CESAREAN SCAR PREGNANCY

Definition of scar pregnancy: A cesarean scar pregnancy is when the current gestational sac implants where the uterus was cut in a previous cesarean section.

Incidence of scar pregnancy: Contrary to the literature, the incidence is high and increasing. Every placental adhesion or invasion anomaly (placenta acreata, increata, percreata) is actually a scar pregnancy. In addition, when unnecessarily misdiagnosed scar pregnancies are added, contrary to popular belief, the frequency is higher.

Is every placenta percreata a scar pregnancy? Yes, it is a scar pregnancy (provided that the partner, the placenta, is implanted instead of the previous cesarean section).

Diagnosis of scar pregnancy: It is diagnosed by ultrasound.

What are the difficulties in diagnosing a scar pregnancy? Due to misdiagnosis in the early weeks of pregnancy, a normal pregnancy can be wrongly terminated. In addition, a late diagnosis at 9 or 10 or more weeks of gestation can lead to a missed diagnosis of a true scar pregnancy.

Experience is the most important factor in diagnosing a caesarean scar pregnancy.

Is every scar pregnancy a true scar pregnancy? No. Some are normal pregnancies. A true scar pregnancy is often confused with a low-lying sac.

Is a gestational sac located in the area of the caesarean section (incision site) a scar pregnancy or does it progress to a scar pregnancy? Not every gestational sac located in the lower part of the uterus is a scar pregnancy. Not every gestational sac located below the uterus progresses to a scar pregnancy.

Unfortunately, very early in pregnancy, such as in the 5th or 6th or even 7th week of pregnancy, a gestational sac that is located in the lower part of the uterus, that is, in the place of the cesarean incision, is mistakenly considered as a cesarean scar pregnancy all over the world.

The trick is to understand whether the placenta, not the gestational sac, is located at the cesarean incision site; however, this is not very easy because the diagnosis ofscar pregnancy is difficult because the placenta is in the early formation stage.

OUR EXPERIENCES: Having diagnosed and followed up more than 150 cesarean scar pregnancies and delivered these pregnancies, our opinion is that in some cases, even if the placenta settles at the cesarean incision site, it does not progress to placental adhesion anomaly (placenta percreta) in the following weeks of pregnancy.

It is possible to reach a final decision after close follow-up of these cases.

Moreover, even if the scar pregnancy turns into placenta percreta, considering that we do not remove the uterus in every case of placenta percreta, we should not terminate pregnancies very willingly.

According to our experience, about 25% of the cases diagnosed as scar pregnancy are not scar pregnancies. In other words, unfortunately, one out of every 4 pregnancies is unnecessarily terminated due to scar pregnancy.

Some of the cases who came to our clinic or received information by phone reported that their pregnancies were terminated because they were diagnosed with scar pregnancy and that they could not conceive again even though they wanted to. In short, these pregnancies are unnecessarily terminated because those who do not perform scar pregnancy or placenta percreta surgery mislead patients.

Does every scar pregnancy become placenta percreta? No.

Not all scar pregnancies progress to placenta percreta, a more severe adhesion anomaly, in the following weeks. Even if it progresses, not all cases of placenta percreta require hysterectomy, i.e. uterine-sparing placenta percreta surgery. In severe cases of percreta, hysterectomy is difficult andrequiressurgical experience.

NOTE: We do not guide our patients with only literature or classical book knowledge. Our knowledge consists of the follow-up of around 600 cases of percreta (and on average 150of this number are scar pregnancies). There is no center in the literature or in the world that reaches this number. Therefore, if the existing scar pregnancy is a very desirable pregnancy, it should be given a chance of pregnancy and its management should be well planned. Because the same pregnant woman may not have a chance of pregnancy later on. Planning and management should be family-specific.

The danger in diagnosing scar pregnancy: Diagnosis can be misleading in the early weeks of pregnancy, and in the later weeks of pregnancy, the diagnosis of severe scar pregnancy may be delayed.

We provide good follow-up and planning according to the family’s expectations and circumstances.

Scar pregnancy surgery: Generally, laparoscopic surgery is performed; a good repair should be done laparoscopically considering subsequent pregnancies.

In large cases with advanced gestational week, laparotomy is more logical for a better repair.

Can scar pregnancy occur again after scar pregnancy? It may not happen.

Therefore, if it is to be terminated, good repair surgery should be performed in experienced hands so that it does not turn into a severe case if it recurs.

In addition, when terminating a scar pregnancy, many factors such as the expectations of the family, the age of the patient, how much the family wants the current pregnancy or what the chances of the next pregnancy may be should be discussed repeatedly with the family, the ideal way should be chosen and comprehensive counseling should be given.

NOTE: The diagnosis, treatment, follow-up and management of scar pregnancy should be patient-specific, well planned and counseled.