Navigating Outcomes and Tailored Treatment Choices in a Cesarean Scar Ectopic Pregnancy: Insights From Five Cases in a Resource-Limited Facility

Once considered a rare entity, cesarean scar pregnancy (CSP) is now increasingly encountered. However, relatively little is known about its clinical characteristics and management due to the lack of large population-based studies. It results from implantation of a gestational sac within the fibrous scar of a previous cesarean section. Despite increasing awareness, there is no standardized management protocol, which can lead to delayed diagnosis and considerable variation in treatment approaches and outcomes. We report five cases of CSP managed at a tertiary care center between 2023 and 2024. The patients were 27 to 38 years of age, had one to two previous cesarean deliveries, and presented at gestational ages ranging from seven to nearly 17 weeks. Initial presenting complaints included vaginal bleeding, passage of a fleshy mass, and abdominal pain. Two patients had used over-the-counter medical termination kits, and one had a history of failed suction and evacuation. The diagnosis was established primarily by ultrasonography, with serum beta-human chorionic gonadotropin (hCG) used to support the diagnosis and monitor treatment response. Management was individualized: One patient was initially treated with methotrexate and mifepristone but required emergency laparotomy because of persistent vaginal bleeding; another underwent scar site resection and repair after hemodynamic stabilization; a third, with suspected arteriovenous malformation, required bilateral uterine and internal iliac artery ligation before scar excision; a fourth underwent hysterectomy; and the fifth underwent scar excision with concurrent bilateral tubal ligation. There were no maternal deaths, and all patients were discharged in stable condition. These cases demonstrate the varied clinical presentations and management challenges associated with CSP, including misdiagnosis and the need for individualized treatment ranging from conservative, fertility-preserving surgery to hysterectomy. CSP can mimic incomplete abortion and, if misdiagnosed and treated with unsupervised medical termination kits, can lead to catastrophic hemorrhage and potentially fatal outcomes. Therefore, obstetricians should maintain a high degree of suspicion for scar ectopic pregnancy in women with a history of cesarean section who present with early pregnancy bleeding. Early diagnosis and individualized, timely management - medical, surgical, or a combination of both - can achieve satisfactory maternal outcomes and, in many cases, preserve future fertility.