Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.

1. SCAR ECTOPIC

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. ECTOPIC PREGNANCY
• The word "ectopic" means "out of place“.
• The blastocyst normally implants in the endometrial
lining of the uterine cavity. Implantation anywhere else is
considered an ectopic pregnancy. (WHO)
• The first known description of an ectopic pregnancy is
by Albucasis in the 11th century.
Abulcasis an Arab Mu
slim physician and surg
eon

4. SITES OF ECTOPIC PREGNANCY
The most common sites for an ectopic pregnancy are the
• Ampullary mid portion of the fallopian tube (80-90%),
• Isthmic portion of the fallopian tube (5-10%),
• Fimbrial end of the fallopian tube (about 5%),
• Cornual (1-2%),
• Abdomen (1-2%),
• Ovary (< 1%),
• Cervix (< 1%).
• Previous Uterine Scar (< 1%)

5. INCIDENCE
• Ectopic pregnancy accounts for 4 to 10 percent of all pregnancy
related deaths.
• The overall rate of EP is 1–2 % in the general population, and 2–
5 % among patients who have utilized assisted reproductive
technology (ART). *
• The natural incidence of these heterotopic pregnancies
approximates 1 per 30,000 pregnancies.
• Rarely, twin tubal pregnancy with both embryos in the same
tube or with one in each tube has been reported. #
* Practice Committee of the American Society for Reproductive Medicine. Medical treatment of
ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100:638–44.
# Eze, J.N., Obuna, J.A. and Ejikeme, B.N. (2012) Bilateral Tubal Ectopic Pregnancies: A Report of
Two Cases. Annals of African Medicine, 11, 112-115.

6. INCIDENCE

7. RISK FACTORS
RISK FACTORS RELATIVE RISKS
Previous Ectopic Pregnancy 3 – 13
Tubal Corrective Surgery 4
Tubal Sterilization 9
Intrauterine Device 1 – 4.2
Documented Tubal Pathology 3.8 – 21
Assisted Reproductive Technique 2 – 8
Chlamydia 2
Prior Caesarean Section 1 – 2.1
Prior Abortion 0.6 – 3
Smoking 1.7 – 4
Multiple Sex Partners 1.6 – 3.5

8. SCAR ECTOPIC
• Caesarean scar pregnancy (CSP) is an ectopic
pregnancy implanted in the myometrium at the site of
a previous caesarean section scar.
• Caesarean scar pregnancy was first described in 1978
in a South African Journal by Larsen and Solomon. *
• It was recently estimated that 1 in 531 women with a
caesarean scar will have a CSP.
• Prevalence of 1:1800 in total women attending the
early pregnancy assessment.
* Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus--an unusual cause of postabortal haemorrhage.
A case report. S Afr Med J 1978; 53:142-3.

9. SCAR ECTOPIC
• CSP has been described in spontaneously
conceived pregnancy as well as after in vitro
fertilisation (IVF) and embryo transfer.
• IVF associated heterotopic CSP, a rarer event, has
also been described, both with twins and triplets. *
• The gestational age at diagnosis ranged from 5 to
12.4 weeks.
* Hsieh BC, Hwang JL, Pan HS, Huang SC, Chen CY, Chen PH. Heterotopic Caesarean scar
pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for
selective embryo reduction: case report. Hum Reprod 2004;19:285–7

10. NATURAL HISTORY
• Very few of these pregnancies reported in the literature
progressed beyond first trimester.
• A pregnancy in a caesarean section scar were to continue
to the second or third trimesters, there would be a
substantial risk of uterine rupture with catastrophic
haemorrhage, with a high risk of hysterectomy causing
serious maternal morbidity and loss of future fertility.
• If the pregnancy continues within the uterus, the risk of
placenta accreta is significantly increased, up to three- to
five-fold.

11. NATURAL HISTORY
• A pregnancy that protrudes through the scar, if viable, can
implant on other abdominal organs and continue to grow as a
secondary abdominal pregnancy.
• A Caesarean Scar Pregnancy progressing to 35 weeks of
gestation has been described in British Journal in 1995. *
• But this case was complicated by massive haemorrhage and
disseminated intravascular coagulopathy at CS, requiring a
life-saving hysterectomy.
* Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and
outcome of isthmic pregnancy located in a previous caesarean section scar. Br J
Obstet Gynaecol 1995;102:839–41.

