CASE OF SCAR PREGNANCY MISDIAGNOSED FIRST AS INEVITABLE MISCARRIAGE.

: This abstract is about scar pregnancy case which was initially misdiagnosed as a case of inevitable miscarriage. Our patient g3 p1+1 presents in ERE as 7 weeks pregnancy with mild bleeding p/v. she was previous 1 LSCS. After scan and per speculum examination diagnosed as inevitable miscarriage as RPOCS was seen protruding through internal os on speculum examination. Patient was admitted for misoprostol as advised by consultant. Patient did not abort after Misoprostol. Consultant advised for evacuation under general anesthesia. As soon as registrar tried to hold RPPOCS with sponge holder patient started bleeding heavily. Registrar abandoned the procedure and called consultant on call. Consultant first tried to stop bleeding by compression methods but failed, so diagnosis of scar pregnancy with possible perforation was made and laparotomy started and RPOCS removed from scar and uterus closed in layers. Hemostasis secured with difficulty bilateral tubal ligation done, vasopressin given and vertical compression sutures applied. (GTG NO 21 / 2016 NICE clinical guideline 154. Manchester: NICE; 2012). Abdomen closed in layers. In ward 2 units of packed RBCS transfused. Patient discharged in stable condition on second postoperative day.


INTRODUCTION
Cesarian scar pregnancy is an early pregnancy complication in which a pregnancy implants in the scar from a previous cesarean delivery.It can be categorized in 2 types.In type 1 pregnancy sac is implanted on the scar and starts growing inside the uterine cavity.In type 2 the sac is attached to the previous caesarian section scar and develops outside in the direction of bladder.Diagnosis is by TVS and also by MRI. ( Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy.Hum Reprod 2007;22: : NICE; 2012) It is a condition which can lead to significant morbidity if misdiagnosed or not properly treated.We report a case of scar pregnancy which is first diagnosed as a case of inevitable miscarriage.Scar pregnancy is uncommon but if its diagnoses is missed it can lead to significant morbidity or mortality.Here risk factor is previous LSCS, so risk factor in history should be kept in mind.( .Ankum WM, Mol BW, Van der Veen F, Bossuyt PM.Risk factors for ectopic pregnancy: a meta-analysis.Fertil Steril 1996;65:1093-9. ) Case Report: 30-year-old, G3, Para 1+1 previous 1 caesarean section came to emergency department as 7 weeks intrauterine pregnancy with bleeding p/v, on speculum examination, OS was open and products seen at upper part of the cervix.On ultrasound no fetal heartbeat was appreciated so she was diagnosed as a case of missed miscarriage presented as inevitable miscarriage.As bleeding was mild so she was admitted in ward and advised stat dose of misoprostol.But she didn't pass out products of conception, so consultant advised for evacuation of products under general anesthesia.Registrar started evacuation as routine and as soon as the products were pulled with sponge holding forceps, Patient started to have intractable bleeding, consultant on call was called, at first consultant tried to stop the bleeding by compression methods, but failed, so provisional diagnoses of scar pregnancy with scar rupture was made and immediate laparotomy was done and uterine cavity opened and scar pregnancy was removed and homeostasis was made with difficulty.Bilateral uterine artery ligation done and then vertical compression sutures applied on uterus.Abdomen was closed and 2 units of packed RBC'S were transfused.(GTG NO 21/ 2016.131-4 Tay JI, Moore J, Walker JJ.Ectopic pregnancy.West J Med 2000;173)

DISCUSSION
Caesarian scar pregnancy is defined as when pregnancy is implanted at the site of previous uterine incision of caesarian, where there is defect in myometrium.
Scar pregnancy although uncommon but if missed, it is a life-threatening condition.It is important for clinicians to know that ultrasound is the first line investigation for diagnosis, sometimes along with transvaginal scan an addition of transabdominal approach is helpful for diagnosis.( GTG NO21 /2016).The transvaginal scan diagnostic criteria for scar pregnancy include ; uterine cavity is clear, gestational sac located at the site of previous lower segment caesarian section, between gestational sac and bladder no myometrial tissues , doppler shows marked circulation , cervical canal is also clear.
As a second line diagnostic tool MRI can be used, if the diagnosis is not clear, provided experts in the MRI diagnosis of caesarian scar pregnancies are available.(GTG /21 /2016).
If the caesarean section scar pregnancy is diagnosed, patient and family should be properly counselled about possibility of severe maternal morbidity and mortality.Recent literature suggests a surgical management is better than medical management.
In this case there is a delay in diagnoses of scar pregnancy as from the beginning on speculum examination OS was open and products seen at upper part of the cervix so misdiagnosed as inevitable.Later on, diagnosed when she was in operation room for evacuation when she started bleeding excessively, as morning time, so consultant was around and the patient was managed properly without any delay.Scar pregnancy should be considered as a possibility in any cases where pregnancy sac is seen in lower part of uterine cavity on scan with history of previous caesarian section.Correct diagnosis with efficient management can prevent possible complications.(GTG/ NO 21// 2016, .Bouyer J, Coste J, Shojaei T, Pouly JL, Fernandez H, Gerbaud L, et al.Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France.Am J Epidemiol 2003;157:185-94), Thirty percent of scar pregnancy cases are initially falsely diagnosed as either intrauterine or cervical pregnancies.The true prevalence of such cases, is not known as many cases are undiagnosed and regarded as first trimester miscarriages or termination.