Laparoscopic Management of Cesarean Scar Ectopic Pregnancy after Failed Medical Management

Abstract

Study Objective We describe a step-by-step approach of laparoscopic resection of cesarean scar ectopic pregnancy. Design A case report video. Setting Teaching hospital. Patients or Participants A 29-year-old gravida 4 para 1 woman who underwent a cesarean section two years back. She was diagnosed with cesarean scar ectopic pregnancy by transvaginal ultrasound scan with a 6-week live pregnancy. The patient received 2 doses of intramuscular injections of methotrexate. But on monitoring, the size of the ectopic sac remained the same with decline in the beta hCG. Suction evacuation was planned and post suction evacuation, patient started bleeding through os profusely for which uterine tamponade was done. After keeping patient in observation for 24 hours, the bleeding had not stopped. Thus, patient was considered for life saving laparoscopic excision of cesarean scar ectopic pregnancy. Interventions Laparoscopic management of cesarean scar ectopic pregnancy. Measurements and Main Results The diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The lower uterine segment was extremely thinned out. The uterovesical fold of peritoneum was dissected and bladder was pushed caudally. Adhesiolysis was done between the previous cesarean scar and the bladder. The ectopic gestational sac was identified, and incision was given at the most prominent site of the cesarean scar. The products of conception were evacuated in an EndoBag and extracted through the infra-umbilical port. The specimen was sent for histopathological examination. The margins of the previous scar were excised, and the uterine defect was repaired in two layers. Hemostasis was achieved. Intraoperative blood loss was minimal. Patient tolerated the procedure well and was discharged on POD3. Conclusion Laparoscopy is a safe and effective procedure of managing cesarean scar ectopic pregnancy after failed medical management. This gives an advantage of minimal blood loss, decrease post-operative pain and better cosmetic results.