Maternal near-miss from cesarean scar ectopic pregnancy: emerging clinical challenge in resource-limited settings-a...

Cesarean scar ectopic pregnancy is a rare but increasingly recognized form of ectopic pregnancy in which a pregnancy is implanted into a myometrial defect caused by a cesarean scar. If not promptly identified, it can lead to life-threatening complications, underscoring the need for heightened clinical suspicion, timely diagnosis, and context-appropriate management. Reports from resource-limited settings remain scarce, making this case series from Ethiopia important for raising clinical awareness and highlighting the challenges of timely recognition and management.

We reported two consecutive cases of maternal near misses that met the WHO criteria, both resulting from cesarean scar ectopic pregnancy, along with a third case involving delayed diagnosis. All were Ethiopian (East Africa), managed at a teaching hospital in Ethiopia between January 2023 and May 2025. Patient 1: a 28 year-old (gravida 4, two prior cesareans) who was initially misdiagnosed with threatened miscarriage at a gestational age of 10 weeks, was managed expectantly for 2 weeks and was later misdiagnosed with incomplete miscarriage, underwent manual vacuum aspiration, and experienced severe hemorrhage; cesarean scar ectopic pregnancy was subsequently diagnosed, ultimately requiring emergency hysterectomy and transfusion of five units of whole blood. Patient 2: a 25 year-old woman with one prior cesarean section presented with recurrent vaginal bleeding following an induced medical abortion, resulting in severe anemia with a hemoglobin level of 4.7 g/dL. Ultrasound revealed a 3.5 cm × 4 cm mass at the anterior isthmus consistent with cesarean scar ectopic pregnancy, which was managed by laparotomic wedge resection of the scar‑site lesion, bilateral uterine artery ligation, and transfusion of six units of whole blood. Patient 3: a 30 year-old woman (gravida 3, one prior cesarean delivery) had cesarean scar ectopic pregnancy missed during antenatal care; her diagnosis at 10 weeks followed the onset of pain and bleeding, and she underwent laparotomic resection of the scar‑site lesion. Histopathology confirmed cesarean scar ectopic pregnancy in all patients.

Cesarean scar ectopic pregnancy is an emerging, potentially life-threatening complication in low-resource settings, where limited diagnostic capacity and low clinical suspicion often impede timely diagnosis and management. The avoidance of blind uterine evacuation until cesarean scar ectopic pregnancy is excluded, the adoption of lesion-tailored treatment strategies, and the strengthening of targeted clinical training and diagnostic access are critical to improve maternal health outcomes and reduce morbidity in these settings.