or exogenic CSP, occurs when the gestational sac is
deeply embedded in the scar and the surrounding myometrium
and grows towards the bladder

68. Type one or endogenic Scar Pregnancy
Type two or exogenic Scar Pregnancy

69.  How is a caesarean scar pregnancy diagnosed?
 Ultrasound is the primary diagnostic modality,
using a transvaginal approach supplemented by
transabdominal imaging if required.
 Magnetic resonance imaging (MRI) can be used
as a second-line investigation if the diagnosis is
equivocal and there is local expertise in the MRI
diagnosis of caesarean scar pregnancies.

70.  What are the ultrasound criteria?
 Empty uterine cavity.
 Gestational sac or solid mass of trophoblast located anteriorly at
the level of the internal OS embedded at the site of the previous
lower uterine segment caesarean section scar.
 Thin or absent layer of myometrium between the gestational sac
and the bladder.
 Evidence of prominent trophoblastic/placental circulation on
Doppler examination.
 Empty endocervical canal.

71.  What biochemical investigations should be
carried out?
 A serum b-hCG level does not have a role in the diagnosis of
caesarean scar pregnancy.

72.  What are the various treatment options available?
 Medical management
 Surgical management
 Expectant management

73.  What are the available medical management
available?
 Primary medical treatment consists of using methotrexate, which
may be administered by local injection into the gestational sac
under ultrasound guidance or systemically by intramuscular
injection.
 Local injection seems to be a more effective means of terminating
the pregnancy.

74.  What are the disadvantages of medical
management?
 The disadvantage of using medical treatment is that the
trophoblast remains in situ; there is a risk of haemorrhage as the
retained, often very vascular, placental tissue degenerates
 So some authors have advocated using suction evacuation in
addition to methotrexate to hasten resolution and reduce the risk
of unpredictable haemorrhage in the follow-up period.

75.  What are the surgical options available?
Surgical treatment consists of:
 Evacuation of the pregnancy (using suction or hysteroscopic
resection)
 Excision of the pregnancy as an open, laparoscopic or transvaginal
procedure.
 Hysterectomy
 Suction evacuation is probably the most frequently described
procedure and has been combined with cervical cerclage, Foley
catheter insertion or UAE as additional haemostatic measures.

76.  When should expectant management be
employed?
 Expectant management may be suitable for women with small,
nonviable scar pregnancies
 It may be considered if the pregnancy is partially implanted into
the scar and grows into the uterine cavity
 Woman is counselled regarding the associated potential risks,
haemorrhage and morbidly adherent placentation, and she
declines termination of the pregnancy.

77.  Do rhesus D (RhD)-negative women with an
ectopic pregnancy require anti-D
immunoglobulin?
 Offer anti-D prophylaxis as per national protocol to all RhD-negative women
who have surgical removal of an ectopic pregnancy, or where bleeding is
repeated, heavy or associated with abdominal pain.

78.  What is the rate recurrence of scar ectopic?
 The risk of recurrence has been reported to be 3.2% -5% in
women with one previous CSP treated by dilatation and curettage
with or without uterine artery embolization

79.  What are the factors associated with
recurrence?
Factors associated with increased risk of recurrence include:
 Lower uterine segment thickness less than 5mm
 Gestational sac bulging into the utero-vesical fold
 Caesarean delivery in rural community hospital