Setting the Scene
In this case, the patient presented with per vaginal (PV) bleeding early on in her pregnancy and requested a termination of pregnancy. The patient had a history of multiple caesarean sections in the past. Initially, the patient attended a private pregnancy clinic and underwent a scan which revealed a suspected caesarean section scar pregnancy or CSP. This is a rare but potentially dangerous form of ectopic pregnancy where the foetus implants in the scar tissue from a previous caesarean section scar. Major haemorrhage and possible hysterectomy are the main risk factors associated with a CSP. Despite suspecting a potential CSP, the patient was referred to the British Pregnancy Advisory Service (BPAS) for a termination of pregnancy. This service usually provides terminations for ‘normal’ pregnancies.
A repeat Ultrasound scan at BPAS also suspected an abnormal pregnancy. Given the scan findings, and that the patient was bleeding heavily, BPAS were unable to offer a termination and subsequently referred the patient to the Early Pregnancy Unit (EPU) of a hospital for further assessment. At the EPU, the patient was scanned by a trainee sonographer who also noted an abnormal looking intrauterine pregnancy. However, the claimant was discharged from EPU and advised to reattend the BPAS for a termination as previously planned
During the surgical termination at BPAS, the patient suffered a major haemorrhage. Given the ongoing bleeding, the patient needed to be transferred to a hospital for ongoing surgery and resuscitation. The patient was diagnosed intraoperatively as having a CSP. Although the patient fortunately went on to make a full recovery, had her CSP been correctly diagnosed and managed, she would have had her termination in a more suited location and would not have needed to be transferred between sites whilst haemodynamically unstable with ongoing bleeding, which compromised her overall care.
Reducing the Risk of Litigation
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Patients with a suspected CSP should be managed in an early pregnancy assessment unit in a hospital and have consultant led care.
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Patients with a suspected CSP should be managed by senior staff given the complexity and risks associated with this form of ectopic pregnancy. Given the risk of significant haemorrhage, patients suspected of having this gynaecological emergency should be managed in units which have the appropriate expertise and facilities to treat such emergencies.
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Ultrasound imaging is the principal diagnostic tool used to confirm CSP. However, if the diagnosis is unclear, it is imperative that patients are reviewed and assessed by senior staff to help in making a definitive diagnosis. MRIs can also be used as a second-line investigation to help make a diagnosis.
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A patient’s clinical history should always be taken into consideration when making a clinical diagnosis. In this case, the patient was high risk for having a CSP given that she had undergone 3 previous caesarean sections. In addition to this, she had had 3 scans that all raised the suspicion of a possible CSP. The patient should have been managed as a CSP until proven otherwise.
- Patients who have a suspected CSP should be counselled that these pregnancies are associated with significant maternal morbidity and mortality. Correct diagnosis allows clinicians to appropriatly plan the care and treatment for patients, to minimise the risk of complications and improve overall outcome.
Conclusions
Given the patient’s history of three previous caesarean sections, her history of vaginal bleeding and the three scans that suspected a CSP, the patient should have been managed as having a CSP until proven otherwise. It is not always possible to make an exact diagnosis on ultrasound scan, however, once suspected, patients should have their care escalated to more senior staff for further assessment and investigation.
CSPs are well recognised to be associated with significant haemorrhage, and meticulous planning and early recourse to escalation of care is mandatory in order to minimise complications and improve patient outcome. Given the complexity of these cases, patients with a suspected CSP should be managed at an early pregnancy unit in a hospital, under consultant led care and not in community clinics.
Although in this case, the patient had several scans that suspected a CSP, the implications of this were not considered adequately and the patient was inappropriately referred back out into the community to have her termination of pregnancy and unfortunately went on to have a massive haemorrhage, that was not anticipated. As previously stated, CSP is a rare but potentially life-threatening form of ectopic pregnancy and correct diagnosis and management is the key to improving patient outcomes. By not appreciating the severity of this condition and mismanaging the patient, the risk of harm to the patient is increased. Not only does this cause issues with healthcare standards and patient safety, but it also exposes clinicians to the possibility of litigation which is to be avoided.
