Laparoscopic Management of Partial Molar Caesarean Scar Ectopic Pregnancy

Abstract

Study objective: To demonstrate laparoscopic management of a molar scar ectopic pregnancy.

Design: Stepwise demonstration of the technique with narrated video footage.

Setting: Cesarean scar ectopic pregnancy and molar pregnancy are 2 separate extremely rare pathologies with an incidence range from 1/1800 to 1/2500 of all pregnancies for the former [1,2]. The concurrence of both cesarean scar ectopic and molar pregnancy is furthermore exceptionally rare, and there are only 8 reported cases of cesarean scar molar pregnancy in literature till date [3]. There is a high risk of uterine rupture, uncontrolled hemorrhage, hysterectomy, and significant maternal morbidity owing to thin myometrium and fibrous scar after cesarean section [4,5]. Knowledge and awareness about this clinical condition aid in early diagnosis and reduced morbidity. Here, we present a rare case of cesarean scar ectopic pregnancy that was operated for failed medical management and diagnosed to be molar scar ectopic pregnancy intraoperatively.

Interventions: Total laparoscopic approach to molar scar ectopic pregnancy excision involved the following steps, strategies to minimize blood loss, and complete enucleation of tissue: (1) Hysteroscopy to localize the scar ectopic and its type and size (2) Bladder dissection to expose scar (3) Intramyometrial injection of vasopressin (4) Use of harmonic scalpel to delineate the gestational sac (5) Complete evacuation of products of conception (6) Excision of scar tissue (7) Uterine repair in 2 layers CONCLUSION: There are only 8 reported cases of cesarean scar molar pregnancy in literature till date, and all patients had at least 2 previous uterine curettages with abnormally increased β-hCG levels. The clinical manifestations were varied, the most common symptom being vaginal bleeding for a period >1 month, including our case [3]. Considering the limitations of ultrasound, magnetic resonance imaging, and serum hCG levels in the differential diagnosis of molar cesarean scar pregnancy from normal cesarean scar pregnancy, postoperative specimen should be sent for histologic examination [6]. As seen in our case, the possibility of molar pregnancy at cesarean scar ectopic site should be kept in mind in cases with rising β-hCG levels despite continuous medical interventions, which was being medically managed for 3 months. Our case is the first to be successfully managed with laparoscopic surgery as the previously reported cases were managed with suction evacuation, chemotherapy, laparotomy, or hysterectomy [3].

Keywords: Cesarean scar ectopic pregnancy; Hydatidiform mole; Hysteroscopy; Laparoscopic caesarean scar repair; Partial molar pregnancy.