Strategies to Minimize Blood Loss during Laparoscopic Hysterectomy for Management of Cesarean Scar Ectopic Pregnancy

Study Objective Demonstrate techniques to minimize blood loss during laparoscopic hysterectomy for management of cesarean scar ectopic pregnancy. Design Stepwise demonstration using narrated video footage. Setting An academic tertiary care hospital. Patients or Participants 33-year-old G5P4004 with one prior cesarean delivery presented to the ER with abdominal pain and vaginal spotting in early pregnancy. Her vital signs were normal with a Hemoglobin of 8.9. Ultrasound revealed a ∼6-week cesarean scar ectopic pregnancy. She was counseled on management options including laparoscopic resection of the ectopic with repair of uterine defect or laparoscopic hysterectomy. The patient was satisfied with her parity and opted for hysterectomy. Interventions The patient underwent total laparoscopic hysterectomy, bilateral pelvic wall dissection, bilateral salpingectomy, and cystoscopy. Various considerations and techniques were used intraoperatively to minimize blood loss. 1. Major vasculature (uterine and utero-ovarian arteries) was interrupted before placement of uterine manipulator 2. Uterine manipulator was placed under laparoscopic guidance in a retroverted fashion to avoid disruption of pregnancy 3. The correct plane was identified during dissection between the bladder and pregnancy to avoid injury or bleeding 4. Additional bleeding was anticipated and encountered even after major blood supply was interrupted, likely related to collateral vasculature to the pregnancy Measurements and Main Results Successful management of cesarean scar ectopic pregnancy was performed via laparoscopic hysterectomy. Estimated blood loss was 100cc and the surgery was uncomplicated. Conclusion Cesarean scar ectopic pregnancy is more common with the rising rate of cesarean deliveries. Risk of hemorrhage in this scenario is higher due to possible trophoblastic involvement up to level of uterine arteries. However, various techniques may be used to decrease blood loss during definitive surgical treatment. Demonstrate techniques to minimize blood loss during laparoscopic hysterectomy for management of cesarean scar ectopic pregnancy. Stepwise demonstration using narrated video footage. An academic tertiary care hospital. 33-year-old G5P4004 with one prior cesarean delivery presented to the ER with abdominal pain and vaginal spotting in early pregnancy. Her vital signs were normal with a Hemoglobin of 8.9. Ultrasound revealed a ∼6-week cesarean scar ectopic pregnancy. She was counseled on management options including laparoscopic resection of the ectopic with repair of uterine defect or laparoscopic hysterectomy. The patient was satisfied with her parity and opted for hysterectomy. The patient underwent total laparoscopic hysterectomy, bilateral pelvic wall dissection, bilateral salpingectomy, and cystoscopy. Various considerations and techniques were used intraoperatively to minimize blood loss. 1. Major vasculature (uterine and utero-ovarian arteries) was interrupted before placement of uterine manipulator 2. Uterine manipulator was placed under laparoscopic guidance in a retroverted fashion to avoid disruption of pregnancy 3. The correct plane was identified during dissection between the bladder and pregnancy to avoid injury or bleeding 4. Additional bleeding was anticipated and encountered even after major blood supply was interrupted, likely related to collateral vasculature to the pregnancy Successful management of cesarean scar ectopic pregnancy was performed via laparoscopic hysterectomy. Estimated blood loss was 100cc and the surgery was uncomplicated. Cesarean scar ectopic pregnancy is more common with the rising rate of cesarean deliveries. Risk of hemorrhage in this scenario is higher due to possible trophoblastic involvement up to level of uterine arteries. However, various techniques may be used to decrease blood loss during definitive surgical treatment.