Abortion in evolution, caesarean scar pregnancy, and cervical ectopic: discerning the triplets on ultrasound

On the second day of my clinical observership in the Obgyn Department of the Vienna University Hospital, I saw a suspected case of caesarean scar pregnancy on follow-up, with one of my very senior professors, in the gynaecology outpatient clinic.

The 29-year-old multigravida with a previous caesarean section had earlier presented to the emergency room with vaginal bleeding at 7 weeks of gestation.

Ultrasound scan revealed a non-viable low-lying gestational sac located near the caesarean section scar, with a myometrial thickness of 0.96 cm. There was minimal vascular flow during the Doppler interrogation. Her quantitative serum beta-human chorionic gonadotropin was 687 IU/l at presentation. This had dropped to 344 IU/l after 48 h, with a further drop to 39 IU/l after a week. Repeat ultrasound scan 1 week after revealed an empty uterus with no visible gestational sac, and vaginal bleeding had resolved. My professor made a final diagnosis of a spontaneous complete abortion.

On reflection, this experience further reinforced the diagnostic dilemma that many clinical conditions can present, the need for a high index of suspicion in diagnosing and differentiating clinical conditions that present similar features, as well as the need for younger clinicians to leverage the better knowledge and experience of more senior colleagues to unknot knotty clinical dilemmas.