Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Laparoscopic Management of Cesarean Scar Ectopic Pregnancy?
- What are the Risks of Laparoscopic Management of Cesarean Scar Ectopic Pregnancy?
- Video Transcript
Video Description
This video outlines the management options for cesarean scar ectopic pregnancies and highlights a case of laparoscopic surgical management.
Presented By
Affiliations
University of Ottawa, The Ottawa Hospital
Watch on YouTube
Click here to watch this video on YouTube.
What is Laparoscopic Management of Cesarean Scar Ectopic Pregnancy?
Laparoscopic management of cesarean scar ectopic pregnancy is a minimally invasive surgical technique used to address a rare type of ectopic pregnancy where the embryo implants within the scar of a previous cesarean section. This approach minimizes the need for major abdominal surgery and aims to preserve fertility while effectively treating the ectopic pregnancy. Key components of the approach include:
- Preoperative Assessment: Involves detailed imaging, typically using transvaginal ultrasound and possibly MRI, to confirm the diagnosis and plan the surgical procedure.
- Surgical Technique: The procedure is carried out using small incisions in the abdomen through which a laparoscope and other surgical instruments are inserted. The goal is to carefully remove the ectopic pregnancy from the cesarean scar.
- Benefits: Offers advantages such as reduced blood loss, shorter hospital stay, quicker recovery, and less postoperative pain compared to traditional open surgery.
- Postoperative Care: Includes monitoring for complications and follow-up evaluations to ensure complete recovery and to discuss future pregnancy planning.
What are the Risks of Laparoscopic Management of Cesarean Scar Ectopic Pregnancy?
The laparoscopic management of cesarean scar ectopic pregnancy, while beneficial for its minimally invasive nature, carries specific risks associated with the procedure and the complexity of the condition. Key risks include:
- Hemorrhage: There is a significant risk of bleeding due to the location of the pregnancy in highly vascular scar tissue. This may require additional interventions, such as blood transfusion or conversion to open surgery.
- Injury to Surrounding Organs: The proximity of the ectopic pregnancy to critical structures like the bladder and intestines poses a risk of accidental damage during surgery.
- Incomplete Removal of Trophoblastic Tissue: There is a possibility that some pregnancy tissue may not be completely removed, which could lead to persistent trophoblastic disease requiring further treatment with medication or additional surgery.
- Infection: As with any surgical procedure, there is a risk of infection which can complicate recovery.
- Future Pregnancy Complications: Surgical intervention at the site of a cesarean scar can affect the integrity of the uterus, potentially complicating future pregnancies. This might increase the risk of recurrent cesarean scar pregnancies or other placental abnormalities.
- Conversion to Open Surgery: In some cases, complications or the inability to safely complete the procedure laparoscopically may necessitate converting to an open surgical approach, which has a longer recovery period and more potential complications.
Careful preoperative planning and postoperative monitoring are essential to manage these risks effectively.
Video Transcript: Laparoscopic Management of Cesarean Scar Ectopic Pregnancy
The University of Ottawa’s Department of Obstetrics and Gynaecology, Division of Minimally Invasive Gynaecology, presents a stepwise approach to the laparoscopic management of a caesarean scar ectopic pregnancy.
This rare but potentially life-threatening diagnosis complicates approximately one in every 200 pregnancies, or 6% of pregnancies among women with a prior caesarean section. Risk factors reported in the literature include multiple caesarean sections, uterine retroversion, in vitro fertilisation, adenomyosis, dilation and curettage, and manual placental removal. Potential complications of this rare entity include life-threatening haemorrhage, hysterectomy, and loss of fertility.
Sonographic diagnostic criteria proposed by Vial and colleagues include presence of trophoblast between the bladder and the lower uterine segment, absence of foetal parts within the uterine cavity, and, on the sagittal view that runs through the amniotic sac, no myometrium can be seen between the gestational sac and the urinary bladder.
Management of these rare pregnancies is based on case reports and small observational studies, Options include expectant management, which has a high rate of uterine rupture, haemorrhage, and hysterectomy. Medical management, including systemic methotrexate, with its highest success rate in early gestations. Intragestational methotrexate. Combined systemic and intragestational methotrexate. Intragestational potassium chloride. And uterine artery embolization followed by systemic methotrexate.
Surgical management options include dilation and curettage, which has a high rate of severe haemorrhage and laparotomy, hysteroscopy, laparotomy with wedge excision, and laparoscopy, of which there are three cases reported in the literature.
We present the management of a 32-year-old multiparous patient transferred to our centre from a remote arctic community with a caesarean scar ectopic pregnancy. Her obstetrical history was remarkable for one prior caesarean section for breech presentation. Upon arrival, her beta-hCG was 95,687 IU/L. Her haemoglobin was stable at 137 g/L.
An ultrasound was obtained shortly after her arrival. The ultrasound revealed a gestational sac over the lower uterine segment containing a live embryo of eight weeks’ size. There was significant decidual reaction over the previous caesarean section scar. No myometrium could be seen anterior to the ectopic. A portion of the endometrium appeared to be part of the area of implantation.
Successful transabdominal intragestational potassium chloride and methotrexate injections were conducted on the day of admission. The patient was admitted for ongoing observation, and her beta-hCG declined to 65,948 IU/L. The patient was then given a systemic dose of methotrexate, and her beta-hCG declined to just under 3,000 IU/L within two weeks. She was admitted for ongoing close observation.
A follow-up ultrasound revealed that the mass remained unchanged in size and was highly vascular. Due to the patient’s remote location of residence and the ongoing risk of rupture, the decision was made to proceed to surgical excision.
Upon entering into the pelvis, a large mass can be seen over the lower uterine segment. The harmonic scalpel and bipolar electrosurgical unit were used to reflect the vesicouterine peritoneum. In this manner, the gestational sac was isolated with ongoing dissection. Ligation of the mass from its base was then conducted with an Endoloop to ensure adequate haemostasis. The base of the mass was also infiltrated with a vasopressin, which is not shown here.
The mass was then incised with endoscopic scissors. Prior to performing this procedure, the uterine arteries were isolated via the broad ligaments. The mass was then dissected away from its stump using endoscopic scissors. Excellent haemostasis was achieved at this point of the procedure.
Here we see the mass being removed from the caesarean scar defect. Hysteroscopic guidance was used to further delineate the defect. Once the defect had been fully delineated, both laparoscopically and hysteroscopically, intracorporeal delayed absorbable sutures were used to repair the defect. Great care was taken to ensure that the entire defect was repaired. We can see that excellent haemostasis was achieved throughout this procedure.
Following repair of the caesarean scar defect, the peritoneum was closed, and haemostasis was ensured.
Following surgery, the patient was discharged home with a haemoglobin of 118 g/dL and will be followed with future hysteroscopy to ensure adequate healing of her caesarean section scar.