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A 29-year-old woman presented to the emergency room with symptoms of abdominal pain and vaginal bleeding. Ultrasound confirmed a 9+5 week pregnancy located within the lower uterine segment with crown lump length measuring 22mm, which extended into a previous cesarean section scar. The lower uterine segment was ballooned anteriorly abutting the bladder without an obvious plane. She had six previous pregnancies including four previous cesarean section deliveries, and a strong desire for uterine preservation. Other relevant medical history included triscuspid valve replacement in 2016. Physical exam revealed a 10-week uterus, mildly tender to palpation, and speculum examination revealed a closed cervix with scant red brown blood. Her blood pressure and pulse were within normal limits; her HCG was 53,654 mIU/ML.
A definitive diagnosis of cesarean scar ectopic pregnancy (CSEP) was made and the patient was admitted for uterine artery embolization and ultrasound guided intra-gestational sac methotrexate injection to decrease the blood flow to the ectopic pregnancy. She was followed with serial ultrasounds and beta HCGs, which trended down to 58.6 mIU/ML. She was ultimately scheduled for laparoscopic resection of the CSEP, isthmocele resection and repair, and lysis of adhesions.
Following initiation of general anesthesia, we prepped and draped the patient. After placing a Foley catheter in the bladder, we inserted a speculum into the vagina and injected vasopressin solution intracervically. We then placed a sponge stick in the vagina.
Turning our attention to the abdomen, we made a 1 cm infraumbilical vertical skin incision using an 11 blade scalpel. After grasping the underlying fascia with Crile clamps, we elevated the fascia and entered sharply using a scalpel. We tagged the edges of the fascia with stay sutures of 0 Polysorb and placed a 10/12 blunt Hasson trocar through the incision. We insufflated the abdomen to a maximum filling pressure of 15 mmHg. We then placed the laparoscope through the trocar and confirmed entry into the peritoneum without incident, specifically without any apparent injury to the underlying bowel or bladder. We then placed 5 mm ports as accessory ports in the bilateral lower quadrants, with care to avoid epigastric vessels, as well as one port in the suprapubic area with care to avoid the bladder.
We placed the patient in the Trendelenburg position and performed a thorough survey of the abdomen. We noted normal posterior cul-de-sac, left and right ovarian fossa and uterosacral ligaments. The patient had minimal bladder adhesions to the lower uterine segment and moderate omental adhesions over the anterior abdominal wall. Notably, we confirmed the presence of a 3 cm lower uterine segment ectopic pregnancy within the scar of a previous cesarean section. The fallopian tubes and ovaries appeared normal bilaterally, and the bowel, appendix and diaphragmatic peritoneum appeared normal
We used monopolar endoshears for electrosurgery, first directing our attention on lysis of omental adhesions. We temporarily clipped bilateral IP ligaments and mobilized the bladder below the cervix. Subsequently, we backfilled the bladder to delineate its borders. We injected vasopressin solution 20 U in 60 cc of saline, and placed 15 cc around the ectopic pregnancy. Using LigaSure, we incised the superior aspect of the isthmocele and identified the products of conception. We then dissected the remaining gestational sac from the isthmocele. After noting that the gestational sac contained a fetus at 9 weeks gestation, we placed it in a 10 mm endocatch bag. We then excised the remaining isthmocele, inserted a RUMI manipulator and performed a gentle curettage through suprapubic port to ensure all products of conception were removed. We then closed the myometrium in two layers with 2-0 V-Lock. After ensuring water-tight closure, we placed the isthmocele tissue in a 10 mm endocatch bag, and then removed both bags through the umbilicus without difficulty.
After irrigating the abdomen and clearing all clots and debris, we closed the suprapubic 10mm port with interrupted 0-vicryl, removed the bilateral clips from the IP ligaments, and removed the ports under direct laparoscopic visualization. We then removed the camera from the abdomen and allowed the pneumoperitoneum to escape. We closed the umbilical fascia with 0-PDS with adequate reapproximation of the fasical edges, and then closed all skin incisions with 4-0 moncryl. We covered the lateral ports with steri-strips and all incisions were covered in bandages. We extubated the patient and transferred her to the PACU in stable condition. The patient was discharged home on postoperative day 0.
Diagnosis requires high index of suspicion
CSEP — defined as the implantation of a blastocyst within a previous cesarean scar — is rare, occurring in approximately 1 in 2,000 pregnancies. CSEP accounts for only about 6% of all ectopic pregnancies in patients who have had previous cesarean sections. Before implanting, it is thought that the embryo may migrate through a defect in the lower uterine segment or a microscopic fistula in the scar. Patients may present with abdominal cramps, low abdominal pain or vaginal bleeding, or they may be asymptomatic and present for evaluation for ectopic pregnancy. If undetected, CSEP can lead to uterine rupture or hemorrhage. Diagnosis is made via ultrasound, and often requires a high index of suspicion. Medical treatment may take months and carries the risk of uterine rupture and life-threatening hemorrhage. Laparoscopic resection, in this particular case, removed the products of conception and allowed for repair of the defect with uterine preservation.