August 18, 2023

Natalie Sten’s Pregnancy Journey

Young adult woman smiling

This is a firsthand account submitted through SWHR’s Share Your Story portal, as part of SWHR’s Women’s Health Perspective series.

My husband and I were trying to get pregnant for over a year through on and off infertility treatments. In July 2022, due to an insurance change, we were not able to go through the treatment process.

Surprisingly, I discovered I was pregnant, without any intervention, at the end of July. Because my fertility journey was being so closely followed, I was able to have an ultrasound at seven weeks at the fertility clinic. At that time, I was told there was no fetal pole or heartbeat and contacted my then OBGYN to proceed with a consultation appointment for a dilation and curettage (D&C) procedure, to discuss my situation and get on the eventual D&C scheduled. At that appointment, I was told they would use the ONE ultrasound record from the fertility clinic to reference for the D&C procedure. I asked for a confirmation ultrasound for my own peace of mind. I was told I could request the additional ultrasound but that it was not a routine procedure before having a D&C because they could use the first ultrasound as confirmation, which is shocking. All facilities should perform, and insurance should cover, a confirmation ultrasound before completing a D&C or a dilation and evacuation (D&E) procedure. This should be a standard of care!

I scheduled the confirmation ultrasound for the following day. I was eight weeks pregnant at this point, and the ultrasound showed a heartbeat, though the sac was abnormally shaped and the heartbeat was a bit slow. The D&C was, therefore, canceled, and I held onto hope, even knowing the outcome would likely not be good. I would realize later that the baby’s heartbeat essentially saved me from a lot of serious medical complications and, potentially, my life.

At my 9-week follow-up appointment, there was no heartbeat, and the physician discovered the placenta was growing into my C-section scar from my earlier pregnancy in 2018. The physician I met with after the ultrasound suggested that I wait a week to see if I would miscarry on my own. I did not miscarry on my own. A week later on the day before my scheduled D&C procedure, the physician who was going to perform the D&C said she was not comfortable performing the procedure due to how vascular the area was. After hearing this, I was so grateful for demanding the confirmation ultrasound prior to the D&C. If I would not have had the confirmation ultrasound that showed a heartbeat, I would have proceeded with scheduling a D&C that would have been conducted in a clinic. Therefore, leading to a very good chance I would have bled out and been rushed to the hospital to have a hysterectomy to save my life.

The D&C was canceled, and I was promptly referred to the head of maternal-fetal medicine (MFM), which is when I learned more about ectopic cesarean scar pregnancy. I was told my human chorionic gonadotropin (hCG) levels were rising and that the placenta had continued to grow despite my body not being pregnant anymore. I wanted a second opinion due to the severity and uniqueness of my situation and the conflicting information I had received up until that point.

This is when Penn Medicine in Philadelphia, PA came into my life. I was quickly scheduled for a consultation at their MFM department. During that appointment, I was told that this was the first time the MFM physician had ever seen placenta growth and hCG levels increasing after a non-viable ectopic cesarean scar pregnancy. I was admitted into the hospital that night due to the placenta growth, which doctors were concerned could rupture my uterus.

Around 4:00 a.m. the next morning, I received a methotrexate injection. Then, a uterine artery embolism was performed through interventional radiology, and a D&C occurred the following day. Three months later, I had the isthmocele repair surgery. It was a huge relief to learn that I was safe and that my fertility had been preserved after all of this.

After the whirlwind of being admitted to the hospital and having the procedures completed, I was finally able to process everything that happened to me. I was disheartened by the care I received at the first facility I went to. No one knew what to do with me, and the outcome could have been deadly. I was devastated that I lost my baby from something that could have potentially been prevented if better perinatal care was provided for women. I am furious that, after my first pregnancy, my C-section scar was not checked to determine if an isthmocele repair was necessary – and to know other women may not be checked for this too.

I am 40 years old, and I can’t help but think this could have been my last chance of having a second child. I felt like I lost the most important thing due to a preventable medical issue –finding the ectopic cesarean scar pregnancy early –that could have been corrected years ago.

I was informed by my Penn Medicine physician that my case was going to be shared during roundtables and other medical meetings as a case study and to potentially explore more ways to conduct imaging on women after C-sections to determine if a repair is necessary. While I lost my baby and feel immense sadness about this whole situation, it helps to know that ultimately, my doctors listened to me and that they can use my story to improve women’s maternal health in the future.

I have begun the fertility process again, and I know I still have another chapter in this journey. My hope is that the physicians, advocates, nurses, researchers, and patients that read my story will work with women like me to provide better care for all women before, during, and after pregnancy – especially for women that have had a cesarean section delivery – to prevent this from happening again. I understand a cesarean scar defect is a rare occurrence, but it nearly cost me everything. I lost my baby, and I wonder how many others lost their babies, too, from something that could be prevented. If all women were checked after their C-section to ensure it healed correctly, babies could be saved and women would be given the option to have the defect corrected before trying to get pregnant again.