What is the management for a cesarean (c-section) scar impending rupture at 20 weeks of intrauterine pregnancy (IUP)?

Management of Cesarean Scar Pregnancy with Impending Rupture at 20 Weeks

Immediate surgical intervention with emergency laparotomy is required for a cesarean scar pregnancy with impending rupture at 20 weeks gestation, as this represents a life-threatening obstetric emergency with high risk of maternal mortality from hemorrhage and uterine rupture. 1

Immediate Emergency Management

Surgical Approach

• Emergency laparotomy must be performed immediately when impending rupture is suspected, as cesarean scar pregnancies at this gestational age carry extremely high risk of catastrophic hemorrhage and complete uterine rupture 1
• The procedure should include careful resection of placental tissue and repair of the ruptured or weakened isthmic region of the uterus 1
• Hysterectomy may be necessary if hemorrhage cannot be controlled with conservative surgical repair 2
• Do not delay for transport to an operating room if the patient is unstable—the procedure can be performed under rudimentary aseptic conditions if necessary 3

Resuscitation Priorities

• Establish large-bore IV access and initiate aggressive fluid resuscitation immediately 1
• Prepare for massive transfusion protocol with blood products readily available 1
• Position the patient with left uterine displacement to optimize maternal hemodynamics and uteroplacental perfusion 3
• Ensure adequate maternal oxygenation throughout resuscitation and surgical intervention 3

Critical Diagnostic Considerations

Why Conservative Management is Contraindicated

• At 20 weeks gestation, the pregnancy has reached a size where the risk of catastrophic rupture is extremely high 1
• Conservative management with methotrexate has high failure rates and is inappropriate when rupture is impending 2
• Case reports document that delayed intervention in cesarean scar pregnancies at advanced gestational ages results in life-threatening hemorrhage requiring emergency hysterectomy 2
• One documented case of ruptured cesarean scar pregnancy at 20 weeks resulted in abundant hemoperitoneum requiring emergency surgery 1

Fetal Considerations

• At 20 weeks, the fetus is previable (survival is not expected) 4
• The primary goal is maternal survival—fetal outcomes are universally poor in ruptured cesarean scar pregnancies at this gestational age 1
• Emergency cesarean section for fetal indication is not appropriate as the fetus is previable 3

Intraoperative Management

Anesthetic Considerations

• Regional anesthesia is preferred if time permits and the patient is hemodynamically stable 3
• General anesthesia may be necessary if the patient is unstable or requires emergency intervention 3
• Maintain maternal oxygenation, avoid hypotension, and ensure optimal uteroplacental perfusion throughout the case 3
• Multimodal analgesia including regional techniques and local anesthetic infiltration should be employed 3

Surgical Technique

• Perform midline laparotomy for optimal exposure 1
• Carefully evacuate hemoperitoneum and identify the rupture site 1
• Resect placental tissue meticulously to control bleeding 1
• Repair the uterine defect in two layers if uterine preservation is possible, as this may reduce future rupture risk 3
• Consider hysterectomy if bleeding cannot be controlled or if the patient does not desire future fertility 5

Postoperative Management

Immediate Postoperative Care

• Monitor vital signs closely for signs of ongoing hemorrhage 1
• Provide adequate pain control with acetaminophen as first-line, adding short-term opioids as needed 6
• Avoid NSAIDs entirely as they can cause oligohydramnios and premature ductus arteriosus closure, though this is less relevant post-delivery 6
• Administer prophylactic antibiotics (first-generation cephalosporin with azithromycin) to reduce postoperative infection risk 3

Thromboprophylaxis

• Initiate low-molecular-weight heparin for venous thromboembolism prophylaxis, as pregnant patients undergoing surgery are at very high risk 3
• Use pneumatic compression devices for lower extremities during bedrest 3

Common Pitfalls to Avoid

• Never attempt conservative management with methotrexate when rupture is impending at 20 weeks—this will result in maternal death from hemorrhage 1, 2
• Do not delay surgical intervention for additional imaging or consultation—impending rupture requires immediate action 1
• Do not transport an unstable patient to the operating room—perform the procedure where the patient is located if necessary 3
• Do not underestimate blood loss—cesarean scar pregnancies can cause massive hemorrhage requiring multiple units of blood products 1, 2
• Do not attempt uterine artery embolization as primary management when rupture is impending—one case report documented failure of UAE followed by life-threatening hemorrhage requiring emergency hysterectomy 2

Prognosis and Counseling

• Maternal survival is excellent with prompt surgical intervention 1
• Recovery is typically uncomplicated with discharge by postoperative day 6 1
• Future fertility may be preserved if uterine repair is successful, though the risk of recurrent cesarean scar pregnancy is increased 5
• Patients should be counseled about the extremely high risk of recurrence and the need for early ultrasound in future pregnancies 5, 1