Successful myometrial closure over protruding Cesarean scar pregnancy.

Abstract

A proportion of Cesarean scar pregnancies (CSP) are ultimately diagnosed as abnormally invasive placenta with a high risk of uterine rupture, maternal hemorrhage and need of intrapartum hysterectomy1. The degree of complications mainly depends on the location of the gestational sac within the Cesarean scar2. Sonographic diagnosis is feasible as early as in the early first trimester. In the context of termination of pregnancy, successful conservative and operative management have been reported3, including rare cases of robotic-assisted CSP treatment4. Here, we report on a case of live birth after robotic-assisted repair of dehiscent myometrium in a poor- prognosis CSP diagnosed in the first trimester. A 38-year-old woman, gravida 3, para 2, with two previous Cesarean sections (CS) presented at 5 + 3 weeks of gestation. A transvaginal scan using a 4–9-MHz ultrasound transducer (Voluson E8; GE Healthcare, Zipf, Austria) identified a CSP with the gestational sac protruding towards the abdominal cavity. Residual overlying myometrium was absent, and rapidly expanding neovascularization and lacunae of the chorion were observed (Figure 1). Abnormally invasive placenta with a high risk of early uterine rupture was suspected. Since the patient declined termination of pregnancy, we offered DaVinci® robotic laparoscopic closure of the dehiscent myometrium. The procedure was performed at 7 + 0 weeks of gestation, with the patient under general anesthesia (Videoclip S1). The vesicouterine peritoneum was incised, the bladder wall was separated from the cervical fascia and the protruding gestational sac was identified. The retracted myometrium bordering the gestational sac cranially and caudally was closed by gradual approximation using a two-layer suture (Ethibond 2-0 Excel non-absorbable sutures; barbed knotless V-Loc continuous suture). Follow-up ultrasound examinations showed an intact anterior uterine wall covering the growing gestational sac (Figure 2). Ongoing placental growth resulted in placenta percreta with cervical infiltration. Fetal development and the further course of pregnancy, with outpatient surveillance, were uneventful until 26 + 0 weeks of gestation. Inpatient surveillance was initiated after recurrent vaginal bleeding. As the patient reported non-specific abdominal pain, risk of uterine rupture was anticipated and a CS with planned intrapartum hysterectomy was performed at 30 + 0 weeks of gestation. Ureteral stents but no iliac artery balloons were placed. For CS, longitudinal laparotomy was performed with fundal incision of the uterus for fetal extraction followed by hysterectomy with the placenta untouched in situ. No uterine rupture at the site of Cesarean scar repair occurred. Examination of the specimen showed distended but intact Ethibond sutures within the pervading placenta. An iatrogenic bladder injury was repaired and the patient received two units of red blood cell concentrates. The postoperative recovery of the patient as well as the neonatal period of the female baby (birth weight of 1800 g) were uneventful. To our knowledge, this is the first case of successful relocation of a poor-prognosis CSP by robotic-assisted laparoscopic surgery resulting in live birth. The DaVinci® robotic system offers advantages compared to conventional laparoscopic or laparotomic approaches by integrating a high-definition three-dimensional camera and wristed instruments with seven degrees of freedom for perceptive, tremorless surgery enhancing surgical accuracy and enabling microsuturing5. Robotic surgery may offer new pregnancy-preserving strategies in extreme variants of poor-prognosis CSP. Marci Vigil and Anne Craig gave support in language editing. Dr Guenther Nowitzke gave technical support. Videoclip S1 Operation for the uterine closure of the dehiscent myometrium using DaVinci® surgical system. Operator: R.K.; videographer: Robert Ciurej. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.