12. WHY THERE IS AN INCREASE IN
SCAR ECTOPIC?
• TRUE INCREASE : as there is tremendous increase in
caesarean section rate, the rates of caesarean scar
pregnancy has also gone up.
• Half of the reported CSP cases have been published within
the last year, primarily from China. This bias in contribution
by country is most likely explained by the high frequency of
CS rates (two to four million per year)
• FALSE INCREASE : with improved diagnostic techniques,
like 3D Sonography and MRI , Diagnosing CSP is becoming
more and more common.

13. TYPES
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

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

15. PATHOPHYSIOLOGY
• In CSP, the gestation sac is completely surrounded by
myometrium and the fibrous tissue of the scar, quite
separate from the endometrial cavity.
• The most probable mechanism is that there is invasion of
the myometrium through a microtubular tract between the
caesarean section scar and the endometrial canal.
• Such a tract can also develop from the trauma of other
uterine surgery, e.g. curettage, myomectomy, metroplasty,
hysteroscopy and even manual removal of placenta.

16. PATHOPHYSIOLOGY
• 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.
• The impact of the time interval between the previous caesarean
sections and the subsequent CSP implantation is also not clear.

17. CLINICAL PRESENTATION
• CSP may present from as early as 5–6 weeks5 to as late as
16 weeks.
• A light, painless vaginal bleeding (39%).
• Abdominal pain with bleeding (16%)
• Only abdominal pain (9%)
• Incidental finding in an asymptomatic woman (37%).
• Severe acute pain with profuse bleeding implies an
impending rupture.
• Collapse or haemodynamic instability strongly indicates a
ruptured CSP.

18. DIAGNOSIS
ULTRASOUND
• Ultrasound is the first-line diagnostic tool for CSP.
• The following ultrasound criteria have been put forward for
the diagnosis of a CSP.
1. An empty uterine cavity, without contact with the sac
2. A clearly visible empty cervical canal, without contact
with the sac
3. Presence of the gestation sac with or without a fetal
pole with or without fetal cardiac activity (depending
on the gestation age) in the anterior part of the
uterine isthmus, and
4. Absence of or a defect in the myometrial tissue
between the bladder and the sac.

19. DIAGNOSIS
DOPPLER
• Shows distinct circular peritrophoblastic perfusion
surrounding the gestation sac and can help show the
relation of placenta to the scar and bladder.
THREE DIMENSIONAL ULTRA SOUND
• New 3-D colour Doppler imaging technique (termed 3-
D-virtual organ computer-aided analysis [VOCAL])
can be used to monitor the quantification of changes of
uterine neovascularisation characteristics before and
after successful treatment of CSP. *
* Chou MM, Hwang JI, Tseng JJ, Huang YF, Ho ESC. Cesarean scar pregnancy: Quantitative assessment of
uterine neovascularization with 3- dimensional color power Doppler imaging and successful treatment
with uterine artery embolization. Am J Obstet Gynecol 2004;190:866–8.

20. DIAGNOSIS
MRI
• MRI can measure the volume of the lesion and thus help
assess the indication and success of local methotrexate
(MTX), with an added advantage that it can also improve
intraoperative orientation.
DIAGNOSTIC LAPAROSCOPY
• The uterus is usually seen normal sized or bulky with the
CSP arising as a hillock with a ‘salmon red’ ecchymotic
appearance, bulging the uterine serosa from the
previous caesarean section scar behind the bladder.

21. HISTOPATHOLOGY *
• The myometrium usually thins out to merge with the thin
and fibrous scar of previous caesarean section.
• The placental attachment in the lower segment may lack
both decidua basalis and myometrium, merely consisting
of some connective tissue.
• These microscopic features coupled with absence of
surrounding endocervical glands confirm a CSP and rules
out a cervical pregnancy.
• Immunostaining with b-human chorionic gonadotrophin
(bhCG) and desmin confirm the presence of trophoblast
cells within smooth myometrial muscle fibres.
* European Society of Human Reproduction and Embryology

22. DIFFERENTIAL DIAGNOSIS
1. Spontaneous Abortion : the gestation sac should be
seen in the cervical canal on TVS, and on colour flow
Doppler, the sac should appear avascular, indicating that
the sac has been detached from its implantation site, in
contrast to the well-perfused CSP located in its unique
site.
2. Cervicoisthmic Pregnancy :unlike a CSP, there would be
a layer of healthy myometrium visible between the
bladder and the gestation sac on USG and bleeding as
the presenting symptom is much heavier.
3. Trophoblastic Tumour
4. Very low implanted intrauterine pregnancy

23. MANAGEMENT
• Treatment of CSP should be evidence based and focus on
prevention of severe complications and conservation of fertility.
• A recent article from Timor-Tritsch and Monteagudo identified
31 different primary treatment options in 751 women with CSP.
*
• American Society of Reproductive Medicine published a largest
systematic review treatment studies for CSP in January 2016. It
included 14 treatment modalities.
* Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta
accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012;207:14–29.

