Laparoscopic management or laparoscopy combined with transvaginal management of type II cesarean scar pregnancy

Abstract

Objective: To evaluate the clinical effectiveness of laparoscopic management of cesarean scar pregnancy (CSP) by deep implantation.

Background: A pregnancy implanting within the scar from a previous cesarean delivery is a rare condition of ectopic pregnancy. There are two different types of CSPs. Type I is caused by implantation of the amniotic sac on the scar with progression toward either the cervicoisthmic space or the uterine cavity. Type II (CSP-II) is caused by deep implantation into a previous CS defect with infiltrating growth into the uterine myometrium and bulging from the uterine serosal surface, which may result in uterine rupture and severe bleeding during the first trimester of pregnancy. Thus, timely management with an early and accurate diagnosis of CSP-II is important. However, laparoscopic management in CSP-II has not yet been evaluated.

Methods: Eleven patients with CSP-II underwent conservative laparoscopic surgery or laparoscopy combined with transvaginal bilateral uterine artery ligation and resection of the scar with gestational tissue and wound repair to preserve the uterus from March 2008 to November 2011. Patients with CSP-II were diagnosed using color Doppler sonography, and the diagnosis was confirmed by laparoscopy. The operation time, the blood loss during surgery, the levels of β-human chorionic gonadotropin (β-hCG) before surgery, the time taken for serum β-hCG levels to return to <100 mIU/mL postoperatively, and the time for the uterine body to revert to its original state were retrospectively analyzed.

Results: All 11 operations were successfully performed using laparoscopy with preservation of the uterus. One patient underwent a dilation and curettage after laparoscopic bilateral uterine artery ligation. Eight patients were treated solely by laparoscopic bilateral uterine artery ligation and resection of the scar with gestational tissue and wound repair. The remaining two patients underwent laparoscopic bilateral uterine artery ligation and transvaginal resection of the CS with gestational tissue and wound repair because of dense adhesions and heavy bleeding. The average operation time was 85.5 (±17.5) minutes, and the blood loss was 250.0 (±221.4) mL. The blood serum level of β-hCG returned to <100 mIU/mL in 16.4 (±5.3) days postoperatively. Among the 10 patients who underwent resection of CS and wound repair, the time for the uterus to revert to its original state (judged by ultra-sonography) was 10.8 (±3.0) days postoperatively.

Conclusions: Laparoscopy can remove ectopic gestational tissue and allow subsequent wound repair, as well as provide diagnostic confirmation. Being a minimally invasive procedure, laparoscopic or laparoscopy combined with transvaginal bilateral uterine artery ligation and resection of the scar with gestational tissue and wound repair can become an effective alternative for the treatment of CSP-II.

Figure 1.

A bulging mass over the serosal surface of the lower uterus (arrow) in patients 6 (A) and 7 (B) under laparoscopy. A bluish mass made up of gestational tissue, blood clots, fibrin, and myometrial scar, covered by a thin wall of myometrium, when the bladder peritoneum was incised in patients 6 (C) and 7 (D).

Figure 2.

(A) Transverse incision over the most prominent area of the mass in patient 6. (B) The mass was removed using grasping forceps, and the resulting space in the myometrium is cleaned using suction irrigation and then clipped using scissors. (C) One layer of continuous sutures along the affected uterine wall was made under laparoscopy. (D) The appearance of the uterus after sutures.

Figure 3.

(A) In patient 7, severe bleeding occurred when the bladder was pushed down because of the dense adhesion between the bladder and the lower uterine segment. (B) The myometrial scar broken and the conceptus (arrow) was seen. (C) The anterior fornix was incised, and the bladder was separated from the cervix using a finger transvaginally. (D) The closure checked by laparoscopy.