{"paper_id":"7ec0afd4-88b4-46bb-82ca-5d16f75337ab","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: CSD, cesarean scar defect; CSEP, cesarean \nscar ectopic pregnancy; CSP, cesarean scar pregnancy; LESS, \nlaparoendoscopic single-site surgery; MTX, methotrexate; UAE, \nuterine artery embolization; RMT, residual myometrial thickness; \nSILS, single-incision laparoscopic surgery\nBackground\nCesarean scar ectopic pregnancy (CSEP) is the rarest location \nfor ectopic pregnancy (incidence of 1:1,800 to 1:1,216); 1,2 with \nimplantation in the cesarean scar defect (CSD) of the uterus, 3,4 There \nare two types of CSEP; Type 1 has progression toward the uterine \ncavity; Type 2 is deep within the myometrium. 5 The primary \npathology stems from poor wound healing, resulting in focal thinning \nof the uterine scar or migration of the embryo through a microscopic \nfistula wedge defect exposing the site for implantation. 6,7 Additional \ncomplications include rupture, hemorrhage, and uterine rupture due \nto weakness of the cesarean scar.8−10\nUltrasound is the preferred diagnostic method for CSEP, with \ndiagnostic criteria set as:\na. Diagnosis of an empty uterine cavity\nb. Diagnosis of an empty cervical canal\nc. Development of the sac in the anterior isthmic segment\nd. Circumferential flow using color Doppler\nAbsent or diminished myometrial thickness between the sac and \nmaternal bladder.11,12\nSince CSEP is so rare, no standard treatment exists - current \napproaches include methotrexate (MTX), bilateral uterine artery \nembolization, dilation and curettage (D&C), and open or laparoscopic \nsurgical repair. 6,9,13 However, without surgical repair, the risk of \nrecurrent CSEP still remains.14\nWe report a case of CSEP diagnosed via ultrasound and managed \nwith MTX, D&C and single-incision laparoscopic surgery (SILS) \nresection of the CSEP.\nPresentation of the case\nA 38-year-old, gravida 4 para 3003 at 7 weeks and 4 days gestation \nby last menstrual period presented with intermittent bleeding, passage \nObstet Gynecol Int J. 2018;9(3):158‒160. 158\n©2018 Rezai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestrited use, distribution, and build upon your work non-commercially.\nSingle-incision laparoscopic surgery of cesarean \nscar ectopic pregnancy: a case report and review of \nliterature\nVolume 9 Issue 3 - 2018\nShadi Rezai,1,6  Alexander C Hughes,2 Neil D \nPatel,2 Elise Bardawi,1,6 Yiming Zhang,3 Ninad \nM Patil,4 Cassandra E Henderson,5 Xiaoming \nGuan6 \n1Department of Obstetrics and Gynecology, Southern California \nKaiser Permanente, USA\n2St George’s University, School of Medicine, Grenada\n3Division of Reproductive Medicine, Jinan Central Hospital \nGroup, China\n4Department of Pathology & Immunology, Baylor College of \nMedicine, USA\n5Maternal and Fetal Medicine, Department of Obstetrics and \nGynecology, Lincoln Medical and Mental Health Center, USA\n6Division of Minimally Invasive Gynecologic Surgery, \nDepartment of Obstetrics and Gynecology, Baylor College of \nMedicine, USA\nCorrespondence: Xiaoming Guan MD PhD, Section Chief and \nFellowship Director, Division of Minimally Invasive Gynecologic \nSurgery, Department of Obstetrics and Gynecology, Baylor \nCollege of Medicine, 6651 Main Street, 10th Floor, Houston, \nT exas, 77030, USA, T el (832) 826-7464, Fax (832) 825-9349, \nEmail \nReceived: March 24, 2018 | Published: May 22, 2018\nAbstract\nBackground: Cesarean scar ectopic pregnancy (CSEP) is the rarest location for ectopic \npregnancy; with implantation within the cesarean scar defect (CSD) of the uterus. The \nprimary pathology stems from wound poor healing, resulting in focal thinning of the \nuterine scar; predisposing the site for gestational sac implantation. Current CSEP treatment \napproaches include methotrexate (MTX), bilateral uterine artery embolization, dilation \nand curettage (D&C), and open or laparoscopic surgical repair. We report a case of CSEP \ndiagnosed via ultrasound and managed with methotrexate, (D&C) with single-incision \nlaparoscopic surgery (SILS) resection of the CSEP.