24. MANAGEMENT
I. EXPECTANT
MANAGEMENT
II. MEDICAL
MANAGEMENT
III. SURGICAL
MANGEMENT
II.A Systemic Methotrexate
II.B Local injection of
embryocides
II.C Combined medical
treatment
II.D Medical treatment
combined with surgical sac
aspiration
III.A Uterine curettage
III.B Hysteroscopic
evacuation
III.C Laparoscopic removal
III.D Primary open surgical
treatment
III.E Hysterectomy
IV. OTHERS
IV.A High-intensity Focused
Ultrasound Ablation
IV.B High-intensity Focused
Ultrasound with
Hysteroscopic Suction
Curettage

25. I. EXPECTANT MANAGEMENT
• If woman does not wish to have a TOP and wants to
continue the pregnancy, and there is sonographic
evidence of the sac growing towards the uterine cavity,
an EXPECTANT Management can be considered at life
threatening risks.
• The minimum thickness of the myometrium anterior to
the CSP sac to warrant safety of a continuing pregnancy
is unknown.
• An elective delivery by caesarean section around 28–30
weeks with antenatal corticosteroid administered 24–48
hours before delivery.
• The efficacy is low (41.5%), and the complication rate is
high (53.7%).

26. II. MEDICAL MANAGEMENT
II.A Systemic Methotrexate
II.B Local injection of embryocides
II.C Combined medical treatment
II.D Medical treatment combined with
surgical sac aspiration

27. II.A SYSTEMIC METHOTREXATE
• Dose : single dose of 50 mg/m2 IM
• CRITERIA: Hemodynamically stable
Patients without pain
Gestation age < 8 weeks
Myometrium thickness <2 mm between
pregnancy and the bladder
Serum hCG < 5000IU/L
Gestation sac <2.5 cm
No foetal heart
• Complications rate is 13%

28. II.B LOCAL INJECTION OF EMBRYOCIDES
• Local injection of MTX, potassium chloride (KCl), hyperosmolar
glucose36 and crystalline trichosanthin have been used for
termination of CSP, but Methotrexate is the preferred agent.
• Under ultrasound guidance, MTX can be injected locally to the
gestation sac via transabdominal or via transvaginal route.
• The usual technique for injection of MTX uses 20- to 22-gauge
needle.
• 16-gauge double-lumen oocyte-retrieval IVF needles ensure
better aspiration of the trophoblastic tissue via one lumen and
injection of MTX through the other.

29. II.C COMBINED MEDICAL TREATMENT
• Combined medical treatment in varying regimens has
been described by many authors.
• Local injection of 8 mEq potassium chloride (2 mEq/ml)
followed by 60 mg of MTX injected into the gestation
sac.
• Direct injection of 3 ml of 50% glucose plus oral MTX (2.5
mg three times a day for 5 days)
• Cervical injection of crystalline trichosanthin (1.2 mg)
followed by oral mifepristone (50 mg orally every 12
hours for 3 days) or intramuscular MTX and systemic
MXT followed by oral mifepristone.

30. II.D MEDICAL TREATMENT COMBINED
WITH SURGICAL SAC ASPIRATION
• Medical treatment has therefore been combined with surgical
aspiration of the sac in some cases. Various sequences of combination
have been described:
1. Local potassium chloride / TVS-guided sac aspiration / local MTX
injection / intramuscular MTX injection
2. Systemic MTX / TVS-guided sac aspiration
3. Sac aspiration (transvaginal or transabdominal) / local or sytemic
MTX injection
4. Systemic MTX / sac aspiration by vaginal route / local MTX.
• Ultrasound guided D n C with methotrexate is the most common
treatment modality.

31. III. SURGICAL MANGEMENT
III.A Uterine curettage
III.B Hysteroscopic evacuation
III.C Laparoscopic removal
III.D Primary open surgical treatment
III.E Hysterectomy

32. III.A UTERINE CURETTAGE
• The gestation sac of a CSP is not actually within the uterine
cavity. Therefore, not only the trophoblastic tissue is
unreachable by the curette but also such attempts can
potentially rupture the uterine scar.
• Suction curettage can be done under ultrasound guidance
when gestation is < 7 weeks and the myometrial thickness
anterior to the CSP is >3.5 mm. *
• Adjuvant haemostatic measures like local injection of
vasopressin, intrauterine balloon tamponade, bilateral uterine
artery embolization might be required
• Complication rate 21%
* Arslan M, Pata O, Dilek TU, Aktas A, Aban M, Dilek S. Treatment of viable cesarean scar
ectopic pregnancy with suction curettage. Int J Gynecol Obstet 2005;89:163–6

