Objective: Rare case of patient with placental tissue on histology at caesarean scar site post total laparoscopic hysterectomy.
Patient: 37-year-old woman presented with eighteen months history of intermittent severe pelvic pain, dysmenorrhoea, and deep dyspareunia. Her complicated obstetrics history consists of three caesarean sections. The 1st was complicated by placental abruption. She was hospitalized during the 3rd pregnancy due to severe foetal growth restriction and found to have a uterine dehiscence at time of caesarean section. She had laparoscopic excision of endometriosis in 2006. There was no improvement of her symptoms with trial of Depo Provera and was experiencing breakthrough bleeding. She also experienced menstrual constipation and bloating. Ultrasound revealed two complex left adnexal cyst query endometriomas. She had no desire for future fertility and decided for total laparoscopic hysterectomy, bilateral salpingectomy and left oophorectomy.
Procedure: Uterine length was 8cm. BiswasTM uterine manipulator and cup was inserted. On primary survey, the ovaries were normal. Cystic structure on bladder dome and left pelvic side wall was noted, query bladder endometrioma. Cystoscopy was performed to rule out bladder involvement, which revealed a normal bladder. Saline was used to keep bladder distended to identify the borders and bladder adhesions were dissected. Cystic structure over bladder dome and left pelvic side wall was dissected. PK GyrusTM bipolar energy source and monopolar scissors were used to perform a total laparoscopic hysterectomy and bilateral salpingectomy. Both vaginal cuff angles were sutured to the uterosacral ligaments on either side using 1 Vicryl suture. 2.0 V-LocTM 90 barbed suture was used to close the vault.
Post-Surgery: Patent was discharged home well. Histology revealed focally calcified transmural lesion within anterior lower segment/caesarean section site with intermediate trophoblastic cells in keeping with non-neoplastic placental site lesion. Post-surgery, patient had a negative beta-HCG.
Discussion: To our knowledge, there are no similar cases on literature review. In this case, the patient had a complicated caesarean section two years prior. This placental tissue could be from a previous undiagnosed placenta accrete, increta or percreta, and may have been the cause of the scar dehiscence in the third caesarean. Possibly, the lower segment was closed with still some adherent placental tissue left in situ. Interestingly, the patient did not have any abnormal uterine bleeding since the caesarean, but only progressively worsening endometriosis symptoms. Other differential diagnosis is chronic caesarean scar ectopic pregnancy. However, this patient has made full recovery and now asymptomatic.