\nCase: 38-year-old Gravida 4, Para 3003 at 7-4/7weeks presented with intermittent bleeding \nand passage of clots. Bedside transvaginal ultrasound showed CSEP with detectable fetal \nheart tones.  B-hCG value was >30,000mIU/mL. Obstetrical history included a normal \nspontaneous vaginal delivery followed by two cesarean deliveries. For this case the patient \nopted for diagnostic hysteroscopy, suction D&C, with SILS robotic resection of the CSEP, \nand umbilical hernia repair. The patient had an unremarkable recovery course and was \ndischarged from the hospital on postoperative day 1, with plan to follow up weekly for \nquantitative B-hCG levels.\nConclusion: CSEP presents challenges for clinicians as there is conflicting data on the \nbest mode of treatment. Our case presents a SILS surgical approach in combination with \nhysteroscopy for improved visualization. The authors have found this technique to be \neffective, but through review of the literature endorse the 3D-MESIA protocol alternative.\nKeywords: 3D- MESIA, cesarean, cesarean scar defect, cesarean scar ectopic, cesarean \nscar ectopic pregnancy, cesarean scar pregnancy, diagnostic hysteroscopy, ectopic, fetal \nintracardiac potassium chloride injection, pregnancy, laparoendoscopic single-site \nsurgery, methotrexate, uterine artery embolization, sonography directed-in situs aspiration \nsequential therapy based on the pregnancy sac three-dimensional (3d) conformation \nanalysis (3d-mesia), residual myometrial thickness, robotic-assisted laparoscopy, single-\nincision laparoscopic surgery, uterine niche\nObstetrics & Gynecology International Journal\nCase Report\n Open Access\n\n\nSingle-incision laparoscopic surgery of cesarean scar ectopic pregnancy: a case report and review of \nliterature\n159\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Hughes AC, Patel ND, et al. Single-incision laparoscopic surgery of cesarean scar ectopic pregnancy: a case report and review of literature. \nObstet Gynecol Int J. 2018;9(3):158‒160. DOI: 10.15406/ogij.2018.09.00327\nof clots, and morning sickness. Obstetrical history included a normal \nspontaneous vaginal delivery followed by two cesarean deliveries, the \nlast one being 2 years prior. Patient reported sulfa drug allergy, prior \nsmoking status, and Rh positive status; period her body-mass index \nwas 26.73 kg/m2. she was hemodynamically stable.\nBedside transabdominal ultrasound confirmed a gestational sac, \nfetal pole, heart tones, and heart rate within a CSEP defect. B-hCG \nwas >30,000mIU/ml, with all other laboratory values within normal \nlimits.\nTreatment options were discussed with the patient, including \nMTX administration (systemic vs combined systemic and local intra-\ngestational), and hysteroscopy with SILS laparoscopic resection of \nCSEP.\nSurgical evaluation revealed an 8-week size, anteverted, mobile \nuterus with no additional masses; cervix was dilated to fingertip only. \nA 25mm skin incision was made in the umbilicus and a GelPOINT \nMini advanced access single-site laparoscopy device was inserted. \nAbdominal insufflation revealed vesico-uterine adhesions limiting \nimmediate visualization of the ectopic pregnancy. Due to poor \nvisibility, intraoperative hysteroscopy was performed which revealed \na gestational sac at the lower segment of the uterus, adherent to the \nanterior uterine wall approximately 3-4cm superior to the external \ncervical os. The RUMI manipulator was placed in the vagina without \nuse of the uterine balloon. The vesico-uterine adhesions were lysed \nusing the Harmonic scalpel and the ectopic pregnancy was exposed \nwithin the middle of the scar. Vasopressin was used for hemostasis \nand the Harmonic was used to incise this area; amniotic fluid with \nproducts of conception (POC) was noted and removed ( Figure 1 ). \nSuction and graspers were used to remove as much POC tissue as \npossible. The RUMI manipulator was removed, and the endometrial \ntip was placed to ensure that the os was not closed during the repair. \nThe uterine defect was closed in 3 layers using V-loc sutures ( Figure \n2). While maintaining observation with the abdominal camera, a \nsuction D&C was performed. The diagnostic hysteroscopy, suction \nD&C, and SILS robotic resection of the CSEP was performed with an \nestimated blood loss of 30ml.