33. III.B HYSTEROSCOPIC EVACUATION
• Successful treatment of CSP by operative hysteroscopy
and suction curettage in 2005 by Chang et al *
• The gestational sac is dissected free of the uterine wall
through a natural entrance, and hemostasis can be
achieved with electro-coagulation using a wire-loop or
roller-ball.
• A balloon catheter can be placed postoperatively for
compression haemostasis and wound surface drainage.
• Complication rate 3.1%
* Sugawara J, Senoo M, Chisaka H, Yaegashi N, Okamura K. Successful conservative
treatment of a caesarean scar pregnancy with uterine artery embolisation. Tohoku J
Exp Med 2005;206:261–5.

34. III.C LAPAROSCOPIC REMOVAL
• Lee et al. were the first to perform a successful
laparoscopic resection of a CSP in 1999.*
• The CSP mass is incised and the pregnancy tissue
removed in an endobag.
• Bleeding can be minimised by local injection of
vasopressin (1 unit/ml, 5–10 ml)
• Haemostasis achieved by bipolar diathermy and the
uterine defect closed with endoscopic suturing.
• The success rate was very high (97.1%), and there were
no reported severe complications.
* Lee CL, Wang CJ, Chao A, Yen CF, Soong YK. Laparoscopic management of an ectopic pregnancy in a
previous caesarean section scar. Hum Reprod 1999;14:1234–6.

35. III.D PRIMARY OPEN SURGICAL
TREATMENT
• Laparotomy followed by wedge resection of the
lesion should be considered in women who do not
respond to conservative medical and facilities for
endoscopy are not available.
• Laparotomy is mandatory when uterine rupture is
confirmed or strongly suspected.
• Some consider this as the best treatment option, as
the excision of the old scar removes the
microtubular tracts and thus reduces the risk of
recurrence.
• However, there is higher chance of placenta accrete
latter on.

36. III.E HYSTERECTOMY
• Hysterectomy is not advised as a primary procedure of
treatment except in cases of intractable haemorrhage
due to rupture.
• It is generally used as a last resort to previously failed
procedures or any life threatening complications of the
procedures.

37. IV. OTHER TREATMENT MODALITIES
IV.A Repeated High-intensity Focused Ultrasound
Ablation
• HIFU beams are precisely focused on a small region of
diseased tissue to locally deposit high levels of energy.
The temperature of tissue at the focus will rise to between
65° and 85 °C, destroying the diseased tissue
by coagulative necrosis.
• This novel treatment modality was only described in one
high-quality case series of 16 women with treatment
failure or complication. *
* Xiao J, Zhang S, Wang F, Wang Y, Shi Z, Zhou X, et al. Cesarean scar pregnancy:
noninvasive and effective treatment with high-intensity focused ultrasound. Am J Obstet
Gynecol 2014;211:356.e1–7

38. IV. OTHER TREATMENT MODALITIES
IV.B Repeated High-intensity Focused Ultrasound
with Hysteroscopic Suction Curettage
Similarly, this novel modality was described in
another high quality case series of 53 women, with a
success rate of 100% and no complications. *
* Zhu X, Deng X, Wan Y, Xiao S, Huang J, Zhang L, et al. High-intensity focused ultrasound
combined with suction curettage for the treatment of cesarean scar pregnancy. Medicine
(Baltimore) 2015;94:e854

39. TREATMENT MODALITY CASES
(n)
SUCCESSS
RATE %
COMPLICATION
RATE %
HYSTERECTOMY
(n)
BLOOD
TRANSFUSION
REQUIRED
LAPAROTOMY
(n)
I. EXPECTANT
MANAGEMENT
41 41.5% 53.7% 17 5 0
II.A SYTEMIC
METHOREXATE
339 75.2% 13% 10 25 9
II.B LOCAL
METHOTREXATE
74 64.9% 4.1% 0 0 3
II.C LOCAL +SYSTEMIC
METHOTREXATE
427 68.6% 2.8% 2 8 1
II.D SAC ASPIRATION
+METHOTREXATE
148 84.5% 13.5% 9 9 2
III.A UTERINE CURETTAGE 243 48.1% 21 11 37 3
III.B HYSTEROCOPIC
REMOVAL
95 83.2% 3.2% 1 0 2
III.C LAPAROSCOPIC
REMOVAL
69 97.1% 0% 0 0 0
IV.A HIFU 16 100% 0% 0 0 0
IV.B HIFU + SUNCTION
CURRETAGE
53 100% 0% 0 0 0

