Conservative management of caesarean scar pregnancy: tissue removal device hysteroscopic treatment after uterine artery embolisation.

Abstract

Background: Caesarean scar pregnancy (CSP) is an uncommon complication in women with prior caesarean deliveries. Treatment options include both medical and surgical approaches, but there is no consensus on definitive management.

Objectives: We propose a step-by-step video demonstration of a conservative approach for CSP, using hysteroscopic treatment with tissue removal device (TRD) after uterine artery embolisation (UAE).

Participant: A 34-year-old woman with two previous caesarean deliveries was diagnosed with a CSP involving an 8-week embryo implanted in the isthmocele. Initial management consisted of UAE performed at another hospital. The patient was then referred to the Digital Hysteroscopic Clinic, CLASS Hysteroscopy of Policlinico Gemelli in Rome, for hysteroscopic removal of residual trophoblastic tissue.

Intervention: Safety and effectiveness of a novel conservative CSP management, involving TRD following UAE. Preoperative assessment, combining transvaginal ultrasound and diagnostic hysteroscopy, revealed trophoblastic remnants inside the uterine niche with an extremely thin myometrial margin. The procedure was performed under general anaesthesia, according to an ambulatory model of care. A TRD with a soft tissue blade was used for the complete removal of the lesion.

Conclusions: This video article suggests that TRD hysteroscopic treatment after UAE is a safe and effective approach for CSP. This conservative management minimises the risk of complications such as bleeding and uterine perforation. Additionally, the TRD avoids the use of electrosurgery, potentially reducing the incidence of subsequent intrauterine adhesions. Further studies are needed to confirm these results in the long term.

What is new?: This is the first reported case of conservative CSP management combining UAE with hysteroscopic resection using a TRD.