Caesarean scar ectopic pregnancy: Pathogenesis, diagnosis and management strategies

Caesarean scar ectopic pregnancy (CSP) represents a rare but potentially catastrophic complication of modern obstetrics, characterised by blastocyst implantation within the fibrotic tissue of a previous hysterotomy scar. Mirroring the global rise in caesarean deliveries, CSP incidence is escalating, posing severe risks of uterine rupture and life-threatening haemorrhage. This comprehensive review elucidates the pathogenesis of CSP, identifying mechanisms such as microscopic scar dehiscence, uterine niches, and aberrant trophoblastic invasion into poorly vascularized tissue. We critically evaluate diagnostic challenges, affirming transvaginal ultrasonography (TVS) as the primary imaging modality, while highlighting the utility of MRI for superior anatomical delineation and preoperative planning. Therapeutic strategies are systematically examined, contrasting conservative medical management using methotrexate both systemic and local with definitive surgical interventions, including laparoscopic and hysteroscopic resection. Furthermore, the integration of adjunctive technologies like uterine artery embolization (UAE) is discussed as a vital measure for haemorrhage control and fertility preservation. The review concludes by addressing the long-term reproductive implications of CSP, including the risk of placenta accrete spectrum disorders, and advocates for a multidisciplinary approach to optimize maternal safety and improve clinical outcomes.