Background: Cesarean section scar ectopic pregnancies are a rare complication of pregnancy that may follow previous hysterotomy for any cause, uterine manipulation, and in vitro fertilization. It has become more common with the increasing cesarean sections as a mode of delivery worldwide. luckily, the use of first- trimester ultrasound imaging has resulted in a significant number of these pregnancies being diagnosed and managed early. Case presentation: We report a case of a 43 years old Saudi female who had three previous cesarean sections and abortion for six times at first trimester which indicated four evacuation and curettage procedures. She presented with mild vaginal bleeding without abdominal pain or other complain. She had no history of contraception use or underlining gynecological illness. Her quantitative serum β-human chorionic β-HCG is 8091 mIU/ml. Transvaginal ultrasound (TVU) showed monochoroinic amniotic gestational sacs, both are non-visible the sacs The ectopic gestation was managed with two doses of methotrexate and one intragestational dose, and then evacuation and curettage was done, and B-HCG levels dropped significantly. Conclusions: Uterine scar ectopic pregnancies are a diagnostic challenge that require a high level of suspicion during clinical imaging and follow-up. A missed diagnosis with delayed management may lead to uterine rupture, severe hemorrhage, and maternal death. Keywords: cesarean scar ectopic pregnancy, Diagnostic challenge, management.