41. FUTURE PREGNANCY
• Uneventful future pregnancies have been reported after
all modalities of conservative management of a CSP.
• The largest study shows a 50% CSP cases were followed
by uneventful pregnancy, with a mean interval of 13.3
months (range 3–34 months) between the previous CSP
and subsequent pregnancy. *
• 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.
* Seow K-M, Hwang J-L, Tsai Y-L, Huang L-W, Lin Y-H, Hseih B-C. Subsequent pregnancy outcome after
conservative treatment of a previous caesarean scar pregnancy. Acta Obstet Gynecol 2004;83:1167–72

42. CASE 1: 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

43. CASE 1: 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

44. 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

45. CASE 1: SONOGRAPHY
• USG suggestive of single live gestation
of 10weeks at lower anterior wall of the
uterus.
• Endometrial cavity empty

46. • This was a case of unruptured CSP.
• Patient was taken for Laparoscopic Removal of
Caesarean Scar Pregnancy electively.
• Intraoperatively Bilateral Internal Iliac Artery Ligation was
first, to reduce the bleeding.

48. CASE 2 : HISTORY
• A 32 years old G3P2L2 previous 2 LSCS B/D 6 weeks wanted
Medical Termination of pregnancy.
• Patient did not have any other significant medical or surgical history.
• Patient had taken MTP pills, but, did not have any withdrawal
bleeding.
• Patient was vitally stable.
• All routine investigations were normal.
• USG was done.

49. CASE 2 : SONOGRAPHY
• TVS was suggestive of an empty uterine and
cervical cavity with a Gestation Sac growing
in the lower anterior uterine wall.
• There was a very thin tissue between the
gestation sac and the bladder.
• A diagnosis of Caesarean Scar Pregnancy
was made on the basis of USG findings.

50. CASE 2 : MANAGEMENT
• Patient was put on Inj Methotrexate 50mg IM , 3 dose alternated with folinic acid.
• CBC, Liver and Renal Functions were monitored.
• On Day7 Beta- hcg decreased by 15%.
• Sonography was repeated.
• USG showed a non viable embryo in the lower anterior uterine wall.
• Suction and Evacuation with MVA cannula under USG guidance was attempted.
• Patient had an uncontrollable bleeding and became vitally unstable.
• Patient was referred to her centre i/v/o ?Uterine Rupture.

51. CASE 2 : MANAGEMENT
• Patient was immediately taken for Emergency
Exploratory Laparotomy with SOS Obstetric
Hysterectomy.
• Intraoperatively : Uterus had ruptured at
Caesarean scar and remnants of gestation sac
was seen at the Scar
Decision do an Obstetric
Hysterectomy was taken.

52. CONCLUSIONS
• Embryo implantation in the region of a previous caesarean section scar is a rare
but potentially catastrophic complication of a previous caesarean birth.
• The exponential rise in its incidence during the past 5–6 years may be because of
rising caesarean section rate worldwide.
• Ultrasound diagnosis by TVS and colour flow Doppler, which yields a high
diagnostic accuracy—this is expected to emerge as a future gold standard.
• There is plethora of treatment modalities available, but there is no guidelines
available regarding the management or follow up of CSP.

53. REFERENCES
• Fertility and Sterility® Vol. 105, No. 4, April 2016 0015-0282/$36.00 Copyright ©2016 American Society for
Reproductive Medicine, Published by Elsevier Inc
• Caesarean scar pregnancy, A Ash, A Smith, D Maxwell, BJOG: An International Journal of Obstetrics &
GynaecologyVolume 114, Issue 3, Version of Record online: 13 FEB 2007
• Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and outcome of isthmic
pregnancy located in a previous caesarean section scar. Br J Obstet Gynaecol 1995;102:839–41.
• Seow K-M, Hwang J-L, Tsai Y-L, Huang L-W, Lin Y-H, Hseih B-C. Subsequent pregnancy outcome after
conservative treatment of a previous caesarean scar pregnancy. Acta Obstet Gynecol 2004;83:1167–72
• Practice Committee of the American Society for Reproductive Medicine. Medical treatment of ectopic
pregnancy: a committee opinion. Fertil Steril. 2013;100:638–44.
• Eze, J.N., Obuna, J.A. and Ejikeme, B.N. (2012) Bilateral Tubal Ectopic Pregnancies: A Report of Two Cases.
Annals of African Medicine, 11, 112-115.
• Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early
placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012;207:14–29