Management of Cesarean Ectopic Pregnancy Via Laparoscopic Supracervical Hysterectomy

INTRODUCTION: A cesarean scar ectopic pregnancy (CSEP) is a rare but potentially life-threatening complication in which an early pregnancy implants in the scar from a previous cesarean delivery. The true incidence of CSEP is unknown but ranges from 1 in 1800 to 1 in 2656 of overall pregnancies and appears to be increasing. The implantation patterns of CSEP can be categorized as either endogenic or exogenic. Ultrasound is the standard diagnostic method with one or all of the following findings: an empty uterine cavity and endocervix; placenta, gestational sac, or both embedded in the hysterotomy scar; an irregularly shaped gestational sac that fills the scar, a thin or absent myometrial layer between the gestational sac and bladder, and a prominent or rich vascular pattern at or in the area of a cesarean scar. Though expectant management has been observed, it is not recommended due to risk of severe maternal morbidity secondary to hemorrhage or abnormal placentation. It is recommended that CSEP be managed surgically with transvaginal or laparoscopic resection and/or medically with intra-gestational methotrexate or potassium chloride. Uterine artery embolization (UAE) can be used as an adjunct to reduce the risk of bleeding. OBJECTIVE: The objectives of this video are to review the discuss the subtypes, diagnostics, and management of patients with cesarean scar ectopic; and to demonstrate methods of reducing blood loss and injury, in the setting of laparoscopic supracervical hysterectomy. METHODS: Educational video highlighting management and surgical techniques. RESULTS: We discuss the presentation, diagnosis, subtypes, and management of cesarean scar ectopic pregnancy. We present a case of a complex patient with a cesarean ectopic pregnancy who underwent laparoscopic supracervical hysterectomy. We then demonstrate specific surgical techniques used in laparoscopic supracervical hysterectomy in the setting of large cesarean scar ectopic, including the use of vasopressin and TXA, back-filling the bladder, cystoscopy, and placement of uterine manipulator under direct visualization. CONCLUSIONS: We have demonstrated appropriate medical and surgical management of a patient with cesarean scar ectopic pregnancy.