Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

Abstract

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> Case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy often requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancy through transvaginal ultrasound and discuss management options in the late 1^st We then show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with relatively low estimated blood loss during laparoscopic total gravid hysterectomy. The final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st trimester ultrasound should be considered in patients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can potentially decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.