Gynecology
7 min read

Surgical Management of Cesarean Scar Pregnancy

Surgical Management of Cesarean Scar Pregnancy
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Video Description

An algorithm is presented for the surgical management of cesarean scar pregnancy.

Presented By

Female doctor avatar
Dr. Lea Luketic
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Dr. Mara Sobel
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Dr. Ally Murji

Affiliations

University of Toronto

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What is Surgical Management of Cesarean Scar Pregnancy?

Surgical management of Cesarean scar pregnancy involves removing a pregnancy implanted in the scar tissue of a previous Cesarean section. This condition, diagnosed via ultrasound, presents significant risks, including severe hemorrhage and treatment failure with non-surgical methods. The surgical approach typically includes laparoscopic techniques, with careful dissection to avoid damaging surrounding organs. Prophylactic clipping of the internal iliac artery is performed to minimize bleeding risk. Depending on the pregnancy’s location, procedures such as laparoscopic-guided aspiration, curettage, and bladder dissection are utilized. Postoperative care includes follow-up imaging to ensure proper healing and prevent complications.

What are the Risks of Surgical Management of Cesarean Scar Pregnancy?

The risks of surgical management of Cesarean scar pregnancy encompass various complications primarily related to the surgical intervention itself and the specific challenges of this condition. Here are some key risks associated with the procedure:

  • Hemorrhage: One of the major risks is severe bleeding during or after surgery. Prophylactic measures like clipping the internal iliac artery are often employed to mitigate this risk.
  • Organ Injury: The surgery involves careful dissection around the bladder, ureters, and bowel, posing a risk of injury to these organs. Damage to these structures can lead to complications such as infection, impaired organ function, and the need for additional surgeries.
  • Incomplete Removal: There is a risk of incomplete removal of the pregnancy tissue, which may necessitate further surgical interventions or lead to persistent complications.
  • Adhesion Formation: Post-surgical adhesions can form, leading to chronic pain, bowel obstruction, or fertility issues in future pregnancies.
  • Infection: Any surgical procedure carries a risk of infection at the incision sites or within the pelvic cavity, requiring antibiotic treatment or further surgical intervention.
  • Anesthesia Risks: General anesthesia used during the procedure carries its own risks, including allergic reactions, respiratory complications, and cardiovascular issues.

It is crucial for patients undergoing surgical management of Cesarean scar pregnancy to be fully informed of these risks and to receive comprehensive preoperative and postoperative care to minimize complications and support recovery.

Video Transcript: Surgical Management of Cesarean Scar Pregnancy

This video will present a new algorithm for the surgical management of caesarean scar pregnancy. The definition of a caesarean scar pregnancy is one that is located outside the uterine cavity, completely surrounded by myometrium and fibrous tissue of the scar in the lower uterine segment. The first case was reported in 1978 and incidence is felt to be increasing with the increased rate of caesarean sections.

Ultrasound is the main method of diagnosis, with a set of specific criteria required. First, an empty uterine cavity is seen without contact with the gestational sac. A clearly visible, empty cervical canal is seen, again without contact with the gestational sac. And a gestational sac, with or without a foetal pull and cardiac activity, is seen in the anterior part of the uterine isthmus. Absence of a defect in the myometrial tissue between the bladder and the sac is observed and no adnexal mass or free fluid is seen in the pouch of Douglas.

Treatment of caesarean scar pregnancy includes expectant, medical management, surgical or a combination of any or all of these. The major risk of expectant and medical therapy is the risk of rupture causing severe haemorrhage as well as treatment failure. When we reviewed cases at our institution over the last five years, more than 50% of these cases initially that were treated medically did eventually require surgery because of bleeding or incomplete resolution of pregnancy.

With these experiences in mind, we have created a caesarean scar pregnancy management algorithm that focusses on surgical management and we presented in this video. Our algorithm begins with the diagnosis based on ultrasound. If the patient is haemodynamically stable and does not have a foetal heart rate, we move on to surgical intervention directly. If a foetal heart is found, multi-dose methotrexate and KCL injection are first carried out and surgical intervention convenes in 48 to 72 hours.

