Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2021 Jul-Sep;25(3):e2021.00039.
doi: 10.4293/JSLS.2021.00039.

Combined Medical and Minimally Invasive Robotic Surgical Approach to the Treatment and Repair of Cesarean Scar Pregnancies

Eva Hoffmann  1 , Sevan Vahanian  1 , Vanessa T Martinelli  1 , Martin Chavez  1 , Michael Mesbah  1 , Farr R Nezhat  1
Affiliations
Case Reports

Combined Medical and Minimally Invasive Robotic Surgical Approach to the Treatment and Repair of Cesarean Scar Pregnancies

Eva Hoffmann et al. JSLS. 2021 Jul-Sep.

Abstract

Background and objectives: The rise in cesarean deliveries, has led to increase in maternal complications in subsequent pregnancies such as abnormal placental implantation, uterine rupture, hemorrhage and, less commonly, cesarean scar pregnancies (CSP). Our objective was to describe patient characteristics following a combined medical and surgical treatment approach to first trimester cesarean scar pregnancies.

Methods: This was a case series approved by the Institutional Review Board of cesarean scar pregnancies over a two-year period at a single academic institution. The study included five patients with diagnosed cesarean scar pregnancies opting for pregnancy termination with the desire for fertility preservation. Medical treatment involved intra-gestational sac injection of lidocaine followed by systemic injection of methotrexate. At a minimum of two months later, surgical resection of cesarean scar pregnancy and repair of the uterus was performed.

Results: Median patient age was 36 (range 34 - 42) years, with 4 (3 - 10) prior pregnancies and 2 (1 - 3) prior cesarean deliveries. 40% (2/5) were Hispanic, 20% (1/5) Caucasian, 20% (1/5) African-American, and 20% (1/5) South Asian. After medical intervention, patients waited on average 4.6 ± 2.3 months before surgery. No post-intervention complications or recurrences occurred. Two patients had a subsequent pregnancy.

Conclusion: This case series demonstrates an ideal management of cesarean scar pregnancy using combined medical and surgical approach in treating current ectopic pregnancy and repairing the uterine defect successfully without recurrence.

Keywords: Cesarean delivery; Ectopic pregnancy; Pregnancy termination.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: The authors declare no conflict of interest.

Figures

Figure 1.
Figure 1.
Low implantation of the gestational sac with loss of myometrial wall thickness anteriorly.
Figure 2.
Figure 2.
Low implantation of gestational sac, above the internal cervical os.
Figure 3.
Figure 3.
Cross-hair lines indicating an empty fundal cavity with gestational sac implanted in lower uterus.
Figure 4.
Figure 4.
Doppler evidence of vascular invasion into the surrounding myometrium.
Figure 5.
Figure 5.
Initial treatment with sonographic mapping for ultrasound guided transabdominal intra-gestational sac injection of lidocaine.
Figure 6.
Figure 6.
Hysteroscopic view of uterine cavity with retained products and use of cold loop electrode.
Figure 7.
Figure 7.
Laparoscopic view of anterior uterus prior to revision prior to lysis of adhesions.
Figure 8.
Figure 8.
Laparoscopic view of uterus after resection of cesarean ectopic pregnancy with well vascularized edges.
Figure 9.
Figure 9.
Laparoscopic view of uterus status post resection of cesarean ectopic pregnancy after water tight closure with barbed suture.
Figure 10.
Figure 10.
Arrow indicating area of uterine repair with no evidence of defect or niche.
See this image and copyright information in PMC

References

    1. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: Final Data for 2017. Natl Vital Stat Rep. 2018;67(8);1–50. - PubMed
    1. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta & cesarean scar pregnancy: a review. Am J Obstet Gynecol. 2012;207;14. - PubMed
    1. Bij de Vaate AJ, van der Voet LF, Naji O, et al. . Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following cesarean section: systematic review. Ultrasound Obstet Gynecol. 2014;43(4):372–382. - PubMed
    1. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol. 2003;21(3):220–227. - PubMed
    1. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Am Coll Obstet Gynecol. 2006;107(6):1373–1381. - PubMed

Publication types

LinkOut - more resources