Location: lower uterine segment
Prerequisite: Some intra-luminal dehiscence at the cesarean section site, sufficient to let a fertilized egg pass into.
The onset of symptoms is usually during the first trimester. Symptoms usually consist of vaginal bleeding or abdominal pain. Some patients may be asymptomatic with diagnosis made on routine ultrasonography.
Most cases can be diagnosed by endovaginal ultrasonography (sensitivity 85%). Diagnostic accuracy is improved if it is suspected.
Complications:
(1) massive hemorrhage
(2) uterine rupture
(3) loss of fertility (if an emergency hysterectomy is performed)
(4) placenta accreta
Dilation and curettage is associated with serious maternal complications and may not be successful in removing a conception deep within the myometrium.
Management before onset of complications - one or more of the following:
(1) Wedge resection and repair at the implantation site, done either at laparotomy or with laparoscopy.
(2) Administration of methotrexate. Systemic therapy alone is used if the serum beta-HCG is < 5,000 mIU/mL. Systemic plus intragestational methotrexate is used at high HCG levels, with or without injection of potassium chloride into the gestational sac.
(3) Selective uterine artery embolization to control hemorrhage.