The procedure that is undertaken will partially depend on the type of caesarean scar pregnancy that is found. One that grows into the uterus is treated differently than one that grows into the abdomen. For a closer look at the surgical steps, the first step is mapping of the pregnancy and determination of type of caesarean scar pregnancy. This involves the dissection of the vesicouterine peritoneum. If location of the pregnancy remains elusive, the use of hysteroscopy can help.

The dissection of the vesicouterine peritoneum is required as demonstrated in the following pictures from one of our cases. It was only after the dissection of the vesicouterine peritoneum were we able to demonstrate that this indeed was a caesarean scar pregnancy that was growing into the abdomen as opposed to one that was growing towards the uterus. With the next patient, we showed that despite vesicouterine peritoneum dissection, we were still unable to determine location and a hysteroscopy was performed.

Only with the hysteroscopy were we able to see the pregnancy is actually uterine, as indicated by the arrow. The next step in our algorithm is the prophylactic clipping of the anterior division of the internal iliac artery. This works to minimise risk of haemorrhage during our procedure. The steps of the internal iliac artery ligation are as follows. We first enter the retroperitoneum above the ureter in the region of the obliterated umbilical ligament.

The retroperitoneum is then opened along the pelvic side wall. We then identify the obliterated umbilical ligament. The ureter is then identified along the medial aspect of the peritoneum and dissected. Once all the structures are identified, the interior division of the internal iliac artery is then ligated with a large vascular clip. In this video, we can see that the ureter is peristalsing on the medial aspect of the peritoneum throughout the clip.

Following the internal iliac ligation, the next step depends on type of caesarean scar pregnancy. If the pregnancy is growing toward the uterine cavity, we then proceed with a laparoscopic-guided aspiration and curettage, confirmation of evacuation by hysteroscopy. Vasopressin para-cervical block in a foley balloon can be used to tamponade the uterus to mitigate bleeding. Here, we see a D&C under direct visualisation as it is extremely important to prevent perforation, but evacuate all contents.

To do this, the curettage must be angled in the anterior defect to evacuate. A hysteroscopy is then performed to both check if all tissue has been evacuated and also touch up any areas that might require. In cases where the pregnancy grows towards the abdominal cavity, the bladder is dissected below the pregnancy. To obtain this goal, we develop the paravesical spaces and can use a colpotomiser. The bladder can also be filled and confirmation can be confirmed by hysteroscopy.

Here, we see the bladder being reflected below the level of the pregnancy after development of the paravesical spaces. We continue the dissection until we are well below the pregnancy. Here, we can see the pubocervical fascia become apparent. A hysterectomy is then made, ensuring excision at the level of the pregnancy and scar. The defect is then repaired in two layers. A uterine stent can be used and hysteroscopy performed to evaluate repair.

Here, we begin the hysterotomy. We initially begin on the inferior margin of the caesarean scar pregnancy and work our way around the entire pregnancy in a circumferential fashion. Here, we have another patient with an abdominal caesarean scar pregnancy. In this case, we injected vasopressin prior to hysterotomy as a means to mitigate bleeding. For this patient, we began our hysterotomy on the superior margin of the pregnancy.

Again, we worked our way around in a circumferential fashion. In this case, we had a more advanced gestation than our previous patient. And during our hysterotomy, we were able to demonstrate placental tissue. At this point in the surgery, we’re working our way on the inferior margin. And again, in this clip, a well dissected bladder is demonstrated. Once the pregnancy has been fully evacuated, we are left with our hysterotomy incision.

We close our uterus with a Hegar dilator in place to ensure we do not obliterate the uterine cavity. The uterus is closed in two layers with a barbed suture. We plan to see our patients at the six-week post-operative mark with a sonohysterogram to evaluate repair. This video has reviewed the surgical management of caesarean scar pregnancy.