In a landmark medical advancement, CK Birla Hospital®, Gurugram successfully performed India’s first scar ectopic pregnancy via robot-assisted surgery on a 44-year-old woman. A team of doctors led by Dr Aruna Kalra, Director, Obstetrics and Gynaecology, CK Birla Hospital, Gurugram performed a robotic-assisted surgery and helped the patient successfully give birth to a healthy baby. The incidence of mortality in ectopic pregnancy is 5-10%. If action is not taken in time, before impending rupture, mortality will happen due to hemorrhagic shock syndrome and abnormal blood clotting throughout the body’s blood vessels, leading to multi-organ failure.
Upon admission to the hospital, the patient was suffering from severe abdominal pain and hypotension. Upon ultrasound, an impending rupture of the uterus at the scar site was observed. The woman had tried to become pregnant multiple times in the past but failed. When she became pregnant for the first time in 2014, the baby was found to have a Spina Bifida (improper development of the baby’s spine and spinal cord, causing a gap in the spine) abnormality at 28 weeks. A cesarean section was performed, but the baby died within her womb. Subsequently, she attempted to conceive again but her tubes were blocked, and she was unable to conceive naturally. Eventually, she underwent in vitro fertilization (IVF), but the result was an ectopic pregnancy in isthmocele pouch at previous cesarean scar site. Scar ectopic pregnancy would have ruptured on growing further and hence it was removed with robotic assisted surgery. Eventually, the woman conceived again and this time it was a successful IVF pregnancy; the scar did not get affected as it was sutured in double layer at the time of robotic surgery. Cesarean delivery was performed at term, and she gave birth to a healthy baby.
Robotic-assisted surgery was adopted in this case as scar ectopic pregnancy is located in the lower uterine segment, very close to both uterine vessels supplying blood to the uterus, which makes this area risky to operate upon. The urinary bladder is plastered on the ectopic pregnancy site, making the dissection extremely delicate and difficult. The risk of inadvertently cutting the blood vessels in an already compromised patient can be morbid. Blunt dissection to separate the bladder can puncture the urinary bladder if done with any instrument other than fine flexible robotic instruments with a magnified view of the adherent tissue planes between the uterus and bladder. Postoperative complications are very common in this surgery, leading to worse recovery. Such surgeries are successful if the surgeon is skilled in robotic technique, the outcome is marvelous, leading to no blood loss, no tissue injury, no complications, and discharge on the same day. The strength of stitching ensures that the patient will be fit to carry a pregnancy after 3 months of surgery.
Giving details of the case, Dr Aruna Kalra Director, Obstetrics and Gynaecology, CK Birla Hospital, Gurugram, said, “This was a rare case of scar pregnancy, which resulted from a prior cesarean section. Because we repaired the scar robotically, it became rather simple to deliver the baby this time. Scar ectopic pregnancy incidence is increasing due to increase in cesarean section rate, which is currently the most prevalent surgical operation performed globally. A ruptured ectopic pregnancy is a catastrophic condition causing 2-3 liters of blood loss into the peritoneal cavity. The patient was diagnosed and operated on just in time to prevent the rupture of the uterus, which might have cost her life. Ectopic pregnancy is a cause of maternal mortality within the first trimester of pregnancy, with a rate of 9–14% and an incidence of 5–10% of all pregnancies. The cause of death is hemorrhage and shock syndrome (multi-organ failure due to Disseminated intravascular coagulation– abnormal blood clotting throughout the body’s blood vessels. Additionally, an increase in scar pregnancy rates and isthmocele may result from this rising prevalence of caesarean section deliveries. Such phenomenon, known as scar ectopic pregnancy, are very rare and occurs in around 1 in 1500–2000 pregnancies, however the prevalence is on the rise.”
An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus. While in many cases the ectopic pregnancies resolve on their own and the pregnancy tissue passes out of the cervix on its own, in a lot of cases it creates trouble around the 6th week of pregnancy. 1 in 100 pregnancies are ectopic and considered an emergency situation for the pregnant woman. There are chances of it being missed by patients or doctors, and if not treated on time, it could be life threatening.
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