Surgical Management of Cesarean Scar Ectopic Pregnancy

  • Rachel Yoon
  • Aarathi Cholkeri-Singh
  • Charles E. Miller

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This video describes cesarean scar ectopic pregnancy and walks viewers through a minimally invasive surgical approach to its treatment and future prevention. Cesarean scar (isthmocele) ectopic pregnancy is a rare but clinically significant occurrence. It comprises 6% of ectopic pregnancies among women with just one prior cesarean delivery and is associated with poor pregnancy outcome due to significant morbidity and mortality from hemorrhage or uterine rupture. Up to 70% of these pregnancies lead to hysterectomy. Thus the diagnosis and management of cesarean scar ectopic pregnancy has a major impact on a woman’s health and fertility. Due to the rarity of this clinical diagnosis and a relative scarcity of centers with high-volume experience with its surgical management, there is no consensus on the best surgical approach. Expert gynecologists present an approach to laparoscopic cesarean scar ectopic pregnancy removal that incorporates complete excision and revision of the scar as well as hysteroscopic evaluation and techniques adapted to minimize impact to a woman’s future fertility.

This is a surgical treatment done laparoscopically allowing for video capture of a step-by-step approach. Viewers will have an increased knowledge of treating a cesarean scar ectopic pregnancy surgically as well as repairing the defect to reduce future recurrence. This is an ideal video for general OB/GYNs, minimally invasive gynecologic surgeons, reproductive endocrinology and infertility specialists, maternal fetal medicine experts, medical students, residents, sonographers, and radiologists.

Introduction

This video covers cesarean scar ectopic pregnancy and a minimally invasive surgical approach to its treatment and future prevention. The laparoscopic cesarean scar ectopic pregnancy removal incorporates complete excision and revision of the scar as well as hysteroscopic evaluation.

About the Author

Rachel Yoon

Dr. Rachel Yoon is currently a Minimally Invasive Gynecologic Surgical Fellow through the AAGL under the mentorship of Drs. Miller and Cholkeri-Singh. Prior to fellowship, she completed OBGYN residency at Mercy Hospital in St. Louis and her medical school training at the University of Ilinois.

 
Aarathi Cholkeri-Singh

Dr. Aarathi Cholkeri-Singh is a Fellow of the American College of Obstetricians and Gynecologists and is in private practice with Dr. Charles E. Miller at The Advanced Gynecologic Surgery Institute in the metropolitan Chicago area. During her fourth year of residency, she was accepted as a Minimally Invasive Gynecologic Surgical Fellow through the AAGL, the world’s largest organization dedicated to minimally invasive gynecologic surgery. Her training was based on the East Coast at Harvard and Brown Universities’ hospital affiliates. She trained with six different surgeons in the fields of General Gynecology, Reproductive Endocrinology, Gynecologic Oncology and Urogynecology.

During Dr. Cholkeri-Singh’s career, she has proven to be an effective leader, educator and contributor to the community and academic societies. She has presented on multiple occasions at national and international meetings, published manuscripts in well-recognized, peer-reviewed medical journals and contributed three book chapters to two different medical textbooks published. Dr. Cholkeri-Singh’s current research concerns are laparoscopic myomectomy, bleeding rates after laparoscopic supracervical hysterectomy, adhesion prevention at time of laparoscopic surgery, enhancing visualization at laparoscopy, minilaparoscopy, and hysteroscopic sampling for abnormal uterine bleeding.

Dr. Cholkeri-Singh is an active member of The American College of Obstetricians and Gynecologists, the AAGL, ISGE and SLS. She has served as a faculty member for these societies, their conferences and committees, and continues to be invited annually for active participation. Dr. Cholkeri-Singh is the Associate Director of Minimally Invasive Gynecologic Surgery, the Associate Director of the AAGL fellowship program in Minimally Invasive Gynecologic Surgery and the Director of Gynecologic Surgical Education at Advocate Lutheran General Hospital in Park Ridge, IL. She also is a Clinical Assistant Professor for the Department of Ob/Gyn at the University of Illinois at Chicago, Chicago, IL and Lecturer for the Department of Ob/GYN at Rosalind Franklin University of Medicine and Science, North Chicago, IL. She continues to be an ad hoc reviewer for The Journal of Minimally Invasive Gynecology (JMIG), The European Journal of Obstetrics & Gynecology & Reproductive Biology, Gynecologic & Obstetric Investigation, International Journal of Fertility & Sterility, as well as many others.

