1
|
Teoh J, Rajendran S, Gupta S. Overlapping imaging features between miscarriage of a low-lying gestational sac and cervical ectopic pregnancy. Australas J Ultrasound Med 2023; 26:199-202. [PMID: 37701772 PMCID: PMC10493346 DOI: 10.1002/ajum.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Early pregnancy ultrasound must satisfy objective criteria to make a safe diagnosis of miscarriage. The differential diagnosis of low-lying gestational sac includes cervical stage of miscarriage and cervical and caesarean scar ectopic pregnancies. Misdiagnosis can lead to significant maternal morbidity. We describe a pregnancy in a 36-year-old primiparous woman where ultrasound findings of a low-lying gestation sac satisfied criteria for miscarriage; however, dilatation and curettage of pregnancy contents resulted in brisk cervical bleeding. Ultrasound at 6 weeks 6 days of gestation showed an intra-uterine pregnancy of uncertain viability. Repeat scan after 11 days confirmed miscarriage based on an absence of interval progression between scans and no embryonic heartbeat. The collapsed gestational sac (GS) was seen at the level of the internal os with decidual reaction and peri-trophoblastic blood flow. Inferior to the sac, minimally vascular trophoblastic appearing tissue was beginning to distend the upper cervical canal: the sliding sign was positive for the GS and negative for the upper cervical contents. Cervical stroma was clearly seen circumferential to the distending tissue. The patient underwent dilatation and curettage of the uterus complicated by 2000 ml haemorrhage requiring blood transfusion and medical and surgical management with intra-cavitary placement of a Foley catheter. Histopathology confirmed pregnancy tissue with the disruption of cervical epithelium but no true invasion. The patient was counselled to attend a specialist obstetric imaging facility for an early dating ultrasound in future pregnancies. The current body of literature does not describe cases of low-lying gestation sac miscarriage with high-risk features of trophoblastic extension into the cervical canal. We suggest maintaining a high index of suspicion and excluding differential diagnoses as the majority of women have no risk factors for ectopic pregnancy. These cases should be recommended for surgical management.
Collapse
Affiliation(s)
- Jessica Teoh
- Women and Babies DepartmentRoyal Prince Alfred HospitalCamperdownNew South WalesAustralia
| | - Sumathi Rajendran
- Women and Babies DepartmentRoyal Prince Alfred HospitalCamperdownNew South WalesAustralia
- Sydney Ultrasound for WomenSydneyNew South WalesAustralia
| | - Sarika Gupta
- Women and Babies DepartmentRoyal Prince Alfred HospitalCamperdownNew South WalesAustralia
| |
Collapse
|
2
|
Hameed MSS, Wright A, Chern BSM. Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques. Gynecol Minim Invasive Ther 2023; 12:64-71. [PMID: 37416110 PMCID: PMC10321345 DOI: 10.4103/gmit.gmit_116_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 07/08/2023] Open
Abstract
The incidence of cesarean scar pregnancy (CSP) is increasing reflecting the global increase in cesarean section (CS) rate which has almost doubled since 2000. CSP differs from other types of ectopic pregnancy in its ability to progress while still carrying a significant risk of maternal morbidity. Little is known about precise etiology or natural history although current interest in the pathology of placenta accretes spectrum disorders might be enlightening. Early detection and treatment of CSP are challenging. Once diagnosed, the recommendation is to offer early termination of pregnancy because of the potential risks of continuing the pregnancy. However, as the likelihood of future pregnancy complications for any CSP varies depending on its individual characteristics, this might not always be necessary nor might it be the patient's preferred choice if she is asymptomatic, hemodynamically stable, and wants a baby. The literature supports an interventional rather than a medical approach but the safest and most efficient clinical approach to CSP in terms of treatment modality and service delivery has yet to be determined. This review aims to provide an overview of CSP etiology, natural history, and clinical implications. Treatment options and methods of CSP repair are discussed. We describe our experience in a large tertiary center in Singapore with around 16 cases/year where most treatment modalities are available as well as an "accreta service" for continuing pregnancies. We present a simple algorithm for approach to management including a method of triaging for those CSPs suitable for minimally invasive surgery.
