This clinical case is challenging due to a late diagnosis of CSP, presenting in the emergency department with abdominal pain and vaginal bleeding.

The expectant management is associated to high morbidity. In a meta-analysis looking at 17 different studies of expectant management in patients with CSP resulted in high burden of maternal morbidity including severe hemorrhage, early uterine rupture, and hysterectomy [9]. “PAS” has been reported in over 50% of CSP cases across various case series, likely reflecting differing diagnostic criteria in the published literature [9,2]. Given the severe maternal morbidity and mortality associated with a CSP, the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists and the American Society of Reproductive Medicine, recommends against expectant management of CSP [3]. The most usual recommendation has been termination of pregnancy [9,3], with a multitude of medical and surgical managements.

Given the lack of randomized controlled trials comparing the different treatment options, there is not one recommended management strategy [3]. The choice of treatment often depends on the specialized skills available within an institution, which may include a minimally invasive gynecologic surgeon, a maternal-fetal medicine specialist, or an interventional radiologist.

For medical management of a CSP, intragestational sac injection of methotrexate with or without systemic methotrexate has high rates of success with low rates of complications, but the patient should be counseled to expect prolonged follow-up [10].

Sharp curettage has the potential to expose deeply invasive blood vessels, leading to hemorrhage, and consequently should be avoided. However, vacuum aspiration has been shown in multiple studies to be efficacious with low rates of complications. Suction aspiration is a commonly used surgical treatment for CSP [11]. It is typically performed for patients in the early first trimester (five to seven weeks of gestation) and can be combined with transcervical balloon catheters [12,13].

In one prospective study including eight cases of CSP (gestational age between 4 to 23 weeks of gestation) treated with suction curettage, all cases were treated successfully, however, three patients (37%) experienced significant bleeding (500 to 1000 mL) requiring the insertion of an intrauterine balloon catheter to tamponade the uterine cavity to achieve hemostasis [12].

Operative resection of the pregnancy can be performed via laparoscopy, hysteroscopy, or laparotomy; laparoscopic-assisted operative hysteroscopic management has also been described [14]. Surgical resection may also be performed as subsequent management after medical therapy (for example, intragestational injection of methotrexate). These procedures must be performed by an experienced surgical team. An advantage of resection over other therapies is that the scar can be excised and the uterus reapproximated.

Laparoscopic excision had a success rate of 97,1% without complications in one systematic review that included 69 cases [8]. In 118 cases of transvaginal excision, there was > 99% efficacy and a 0,9% complication rate [8]. Hysteroscopic excision of a CSP has an efficacy of 83% and a complication rate of 3,2% in 95 cases [15]. Laparotomy had a complication rate of 5,3% [8]. These options are more invasive than those described above and may be more suitable for more advanced gestations.

Hysterectomy should be performed in patients in whom future childbearing is not desired or in those with life-threatening hemorrhage. Gravid hysterectomy may be performed with or without prior uterine artery embolization to decrease the amount of blood loss [16].

The less invasive surgical intervention was chosen, with ultrasound-guided aspiration followed by balloon insertion. However, in this case, a known and possible complication occurred: hemorrhage caused by uterine rupture. In this case, it was possible to control the hemorrhage with pelvic packing, preserving the uterus.