\nFigure 1 Intraoperative images of cesarean scar ectopic pregnancy; products \nof conception (POC) were noted and removed.\nFigure 2 The uterine defect was closed in 3 layers using V-loc sutures.\nPathologic examination confirmed the products of the CSEP (first \ntrimester chorionic villi) as well as fragments of adjacent decidua and \nimplantation site (Figure 3).\nThe patient had an unremarkable recovery course and was \ndischarged on postoperative day 1 with a plan for weekly follow-up \nquantitative B-hCG levels. Future pregnancy prevention methods were \ndiscussed; however the patient opted for abstinence and condoms.\nFigure 3 A & B Pathology slides:  A. Chorionic villi (black arrow) with \nnucleated fetal red cells consistent with first trimester, and extravillous \ntrophoblast (white arrow); H&E stain. B. Implantation-site trophoblast (black \narrow), and fibrinoid (white arrow); (H&E stain).\nDiscussion\nCSEP is the rarest form of ectopic pregnancy with implantation \noccurring in the CSD. 3 The embryo implants within the uterine wall \nbecause of thinning of the uterine scar, increasing the risk of uterine \nrupture.7 Most ectopic pregnancies result in spontaneous abortion, \nhowever, given the ‘normal’ position within the uterus, asymptomatic \npatients report no concern. In a recent review of CSEP, Maheux-\nLacroix et al.15 found that less than half of the cases reviewed had a \nprevious live birth where majority required a cesarean hysterectomy. \nThey concluded that expectant management exposes women to a higher \nrisk of life-threatening hemorrhage and hysterectomy. 15,16 Therefore, \ntermination, evacuation and laparoscopic repair of the uterine scar \nis the preferred treatment; 17 however a gold standard has not been \nestablished.8,9,14,18 For cases presenting with extensive adhesions and \nlimited visibility, intraoperative hysteroscopy has been successfully \nused for scar and implantation isolation.15\nA new protocol called 3D-MESIA was recently introduced by \nWang et al. 14 proposing a systematic protocol for the management \nof CSEP. 3D-MESIA utilizes methotrexate (MTX), uterine artery \nembolization (UAE), and sonography directed-in situs aspiration \n(SIA), with multi-dimensional conformational analysis (3D) ( Table \n1).19 It is postulated to be easier, safer and more efficacious compared \nto previous therapy options. 19 A recent study compares six different \ntherapeutic approaches (3D-MESIA, systemic MTX injection, uterine \nartery chemoembolization/UAE with systemic MTX injection, \nuterine curettage after systemic MTX injection, uterine curettage \nafter UAE, uterine curettage directly) for endogenous and exogenous \nCSEP.19 The 3D-MESIA approach was shown to be superior compared \nto the other five treatments examined. 19 The greatest benefits noted \nwere less intraoperative blood loss, reduced B-hCG clearance time, \nand shorter lesion absorption time of exogenous CSEP. 19 3D-MESIA \nfailure would ultimately require laparoscopic removal and scar \nrepair.19 Although 3D-MESIA was not applied in this case, the authors \nwere impressed by the protocol.\nT able 1 3D MESIA4\nS. no 3D MESIA\n1 Methotrexate (MTX)\n2 Uterine artery embolization (UAE)\n3 Sonography directed In situs Aspiration sequential therapy\n4 Based on the pregnancy sac three-dimensional (3D)\nConclusion\nCSEP presents specific challenges for clinicians limiting a \nsingle gold standard treatment procedure. A SILS surgical approach \nin combination with hysteroscopy has been effective; however, \n\n\nSingle-incision laparoscopic surgery of cesarean scar ectopic pregnancy: a case report and review of \nliterature\n160\nCopyright:\n©2018 Rezai et al.