Page 3 - World Journal of Laparoscopic Surgery

Minimal Access Surgery in Cesarean Scar Pregnancy
treating clinician, it poses a great threat to the patient’s life. This Table 1: Patients with history of previous cesarean section and D&C
study has been planned to evaluate the laparoscopic management Procedure Number of patients
of CSP and its outcome with the aims and objective to study the
efficacy and outcome of laparoscopic management of CSP and LSCS-1 9
to study the demographic characteristics and various etiological LSCS-2 2
factors leading to CSP. D&C before LSCS 2
D&C after LSCS 5
MAterIAls And Methods
This was a retrospective study. It was conducted in the Department Table 2: Duration between previous cesarean section and current
of Obstetrics and Gynecology at a tertiary healthcare center over a pregnancy (years)
period of 2 years. Patients with diagnosed CSP were included in the
study after satisfying inclusion and exclusion criteria. Time elapsed since last LSCS Number of patients
CSEP diagnostic criteria advocated on USG. 12–18 weeks 3

• Empty uterus with clearly visualized endometrium. 9 18–24 weeks 3
9
• Empty cervical canal. >24 weeks 5
• Gestational sac implanted in the lower anterior uterine segment
at the presumed site of cesarean section incision site. 10
• Thin or absent myometrium between the gestational sac and Table 3: Cesarean section—emergency during labor/elective
the bladder. 11 LSCS Frequency Percent (%)
• Doppler flow at the previous caesarean scar and negative-sliding Emergency LSCS during labor 3 27.27
organ sign. 12,13
Elective LSCS (not in labor) 8 72.72
Inclusion Criteria
• Patients with a history of at least one previous CS with β-hCG the majority of them (54.5%) presented with no symptoms on
>5000 IU. admission. A total of seven patients provided a history of dilatation
• Diagnosed case of CSP on ultrasonography. and curettage (D&C) for termination of pregnancy in the past. Five
• Consented for laparoscopic management. patients had undergone D&C after cesarean section (Table 1).
• Desirous of future pregnancy. Eight patients had a history of elective cesarean section in the
• Gestational age <12 weeks. past. All the patients were not aware of the importance of birth
Exclusion Criteria spacing after cesarean section, and hence the contraceptives were
not used regularly by them. Six patients conceived within 24 months
• Chronic medical disorder for which patients were not fit for the of the last cesarean section (Table 2).
laparoscopic surgery. In our study, nine (81%) patients underwent cesarean section
• Patient willing for conservative medical management.
electively at term in the past (Table 3).
Routine history, including demographic characteristics, presenting Seven patients required blood transfusion during surgery, while
complaints, etc., was recorded in an approved proforma. Routine two patients had undergone exploratory laparotomy for bladder
blood investigations and serum β-hCG levels were noted. repair. Both these patients presented with gestational age of more
Gestational age on USG was recorded. Diagnosis inferred from than 10 weeks with higher β-hCG levels and significant-size CSP on
the above investigations was analyzed in the study. Surgical admission. These two patients were managed in the surgical ICU for
management was carried out as per the multimodality approach, 2 days. Overall, nine patients were managed successfully through
i.e., use of minimal access surgery, hysteroscopy, laparoscopy, and laparoscopic surgery. The average blood loss noted was 100–300 mL,
cystoscopy along with ultrasonography. The defective scar was and surgery duration was 90–120 minutes. Only one patient
excised, and the underlying uterine wall repair was done with produced a discharge summary or surgical notes of the previous
intracorporeal suturing. cesarean section, so details of the surgical procedure, the patient’s
Maternal outcomes in the form of successful laparoscopic recovery, and instructions on discharge could not be retrieved for
management, repair of organs like bladder, bowel, ureter, rest of the patients. Overall, nine (81.8%) patients were successfully
hemorrhage requiring blood transfusion, ICU management, managed by minimal access surgery. One patient conceived
follow-up clinical examination, onset of regular menstrual cycles, spontaneously after 2 years of laparoscopic management of CSP.
and future pregnancy outcome were recorded.
dIscussIon
results Mean age of the patients presented with CSP in our study was 28
All the patients enrolled in the study underwent laparoscopic years, which is comparable with the results conducted by Xiao et al.
14
management of CSP. The average age of the patients in the study The mean age in their study was 30.7 ± 3.4 years. It shows that
was 28 years. Nine patients had undergone one cesarean section in young women were at risk of losing their fertility. Chuang et al. 15
the past. Nine patients presented with anemia with Hb <10 gm/dL. argued that the number of previous cesarean sections does not
Six patients presented with gestational age less than 7 weeks, while appear to be a factor for CSP. In our study, nine patients of diagnosed
five patients presented after 8 weeks of gestation. Nine patients CSP had a history of one cesarean section in the past.
presented with β-hCG >10000 IU. Patients with CSP were admitted Nine patients were found anemic on admission (Hb <10 gm/dL).
16
with complaints of vaginal bleeding or pain in the abdomen, but Chen et al., in their study concluded that anemia and single-layer

2 World Journal of Laparoscopic Surgery, Volume 16 Issue 1 (January–April 2023)