Collapse
Affiliation(s)
- Mohamed Siraj Shahul Hameed
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, K. K. Women’s and Children’s Hospital, Singapore
| | - Ann Wright
- Division of Obstetrics and Gynaecology, Department of Maternal Fetal Medicine, K. K. Women’s and Children’s Hospital, Singapore
| | - Bernard Su Min Chern
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, K. K. Women’s and Children’s Hospital, Singapore
| |
Collapse
|
3
|
Placental Insertion into the Cervix with Cervical Shortening as a Clinical Sign to Suspect Cervico-Isthmic Pregnancy: A Case Report and Literature Review. Case Rep Obstet Gynecol 2023; 2023:1816955. [PMID: 36793621 PMCID: PMC9925233 DOI: 10.1155/2023/1816955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 02/09/2023] Open
Abstract
The clinical signs of cervico-isthmic pregnancy during pregnancy remain unknown. We herein report a case of cervico-isthmic pregnancy showing placental insertion into the cervix with cervical shortening, with a final diagnosis of placenta increta at the uterine body and cervix. A 33-year-old multiparous woman with a history of cesarean section was referred to our hospital at 7 weeks of gestation with suspected cesarean scar pregnancy. Cervical shortening with a cervical length of 14 mm was noted at 13 weeks of gestation. The placenta is gradually inserted into the cervix. An ultrasonographic examination and magnetic resonance imaging strongly suggested placenta accreta. We planned elective cesarean hysterectomy at 34 weeks of gestation. The pathological diagnosis was cervico-isthmic pregnancy with placenta increta at the uterine body and cervix. In conclusion, placental insertion into the cervix with cervical shortening in the early pregnancy period may be a clinical sign to suspect cervico-isthmic pregnancy.
Collapse
|
4
|
Lin YH, Ou YC, Kung FT. A novel approach with concomitant laparoscopic uterine artery ligation and D&C as initial treatment for complicated gestational trophoblast disease in cesarean scar and cervical ectopic pregnancies. Taiwan J Obstet Gynecol 2021; 60:1090-1093. [PMID: 34794743 DOI: 10.1016/j.tjog.2021.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Gestational trophoblast disease (GTD) in low-lying implantation ectopic pregnancy (LLIEP) is extremely rare. Surgical removal of GTD lesions which is the initial treatment of choice carries a high risk of intraoperative massive bleeding. Adequate management is challenging and inconclusive. CASE REPORT We present two unusual cases with a diagnosis of GTD in advanced LLIEP. The first case had choriocarcinoma in cesarean scar and the second case had mole pregnancy in cervix. Both cases were managed with laparoscopy uterine artery ligations followed by transvaginal intrauterine curettage and vacuum aspiration with a small amount of surgical blood loss and then resumed regular menstruation. To understand the different surgical approaches and their potential advantages in managing such rare diseases, relevant cases in the literature were reviewed. CONCLUSION Much attention should be paid to avoid massive bleeding at initial surgical intervention in patients with GTD in advanced LLIEP. This novel approach with combination of laparoscopic uterine artery ligations and evacuating curettage in selected patients is highly recommended to minimize surgical blood loss. The obvious advantages include technical feasibility, less surgery-related bleeding and potential fertility preservation.
Collapse
Affiliation(s)
- Yu-Han Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Obstetrics and Gynecology, Chia-Yi Chang Gung Memorial Hospital, Chia-Yi, Taiwan
| | - Fu-Tsai Kung
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Obstetrics and Gynecology, Xiamen Chang Gung Hospital, Xiamen, China.
