Cesarean Scar Ectopic Pregnancy: Laparoscopic Resection and Total Scar Dehiscence Repair.

STUDY OBJECTIVE: To illustrate a laparoscopic technique for the resection of cesarean scar ectopic pregnancy, associated with isthmocele repair.

DESIGN: Case report (Canadian Task Force classification III).

SETTING: A tertiary referral center in Strasbourg, France.

BACKGROUND: Cesarean scar pregnancy is a rare form of ectopic pregnancy. The major risk of this type of pregnancy is the early uterine rupture with massive, sometimes life-threatening, bleeding. Thus, active management of these pregnancies starting immediately after diagnosis is crucial. Therapeutic options can be medical, surgical, or a combination. Numerous case reports or case series can be found in the literature, but there are few clinical studies, which are difficult to conduct because of case rarity and inconclusiveness. A 2016 meta-analysis that included 194 articles published between 1978 and 2014 (126 case reports, 45 cases series, and 23 clinical studies) concluded that hysteroscopy or laparoscopic hysterotomy seems to be the best first-line approach to treating cesarean scar ectopic pregnancy, with uterine artery embolization reserved for significant bleeding and/or a high suspicion index for arteriovenous malformation [1]. There is no consensus on the treatment of reference, however.

PATIENT: The case involves a 38-year-old primiparous women who underwent a cesarean section delivery in 2010 and who was diagnosed by ultrasound scan at 7 weeks gestation with cesarean scar ectopic pregnancy, which was confirmed by pelvic magnetic resonance imaging. The patient initially received medical treatment with 2 intramuscular injections of methotrexate and one local intragestational injection of KCl. Her initial human chorionic gonadotropin (hCG) level was 82 000 IU/L. Rigorous weekly biological and ultrasound monitoring revealed an involution of the ectopic pregnancy associated with decreasing hCG. No bleeding or infectious complications occurred during this period. After 10 weeks of monitoring, her hCG had stabilized at 300 IU/L, and a residual image persisted next to the cesarean scar, and thus surgical treatment was considered.

INTERVENTION: This video illustrates the laparoscopic resection of a cesarean scar ectopic pregnancy associated with isthmocele repair. The originality of this video lies in the fact that it is the first demonstration of the laparoscopic treatment of total caesarean scar dehiscence.

MEASUREMENTS AND MAIN RESULTS: The total operative time was 180 minutes. First, hysteroscopic evaluation revealed the cesarean scar dehiscence and the posterior pole of the ectopic pregnancy. Then the diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The utero-ombilical truncs were clamped bilaterally. Complete enucleation of pregnancy was achieved after dissection of the vesicouterine peritoneum. Isthmocele repair was performed with closure in 2 planes. A blue dye test confirmed the tightness of the stitches. The utero-ombilical truncs were unclamped, and antiadhesion gel was applied to the new uterine scar [1]. The operation was performed successfully without complications. Intraoperative blood loss was <100 mL. The patient was discharged on postoperative day 3. No immediate complications were noticed. At 1 month after the intervention, ultrasound was normal.

CONCLUSION: Surgical management of caesarean scar ectopic pregnancy with total dehiscence of hysterotomy can be performed safely and efficiently under laparoscopy.