Heterotopic cesarean scar pregnancy: how should it be managed?

Heterotopic cesarean scar pregnancy is an extremely rare condition that may cause life-threatening complications. A 24-year-old woman gravida 2, para 1, presented with vaginal bleeding. Vaginal sonography demonstrated 2 gestational sacs containing viable embryos, one located in the uterine fundus and the other in the previous cesarean scar. Fetal reduction of the cesarean scar pregnancy was performed with intracardiac KCl injection and the ongoing intrauterine pregnancy was delivered by cesarean section at 34 week's gestation. To prevent serious complications and preserve intrauterine pregnancy, heterotopic cesarean scar pregnancy must be diagnosed early in gestation. Favorable pregnancy outcome can be achieved with conservative management. However, such management increases the risk of massive bleeding during ongoing pregnancy and cesarean section.