vaginal bleeding and disc...

A 29-year-old woman with vaginal bleeding and discharge visited the hospital. The patient had a H/o 3 caesarean deliveries in the past due to hypertension in her first pregnancy and two subsequent scheduled caesarean deliveries after normal pregnancies. The patient's hemoglobin and hematocrit were within normal limits, as was her white blood cell count. The basic metabolic panel, wet prep, KOH, and STIs were negative. Quantitative Beta-hCG was 67,142 IU/L at presentation. Transvaginal ultrasound at the treating hospital demonstrated a gestational sac (of 10 weeks and four days) located at the internal cervical os, as shown in the figure. 

A fetal pole was noted with the presence of fetal cardiac motion. The gestational sac located in the lower uterine segment of the uterus was found to communicate with the endometrial cavity without the involvement of the cervix. Disruption of the myometrium was suspected between the gestational sac and bladder, with only intact uterine serosa suspected, most consistent with implantation into the prior cesarean scar.