 
Charles E. Miller

Dr. Charles E. Miller is a Fellow of the American College of Obstetricians and Gynecologists and is in private practice in metropolitan Chicago where he specializes in the treatment of infertile couples and minimally invasive gynecologic surgery. Dr. Miller is the Founder, President, and Medical Director of The Advanced IVF Institute and The Advanced Gynecologic Surgery Institute, Charles E. Miller, MD & Associates. Per the Society for Assisted Reproductive Technology’s (SART) 2016 statistics, Dr. Miller’s clinic was number one in the state for fresh embryo transfers for women in the under 35 age group as well the 35-37 age group. Nationwide, Dr. Miller’s clinic ranked number 19 and 16 respectively.

A graduate of the honor’s program in Medical Education at Northwestern University, Dr. Miller completed his residency in Obstetrics and Gynecology at the University of Texas Southwestern Medical School, Parkland Memorial Hospital. Dr. Miller then matriculated at the Hospital of the University of Pennsylvania, where he earned his fellowship in reproductive endocrinology and infertility.

Dr. Miller is an internationally renowned expert in minimally invasive gynecologic surgery and the treatment of infertility. Dr. Miller is a Past President of the International Society for Gynecologic Endoscopy (2011-2013) and is a Past President of the AAGL (2007-2008), the world’s largest organization dedicated to minimally invasive gynecologic surgery. Dr. Miller is the Director of Minimally Invasive Gynecologic Surgery and the Director of the AAGL Fellowship Program in Minimally Invasive Gynecologic Surgery at Advocate Lutheran General Hospital in Park Ridge, Illinois. In addition, given Dr. Miller’s interest and expertise in egg freezing, he was recently appointed the Consulting Reproductive Endocrinologist of Advocate Lutheran General Hospital’s Hematopoietic Progenitor Cell Transplantation (HPCT) Program. Dr. Miller currently holds the position of Clinical Associate Professor, Department of OB/GYN, at the University of Illinois at Chicago.

In June 2017, Dr. Miller was the recipient of The Council on Resident Education in Obstetrics and Gynecology (CREOG) Award for Excellence in Resident Teaching. This award is the National Faculty Award for promoting high standards of residency education in the field of obstetrics and gynecology by The American College of Obstetricians and Gynecologists.

At the recent AAGL 47th Global Congress on Minimally Invasive Gynecology (November 2018 – Las Vegas, NV), Dr. Miller was the recipient of the John F. Steege, MD Mentorship Award. This award recognizes an AAGL member who has provided support and encouragement to the next generation of surgeons in the specialty of minimally invasive gynecology for at least 10 years.

 

About this video

Author(s)
Rachel Yoon
Aarathi Cholkeri-Singh
Charles E. Miller
DOI
https://doi.org/10.1007/978-3-030-39637-4
Online ISBN
978-3-030-39637-4
Total duration
14 min
Publisher
Springer, Cham
Copyright information
© Producer 2020

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Video Transcript

[MUSIC PLAYING]

Cesarean scar pregnancy is a rare, but clinically significant occurrence that leads to severe complications such as early uterine rupture, massive hemorrhage, preterm delivery, and emergency hysterectomy. Prompt diagnosis and proper treatment can avoid these serious complications and preserve future fertility. Unfortunately, because of the rarity of this clinical diagnosis, there is a scarcity of centers with high volume experience with its treatment, and currently no standardized diagnostic or management guidelines are available.

Recent evidence suggests that primary surgical management may be superior to medical management. There is a high failure and complication rate with medical management, with up to 50% of patients requiring further surgical intervention. In contrast, primary surgical management is noted to have high success rates with minimal complications. In this video, we present a primary surgical approach to Cesarean scar pregnancy treatment, which incorporates laparoscopic removal of the ectopic pregnancy. Excision and revision of the scar. Histroscopic evaluation and surgical techniques adapted to minimize impact to a woman’s future fertility.

Our practice consists of high volume gynecologic surgeons with a wide referral network. This has resulted in robust experience and exposure to the diagnosis, management, and treatment of this rare occurrence. We hope that our video allows you to better diagnose, counsel, and manage patients with Cesarean scar pregnancies.