Page 67 - World Journal of Laparoscopic Surgery

Laparoscopic Management of Cesarean Scar Pregnancy
certain C-section indications in previous pregnancies are identified patient should be informed of the possibility of losing the pregnancy
as risk factors for CSP, the most common one being prior C-section as well as hysterectomy in the event of excessive bleeding. 15
for breech presentation. 9 The options for medical management of CSPs include the
following:
Clinical Features
Cesarean scar pregnancy may present from as early as 5–6 weeks (a) Systemic injection of methotrexate (MTX).
to as late as 16 weeks. 39% of women with CSP present with (b) Local injection of MTX and/or potassium chloride/ ethanol/
painless vaginal bleeding though CSP is an incidental finding in hyperosmolar glucose into the gestational sac.
(37%) asymptomatic woman. About 16% of women complain of (c) Oral mifepristone (not commonly practiced).
accompanying mild to moderate pain and 9% complain of only Hemodynamically stable patients may be offered medical
abdominal pain. Profuse vaginal bleeding with severe acute pain management with success rates ranging between 56% and 77%.
or tender uterus on examination hints at an impending rupture. The combination of systemic and local therapy has been reported to
Hemodynamic instability and/or collapse strongly implies a ruptured be associated with highest success rate. The reported complications
CSP. Clinical examination in stable women is usually unremarkable. 5 include hemorrhage (7%) and hysterectomy (3). 14,16 The risk of
complications in subsequent pregnancies due to unrepaired
Diagnosis C-section scar defect is considered as the disadvantage of medical
The ultrasound diagnosis of CSP should be made when the treatment alone over surgical treatment.
pregnancy invades myometrium in the vicinity of the internal OS. Options for surgical treatment include the following:
Cesarean scar pregnancies are implanted anteriorly at the visible
or presumed site of transverse lower segment uterine scar. Internal (a) Dilatation and curettage (D&C) (success rate of 76%).
OS is identified using Doppler and identifying the uterine vessels. 10 (b) Hysteroscopic/laparoscopic/vaginal/open excision of CSP
Sensitivity of 86.4% has been estimated with combined (success rates: 88, 96, 97, and 99%, respectively).
TVUS and color Doppler. 11 The differential diagnoses include (c) Hysterectomy.
cervical ectopic pregnancy, cervico-isthmic pregnancy and The highest complication rate was noted with D&C; the risk of
inevitable abortion. MRI aids in diagnosis when ultrasound diagnosis hemorrhage being 28%, and hysterectomy, 3%. With excision of
is equivocal and patient is hemodynamically stable. Sagittal CSP, the complication rate was much lower; risk of hemorrhage
T2-weighted images may help in identifying placental implanta- being 4% and the risk of hysterectomy, 2%. 16
tion, bladder wall invasion and thickness of myometrium which may The combined medical and surgical treatment options have
12
give us an idea of risk of rupture. There are insufficient data to also been tried and have been found to be associated with higher
support a benefit of routine use of 3D ultrasound imaging for the success rates and lower complication rates. A systemic MTX may
diagnosis or management of CSP. 9 be given followed 7 days later by hysteroscopic resection or
Prognosis laparoscopic excision (success rate, 87%; risk of hemorrhage, 5%;
Cesarean scar pregnancy is typically terminated upon confirmation and risk of hysterectomy, 0%). If there is no disappearance of blood
of diagnosis to avoid life-threatening complications. However, flow around the scar on Doppler or insignificant decline in hCG,
a survey of 36 cases of CSP that continued under expectant it may be prudent to give a repeat dose of MTX before surgical
management showed that, hysterectomy was performed in the treatment. However, the combination of suction curettage with
14,16
second trimester in 10 cases due to genital bleeding, live offspring medical treatment does not seem to be of much benefit.
were delivered in 26 cases, at 26–39 weeks of gestation and In surgical excision of scar ectopic, wedge resection of the

hysterectomy was performed at delivery in 17 cases(only in type 1). 13 uterine wall is done followed by repair of the incision. This may be
done with/without bilateral uterine artery occlusion. Laparoscopic
Complications approach seems to have the advantage of complete removal of
The chorionic villi are either bound to or penetrate the myometrium the products of conception thereby reducing the follow up time.
in CSP unlike in case of placenta accreta where the villi invade Another advantage with laparoscopic technique is excellent
the myometrium. This is said to be the reason for life-threatening view of the pathology facilitating complete reconstruction and
17
complications associated with CSP. 5 good prognosis for future pregnancies. Hysteroscopy could be
considered as a primary treatment modality for type I CSP. 14
Treatment The uterine artery embolization (UAE) is another treatment
The Royal College of Obstetricians and Gynecology London (RCOG)/ option reported, being undertaken before D&C or surgical therapy
16
AEPU Green-top Guideline (No. 13) has highlighted that there is need and sometimes in combination with medical therapy. Although
for research on optimal treatment of CSP as there is no consensus reported to increase the success rate of the primary treatment,
on this. The three reported options include expectant, medical, UAE has its disadvantages, namely, diminished ovarian reserve,
8
and surgical management. Duration of pregnancy, maternal vital fetal growth restriction, preterm delivery, abruption placentae,
parameters, desire to preserve fertility, skill and experience of and placenta accreta. 14
the treating physician, and the resources available determine the The high-intensity focused ultrasound ablation has also been
treatment option to be chosen. The primary goal of treatment should reported either alone or combined with D&C in CSPs of less than 8–9
be to preserve maternal health preserving fertility, the secondary goal. 9 weeks in a few cases (success rate, 93%; risk of hemorrhage, 4; and risk
16
Expectant management is no more recommended as it may lead of hysterectomy, 0%). There is insufficient data comparing success
to severe maternal morbidity. 9,14 If the patient opts for expectant rate with MTX vs UAE prior to surgical treatment in CSP. However,
treatment, it may be considered if there is no cardiac activity. Also, the the blood loss was found to be lower with systemic MTX group. 18

World Journal of Laparoscopic Surgery, Volume 15 Issue 3 (September–December 2022) 253