The rate of births by Caesarean section is increasing. In 2015, 33.4% of Victorian women gave birth by Caesarean section. In comparison, the rate of births by Caesarean section in Victoria was 16% in 1985 (CCOPMM 2017). The prevalence of Caesarean scar ectopic pregnancies is estimated to be 1 in 2000 pregnancies, or 6% of all ectopic pregnancies (Fritz and Speroff 2011). Both the prevalence of Caesarean scar ectopic pregnancies and the proportion of ectopic pregnancies diagnosed as Caesarean scan ectopic pregnancy is thought to be increasing.
We present a 39 year-old patient with a history of one previous Caesarean section who presented to the emergency department with vaginal bleeding 4 weeks and 3 days after embryo transfer. On admission, her quantitative beta HCG was found to be 215000 IU/L and a subsequent pelvic ultrasound confirmed the diagnosis of a live Caesarean scar ectopic pregnancy. Despite a single dose intra-gestational sac and three doses of systemic methotrexate, the patient’s beta HCG continued to rise and a decision was made for surgical management.
At surgery, the pelvic side walls were entered by dividing the round ligaments bilaterally. The bladder peritoneum was carefully dissected to expose the Caesarean scar ectopic pregnancy. Bilateral ureterolysis was performed and the uterine arteries exposed and ligated bilaterally with laparoscopic clip applicators. The Caesarean scar ectopic pregnancy, along with the Caesarean section scar was excised and the uterine defect repaired in layers to reduce the possibility of recurrence. Estimated blood loss was 700mL.
The patient required the transfusion of one unit of packed red blood cells intra-operatively but enjoyed an uncomplicated postoperative course. Her beta HCG levels were monitored on a weekly basis and became negative after 5 weeks. The patient was made aware of the implications of bilateral uterine artery ligation on future pregnancies.
This video presentation demonstrates the technique and effectiveness of laparoscopically ligating the uterine arteries prior to excision of the Caesarean scar ectopic pregnancy. We believe that it is worthwhile exposing the uterine arteries for quick clip ligation for protection against excessive blood loss at removal of Caesarean scar ectopic pregnancies.