Abstract
<h3>Study Objective</h3> To present a case of a hysteroscopic resection of an endocervical fibroid from within a Cesarean scar defect (CSD), also known as an isthmocele. <h3>Design</h3> Video case presentation. <h3>Setting</h3> Operative hysteroscopic procedure performed at an urban, academic surgical center. <h3>Patients or Participants</h3> 37-year-old G4P3013 with a history of 3 prior Cesareans, a hysteroscopic and abdominal myomectomy. For 3 months following a spontaneous abortion, she experienced abnormal uterine bleeding. Saline infusion sonogram and MRI revealed a 2.9 cm anterior endocervical fibroid. Options for management were reviewed. Following a short course of progestins that resulted in persistent intermenstrual spotting, and considering desire for future pregnancy, hysteroscopic resection was subsequently decided. <h3>Interventions</h3> Hysteroscopic myomectomy of CSD myoma. <h3>Measurements and Main Results</h3> Successful hysteroscopic resection and techniques to limit intraoperative and postoperative bleeding are described. Postoperatively, the patient had heavy bleeding in PACU with a quantitative blood loss of 700 mL. <h3>Conclusion</h3> Preoperative, intraoperative, and postoperative considerations for this case are reviewed. Preoperative considerations include adequate counseling, imaging such as MRI, thorough discussion of the risks and understanding of the patient's desires in the event of possible hysterectomy. Intraoperatively, primary prevention of bleeding can be attempted with the use of vasoconstrictive agents for both parametrial and intra-myoma instillation to reduce blood flow to the uterus and fibroid. Minimizing the use of electrosurgery may be preferable given the high risk of perforation. Postoperatively, uterotonics are often ineffective at controlling CSD bleeding given the minimal residual myometrium, but antifibrinolytics such as tranexamic acid may be more helpful. If not placed in the operating room under hysteroscopic or ultrasound guidance, an intrauterine balloon can also be inserted postoperatively for tamponade.
Published Version
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