Cesarean Ectopic Scar Revision

Video Objective To present a laparoscopic approach to secondary surgical management of cesarean scar pregnancy through removal of retained products of conception and scar revision. Setting We present the case of a 29-year-old G4P3 at 6w5d by LMP referred to a tertiary care facility for cesarean scar ectopic pregnancy. Ultrasound revealed a fetal pole with cardiac motion located at the site of patient's previous cesarean section scar, with bHCG 112,000. Interventions The patient underwent primary medical management with intra-sac and intra-placental administration of methotrexate, followed by intra-embryonic potassium chloride injection to achieve cessation of fetal cardiac motion. bHCG down-trended precipitously, but was persistently positive three months following treatment. Repeat imaging was obtained, which demonstrated retained products of conception (POCs) at the cesarean scar measuring 4.7cm. Given patient's desire for future fertility, she underwent laparoscopic removal of POCs and scar revision. We emphasize the following features of secondary surgical management: temporary bilateral uterine artery ligation, lysis of adhesions between the bladder and lower uterine segment, injection of dilute vasopressin adjacent to defect, enucleation of POCs, and two-layer closure of the myometrial defect. Conclusion There is limited large-scale data or clinical consensus surrounding optimal management for cesarean scar pregnancies. For patients who desire future fertility, little is known about recurrence and subsequent pregnancy outcomes. We present a safe and effective option for secondary surgical management of retained products of conception, which allows for repair of the defect and restoration of normal uterine anatomy.