1348 Caesarean Scar Ectopic Pregnancies: Tale of two Approaches

Abstract

Study Objective Demonstrate hysteroscopic and laparoscopic approaches to managing residual caesarean scar ectopic pregnancy tissue. Design Case report discussion. Setting Tertiary Referral Centre and University Teaching Hospital. Patients or Participants Two cases of caesarean scar ectopic pregnancies. Interventions Case 1) Hysteroscopic removal of residual trophoblastic tissue using hysteroscopic forceps. Case 2) Laparoscopic excision of residual trophoblstic tissue using ultrasonic device. Measurements and Main Results Case 1) 32 year old Para 2 (two previous caesarean sections) presented at 8 weeks gestation with a caesarean scar ectopic pregnancy. Primary systemic methotrexate management was followed by surgical suction curettage 4 weeks later. The patient complained of persistent irregular intermenstrual bleeding and retained trophoblastic tissue was seen on ultrasound scan. The patient underwent hysteroscopic resection of retained pregnancy tissue using hysteroscopic forceps. Histology confirmed residual trophoblasts and subsequent to the procedure her symptoms resolved. Case 2) 27 year old Para 1 (two previous caesarean section) presented at 6 weeks gestation with a suspected caesarean scar ectopic pregnancy. Primary surgical management of miscarriage was performed under ultrasound guidance with minimal blood loss. However patient subsequently presented with irregular heavy vaginal bleeding and persistent spasmodic suprapubic pain. Ultrasound showed retained trophoblastic tissue within the caesarean scar niche. Laparoscopic excision of caesarean scar niche and repair was performed. Subsequent to the procedure her symptoms resolved and this patient has had a further successful pregnancy. Conclusion The optimal management for caesarean scar ectopic pregnancies have yet to be established although recent evidence are supportive of primary surgical management by suction evacuation. Retained products of conception after surgical evacuation Caesarean scar ectopic pregnancies can be associated with intermittent heavy vaginal bleeding and intermenstrual bleeding. In cases where conservative management fails retained trophoblastic tissue may be excised via the hysteroscopic or laparoscopic route. Both routes for management have associated advantages and risks and decision for management should be personalised depending on size, location and accessibility of retained tissue.