\nCitation: Rezai S, Hughes AC, Patel ND, et al. Single-incision laparoscopic surgery of cesarean scar ectopic pregnancy: a case report and review of literature. \nObstet Gynecol Int J. 2018;9(3):158‒160. DOI: 10.15406/ogij.2018.09.00327\nincorporation of the 3D-MESIA protocol has shown better treatment \noptions and patient outcomes. The difficulty with managing CSEP \nplaces greater emphasis on patient education and recurrence prevention. \nPatients who desire subsequent pregnancies should be educated about \npossible complications, as well as management options. For patients \nwho prefer to abstain, the use of long-acting reversible contraception \nsuch as Nexplanon subcutaneous implant is the most effective form \nof post-partum and post-procedure contraception-since it does not \nrequire intrauterine placement.19\nAcknowledgements\nNone.\nConflicts of interest\nDr. Xiaoming Guan is a speaker for Applied Medical, Rancho \nSanta Margarita, California. Other authors did not report any potential \nconflicts of interests.\nReferences\n1. Shu SR, Luo X, Wang ZX, et al. Cesarean scar pregnancy treated by \ncurettage and aspiration guided by laparoscopy. Ther Clin Risk Manag. \n2015;11:1139−41.\n2. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic \npregnancies: etiology, diagnosis, and management. Obstet Gynecol . \n2006;107(6):1373−81.\n3. Mahgoub S, Gabriele V , Faller E, et al. Cesarean scar ectopic pregnancy. \nLaparoscopic resection and total scar dehiscence repair.  J Minim \nInvasive Gynecol. 2017;25(2):297−8.\n4. Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet \nGynecol Surv. 2002;57(8):537−43.\n5. Gonzalez N, Tulandi T. Cesarean Scar Pregnancy: A Systematic \nReview, J Minim Invasive Gynecol. 2017;24(5):731−38.\n6. Nankali A, Ataee M, Shahlazadeh H, et al. Surgical management of \nthe cesarean scar ectopic pregnancy: a case report. Case Rep Obstet \nGynecol. 2013:525187.\n7. Chukus A, Tirada N, Restrepo R, et al. Uncommon Implantation \nSites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal \nMass. Radiographics. 2015;35(3):946−59.\n8. Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG. \n2007;114(3):253−63.\n9. Maymon R, Halperin R, Mendlovic S, et al. Ectopic pregnancies \nin a Caesarean scar: review of the medical approach to an iatrogenic \ncomplication. Hum Reprod Update. 2004;10(6):515−23.\n10. Liu S, Durai S. Management of a case of caesarean scar pregnancy and \nall its complications. BMJ Case Rep. 2016.\n11. Seow KM, Huang LW, Lin YH, et al. Cesarean scar pregnancy: issues in \nmanagement. Ultrasound Obstet Gynecol. 2004;23(3):247−53.\n12. Sieczko D, Edwards H, Heggs K, et al. Caesarean scar ectopic pregnancy: \na case report. Ultrasound. 2014;22(2):126−8.\n13. Hudeček R, Felsingerová Z, Felsinger M, et al. Laparoscopic Treatment \nof Cesarean Scar Ectopic Pregnancy. J Gynecol Surg. 2014;30(5):309−11.\n14. Wang YL, Su TH, Chen HS. Operative laparoscopy for unruptured \nectopic pregnancy in a caesarean scar. BJOG. 2006;113(9):1035−8.\n15. Maheux-Lacroix S, Li F, Bujold E, et al. Cesarean Scar Pregnancies: A \nSystematic Review of Treatment Options. J Minim Invasive Gynecol . \n2017;24(6):915−25.\n16. Litwicka K, Greco E. Caesarean scar pregnancy: a review of management \noptions. Curr Opin Obstet Gynecol. 2011;23(6):415−21.\n17. Lee JH, Kim SH, Cho SH, et al. Laparoscopic surgery of ectopic \ngestational sac implanted in the cesarean section scar. Surg Laparosc \nEndosc Percutan Tech. 2008;18(5):479−82.\n18. Roy MM, Radfar F. Management of a Viable Cesarean Scar Pregnancy: \nA Case Report. Oman Med J. 2017;32(2):161−66.\n19. Wang YJ, Zhai Y , Zhang ZY . Clinical features and outcome of cesarean \nscar pregnancy. Zhonghua Yi Xue Za Zhi. 2017;97(13):986−90.\n20. Hubacher D, Spector H, Monteith C, et al. Long-acting reversible \ncontraceptive acceptability and unintended pregnancy among women \npresenting for short-acting methods: a randomized patient preference \ntrial. Am J Obstet Gynecol. 2017;216(2):101−9.","source_license":"CC0","license_restricted":false}