Madam Amslekha Kathirvel experienced excessive bleeding during her second pregnancy as the baby's gestational sac was very close to her C-section scar. PHOTO: COURTESY OF AMSLEKHA KATHIRVEL

SINGAPORE – When legal executive Amslekha Kathirvel became pregnant in 2021 – 13 years after having her first child – she could not wait for her daughter to have a little brother or sister.

But her joy turned into fear about a month into her pregnancy when she experienced excessive bleeding. Doctors at KK Women’s and Children’s Hospital (KKH) discovered that the gestational sac surrounding the embryo was very close to the scar from her caesarean section in 2008.

She faced the risk of caesarean scar pregnancy (CSP), where the embryo, instead of descending into the womb, implants itself either on the scar or the fallopian tube.

Madam Amslekha needed the caesarean section in 2008 as her baby was in a breech position and risked being born feet first, which could have resulted in the baby’s head or shoulders becoming wedged.

Several scans were done to determine whether it would be safe for her to continue with the second pregnancy.

“The doctors recommended that I terminate the pregnancy due to the risks to my baby and myself,” said Madam Amslekha, who is now 43.

If she continued with the pregnancy, she would risk complications like a uterine rupture as the baby developed, and heavy bleeding during childbirth which could turn very serious.

“Ultimately, I made the decision to continue the pregnancy, as I wanted to try to save and protect my baby’s life,” she said.

The risk of CSP has increased as the number of caesarean deliveries worldwide has more than doubled in the last 20 years – whether for medical reasons, factors such as anxiety over natural childbirth, or simply because the procedure is requested by expectant mothers.

New research by the World Health Organisation shows that caesarean deliveries account for more than one in five childbirths (21 per cent) in 2022.

This is set to rise to nearly a third (29 per cent) by 2030. In a 2019 study by Indian professor of obstetrics and gynaecology Monika Anant, caesarean scar ectopic pregnancies occur in about one in 2,000 of all pregnancies. With increasing caesarean-section rates worldwide, Dr Anant said, CSP is bound to increase, with complications such as uterine rupture and catastrophic haemorrhage.

There is no national percentage of how many live births in Singapore are by caesarean section.

According to the KKH Perinatal Audit And Epidemiology Report, 32.7 per cent of the 11,628 deliveries in 2021 were done through caesarean section. Between May 2020 and June 2022, 37 patients in KKH were diagnosed with CSP.

Dr Sim Wen Shan, head of the Antenatal Risk Assessment Unit in the Department of Maternal Fetal Medicine at KKH, said: “In women who have had a caesarean section, the frequency of CSP is approximately 0.15 per cent.”

Dr Sim said the caesarean section rate at KKH in 2005 was 27.1 per cent, and in 2021, it was 32.7 per cent. “Hence, there was an appreciable increase in this rate.”

The diagnosis of CSP is increasing due to advances in imaging and heightened clinical awareness and experience.

Dr Anju Bhatia, obstetrician and gynaecologist at the Department of Maternal Fetal Medicine at KKH, said: “Women with previous caesarean section should be offered early first-trimester screening for CSP, which is best diagnosed before nine weeks using transvaginal ultrasound. Diagnosis is difficult beyond this period as the gestational sac enlarges and grows towards the uterine cavity, mimicking a normally located pregnancy.

“These pregnancies may result in morbidly adherent placenta, where the placenta fails to detach itself from the uterine wall... increasing risks to the mother.”

As the likelihood of pregnancy complications due to CSP varies depending on each individual case, the patient may choose to have her baby if she is asymptomatic and there is no immediate threat to her health, said Dr Mohamed Siraj Shahul Hameed, obstetrician and gynaecologist from the Minimally Invasive Surgery Unit at KKH.

Dr Siraj, who managed Madam Amslekha’s pregnancy along with obstetrician and gynaecologist Dr Ann Wright from KKH’s Department of Maternal Fetal Medicine, said that if a woman chooses to continue the pregnancy, she should ideally be managed in a dedicated obstetrics high-risk clinic and the baby delivered in a tertiary hospital with multi-disciplinary support.

Madam Amslekha delivered her baby at 32 weeks on Feb 22, 2022. Due to the high risks surrounding her pregnancy and her high maternal age of 42, she underwent a caesarean section.

Madam Amslekha Kathirvel delivered her son Reynan Thaavinesh at 32 weeks in February 2022 via C-section. PHOTO: COURTESY OF AMSLEKHA KATHIRVEL

“I lost about three litres of blood and needed to be in the intensive care unit for about 1½ days,” she said. She said it was a small price to pay for having a healthy son, Reynan Thaavinesh, who is now 1½ years old.

“I am thankful the doctors managed to save my uterus,” said Madam Amslekha.

Source: The Straits Times © SPH Media Limited. Reproduced with permission.