Laparoscopic removal of heterotopic cesarean scar pregnancy

Objective: To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options.

Design: Surgical video article. The Institutional Ethics Committee approved the video reproduction.

Setting: Tertiary referral university hospital PATIENT: A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine location and the other in a previous cesarean section scar.

Interventions: Scar pregnancy was excised laparoscopically while preserving intrauterine pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc^TM sutures.

Main outcome measures: Ongoing intrauterine pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery.

Results: The procedure was completed in 67 min. Total blood loss was <100 cc. Ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37^th-38^th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38^th week and reported having pain for 2 days. During cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male baby (weight, 3210 g; Apgar score, 9/10) was delivered.

Conclusions: The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during cesarean section in approximately half cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving intrauterine pregnancy.