Cesarean scar pregnancy with deep serosal invasion at 16 weeks: Uterus‐sparing surgery with posterior hysterotomy after transcatheter arterial embolization

Abstract

We report a case of cesarean scar pregnancy at 16 weeks. Magnetic resonance imaging confirmed the isthmic ectopic location with an empty fundus and a high suspicion of placental invasion to the anterior myometrium. Because of pelvic pain, bleeding and the major risks of hysterectomy, a decision was made to terminate the pregnancy. After a preventive pelvic artery embolization, we performed an unusual posterior isthmic hysterotomy for the extraction of the fetus, followed by conservative management of the placenta. Bleeding loss was 300 mL, and no complication was reported. Successive magnetic resonance imaging was planned and 6 months later, there were no placental remnants. At 7 months, an office hysteroscopy revealed a normal uterine cavity. In case of cesarean scar pregnancy in the second trimester with an emergency need to interrupt pregnancy, posterior hysterotomy with conservative treatment of placenta may be an option to avoid massive bleeding and hysterectomy.

Surgical evacuation combined with Shirodkar cervical suture and selective uterine artery embolization: A fertility preserving treatment for 10–15 weeks' live cesarean scar ectopic pregnancies

“…This distinction between live and failing pregnancies is important as in live pregnancies the risk of severe hemorrhage tends to increase with gestational age, whilst in failing pregnancies the vascularity of pregnancy is the strongest predictor of intraoperative blood loss 24 . A few individual case reports and small case series from other groups have described management of advanced CSEPs ranging from 11 + 5–18 + 0 weeks' gestation 18–23,25 . Conservative management strategies have been described such as local potassium chloride followed by systemic methotrexate, 20,23 preoperative UAE followed by posterior isthmic hysterotomy, 18 stand‐alone UAE, 23 and dilatation and curettage 25 .…”

“…There have only been a few studies in the medical literature that describe the management of advanced CSEPs, particularly live pregnancies. 6 , 18 , 19 , 20 , 21 , 22 , 23 This distinction between live and failing pregnancies is important as in live pregnancies the risk of severe hemorrhage tends to increase with gestational age, whilst in failing pregnancies the vascularity of pregnancy is the strongest predictor of intraoperative blood loss. 24 A few individual case reports and small case series from other groups have described management of advanced CSEPs ranging from 11 + 5–18 + 0 weeks' gestation.…”

“… 24 A few individual case reports and small case series from other groups have described management of advanced CSEPs ranging from 11 + 5–18 + 0 weeks' gestation. 18 , 19 , 20 , 21 , 22 , 23 , 25 Conservative management strategies have been described such as local potassium chloride followed by systemic methotrexate, 20 , 23 preoperative UAE followed by posterior isthmic hysterotomy, 18 stand‐alone UAE, 23 and dilatation and curettage. 25 In one short series, two of the three cases of CSEP underwent emergency hysterectomy because of significant bleeding after dilatation and curettage.…”

Cesarean Section Scar Ectopic Pregnancy in the Second Trimester: An Underrecognized Complication of Cesarean Deliveries

“…The second case series, written by Dickerhoff et al, demonstrated three different second trimester CSP, all of which underwent D&C. Two out of three patients had hysterectomies due to uncontrollable hemorrhage and one patient had a hematometra which required reevacuation. This series concluded the high complication rates associated with D&C for CSP and recommended against this treatment modality [ 8 ]. The most recent case report described by Sroussi et al was published in 2017.…”