Hysterectomy strategies for cesarean scar ectopic pregnancy

Abstract

The objectives of this film are to discuss both medical and surgical management options for c-section scar ectopic pregnancy and understand the importance of hemostatic control and methods to decrease bleeding. Although there is no consensus on appropriate management, there are several options. Expectant management is reported, but successful outcome with no complications is unlikely. Systemic methotrexate and local injection have low success rates. Uterine artery embolization is an adjuvant treatment used to decrease bleeding. Dilation and curettage can be combined with methotrexate. Hysteroscopic resection and laparoscopic resection are additional options. If patient no longer desires fertility, hysterectomy is considered. This is the case of a 34 year old G6P3 at 7 weeks and 5 days gestation with cesarean section scar ectopic found incidentally on ultrasound during prenatal visit. She had a history of three cesarean sections. Patient declined methotrexate and desired hysterectomy. When performing a hysterectomy for a c-section scar ectopic, it is important to prioritize bleeding control. In this case, the uterine manipulator was not placed into the uterus initially, to avoid perforating the pregnancy. Instead, an EndoPaddle was used from above through an assist port to manipulate the uterus without causing trauma and bleeding. The goal is to achieve hemostasis before introducing a uterine manipulator by ligating the uterine arteries at the origin via retroperitoneal dissection. Vasopressin injection into pregnancy implantation site achieves additional hemostasis. In conclusion, taking extra precautions to control bleeding is essential during a hysterectomy for cesarean scar ectopic pregnancy.