Laparoscopic resection of cesarean scar ectopic pregnancy.

Abstract

STUDY OBJECTIVE: To demonstrate a technique for the laparoscopic surgical management of cesarean section scar ectopic pregnancy. DESIGN: Step-by-step presentation of the procedure using video (Canadian Task Force classification III). SETTING: Cesarean section scar ectopic pregnancy is a rare form of ectopic pregnancy with an incidence ranging from 1:1800 to 1:2216. Over the last decade, the incidence seems to be on the rise with increasing rates of cesarean deliveries and early use of Doppler ultrasound. These pregnancies can lead to life-threatening hemorrhage, uterine rupture, and hysterectomy if not managed promptly. Local or systemic methotrexate therapy has been used successfully but can result in prolonged hospitalization, requires long-term follow-up, and in some cases treatment can fail. In the hands of a trained operator, laparoscopic resection can be performed to manage this type of pregnancy. PATIENT: Consent was obtained from the patient, and exemption was granted from the local Internal Review Board (The Womens' Hospital, Parkville). INTERVENTIONS, MEASUREMENTS AND MAIN RESULTS: In this video we describe our technique for laparoscopic management of a cesarean scar ectopic pregnancy. We present the case of a 34-year-old G4P2T1 with the finding of a live 8-week pregnancy embedded in the cesarean section scar. The patient had undergone 2 previous uncomplicated cesarean sections at term. On presentation her β-human chorionic gonadotropin (β-hCG) level was 52 405 IU/L. She was initially managed with an intragestational sac injection of potassium chloride and methotrexate, followed by 4 doses of intramuscular methotrexate. Despite these conservative measures, the level of β-hCG did not adequately fall and an ultrasound showed a persistent 4-cm mass. A decision was made to proceed with surgical treatment in the form of a laparoscopic resection of the ectopic pregnancy. The surgery was uneventful, and the patient was discharged home within 24 hours of her procedure. Her serial β-hCG levels were followed until complete resolution. CONCLUSION: Laparoscopic excision of cesarean section scar ectopic pregnancy is an effective procedure for the management of this increasingly more common condition. The use of vasopressin intraoperatively and laparoscopic suturing can prevent hemorrhage and allow for the safe removal of the ectopic pregnancy with multilayer repair of the uterine defect.