Laparoscopic removal of heterotopic cesarean scar pregnancy

Hakan Guraslan; Ozlem K Akgul; Dogan E Aydin; Evrim E Kovalak; Nursen K Aksoy; Tugba O Aydin

doi:10.1016/j.fertnstert.2024.04.018

Laparoscopic removal of heterotopic cesarean scar pregnancy

Fertil Steril. 2024 Apr 16:S0015-0282(24)00246-2. doi: 10.1016/j.fertnstert.2024.04.018. Online ahead of print.

Authors

Hakan Guraslan¹, Ozlem K Akgul², Dogan E Aydin³, Evrim E Kovalak², Nursen K Aksoy², Tugba O Aydin⁴

Affiliations

¹ Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. Electronic address: guraslanhakan@gmail.com.
² Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
³ Department of Obstetrics and Gynecology, Ministry of Health Havran State Hospital, Balikesir, Turkey.
⁴ Department of Obstetrics and Gynecology, Ministry of Health Edremit State Hospital, Balikesir, Turkey.

PMID: 38636771
DOI: 10.1016/j.fertnstert.2024.04.018

Abstract

Objective: To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options.

Design: Surgical video article. The Institutional Ethics Committee approved the video reproduction.

Setting: Tertiary referral to a university hospital PATIENT: A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine (IU) location, and the other was in a previous cesarean section scar.

Interventions: Scar pregnancy was excised laparoscopically, preserving IU pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc sutures.

Main outcome measures: Ongoing IU pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery.

Results: The procedure was completed in 67 minutes. Total blood loss was <100 cc. The ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During the cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male infant (weight, 3,210 g; Apgar score, 9/10) was delivered.

Conclusions: The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during a cesarean section in approximately half of cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving IU pregnancy.

Keywords: Heterotopic scar pregnancy; laparoscopic management; surgical management.