| |
Collapse
|
5
|
Tsai NC, Cheng LY, Yang TH, Hsu TY, Kung FT. Serum β-human chorionic gonadotropin profile and its correlations with ultrasound parameters in low-lying-implantation ectopic pregnancy in the first trimester. J Obstet Gynaecol Res 2020; 46:844-850. [PMID: 32185850 DOI: 10.1111/jog.14248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/11/2020] [Accepted: 03/07/2020] [Indexed: 11/28/2022]
Abstract
AIM Cervical pregnancy (CP) and cesarean scar pregnancy (CSP), defined as low-lying-implantation ectopic pregnancy (LLIEP), are rare conditions of aberrant implantation around the lowest portion of the uterus. This study aimed to illustrate the serum β-human chorionic gonadotropin (β-hCG) profile of LLIEP and to explore its implications with the clinical characteristics. METHODS Women with LLIEP during the first trimester were retrospectively evaluated at a tertiary referral center from August 1999 to July 2016. Demographic and clinical data were recorded, including maternal age, gestational age (GA), serum β-hCG level, maximal diameter of the gestational mass/sac (MDM/MDS) by ultrasonography and CSP implantation types. The serum β-hCG level was measured on the day of ultrasound imaging. The significance of pretreatment the serum β-hCG level and its correlations with the clinical characteristics were analyzed. RESULTS A total of 88 LLIEP with 64 CSP and 24 CP was included. The mean GA at the time of diagnosis was 7 weeks (range, 5-12 weeks). The β-hCG concentrations rapidly increased from GA 5 to 9 weeks and fluctuated thereafter. The β-hCG levels correlated positively with GA and ultrasound MDM/MDS. In the CSP group, there was no difference in the β-hCG level between superficial and deep implantation types. β-hCG levels demonstrated no significant differences among simple and complicated LLIEP. CONCLUSION This study established the serum β-hCG profile in LLIEP in the first trimester. The exponential increase of β-hCG levels was similar to that of normal intrauterine pregnancies. The β-hCG levels were not associated with placentation complexity of CSP. Higher β-hCG levels did not implicate less success in conservative surgical management.
Collapse
Affiliation(s)
- Ni-Chin Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ling-Yun Cheng
- Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsai-Hwa Yang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Te-Yao Hsu
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fu-Tsai Kung
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Obstetrics and Gynecology, Xiamen Chang Gung Hospital, Xiamen, China
| |
Collapse
|
6
|
Ajong AB, Kenfack B, Agbor VN, Njotang PN. Ruptured caesarean scar ectopic pregnancy: a diagnostic dilemma in a resource-limited setting. BMC Res Notes 2018; 11:292. [PMID: 29751813 PMCID: PMC5948667 DOI: 10.1186/s13104-018-3389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/02/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Caesarean scar pregnancy (CSP) remains a very rare form of ectopic pregnancy associated with serious life threatening obstetric complications and even death in case of late diagnosis and treatment. CASE PRESENTATION We report a case of a ruptured caesarean scar pregnancy in a 29 year-old gravida 5, para 3 with a past obstetric history of two consecutive caesarean sections done 9 and 5 years ago respectively. The patient presented with intermittent lower abdominal pains on a 20 weeks gestation associated with mild epigastralgia and 2 previous episodes of mild pervaginal bleeding (2 and 1 months ago respectively before consultation) managed with injectable progesterone. Her evolution 4 h later was marked by an increase in the intensity of the abdominal pain, an unmeasurable blood pressure and a feeble pulse. Immediate paracentesis revealed 10 cc of fresh non coagulating blood. The diagnosis of ruptured ectopic pregnancy with abundant hemoperitoneum was considered and an emergency laparotomy with fluid and blood resuscitation was carried out. A midline laparotomy revealed a ruptured caesarean scar ectopic pregnancy with an abundant hemoperitoneum. Careful resection of the placenta and repair of the ruptured isthmic region of the uterus was carried out. Recovery after surgery was without complications and the patient was discharged on the 6th day following surgery. CONCLUSION Caesarean scar pregnancy remains a very rare obstetric condition. Late diagnosis of this condition can be associated with serious life threatening obstetric complications. The rarity of the condition warrants a high index of suspicion among clinicians.
Collapse
Affiliation(s)
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Dschang, Cameroon
| | | | - Philip Nana Njotang
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Obstetrics and Gynaecology Unit, Yaoundé Central Hospital, Yaoundé, Cameroon
| |
Collapse
|
7
|
Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol 2017; 24:915-925. [DOI: 10.1016/j.jmig.2017.05.019] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/29/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
|
8
|
Tsai HJ. Terminology of "cesarean section ectopic pregnancy" and "placenta previa and accrete". Taiwan J Obstet Gynecol 2016; 55:760. [PMID: 27751435 DOI: 10.1016/j.tjog.2016.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/18/2022] Open
Affiliation(s)
- Horng-Jyh Tsai
- Department of Obstetrics and Gynecology, Kuang Tien General Hospital, Taichung 433, Taiwan.
| |
Collapse
|
9
|
Kanat-Pektas M. Response to the terminology of “cesarean section ectopic pregnancy”. Taiwan J Obstet Gynecol 2016; 55:763. [DOI: 10.1016/j.tjog.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2016] [Indexed: 11/25/2022] Open
|
10
|
Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass. Radiographics 2015; 35:946-59. [PMID: 25860721 DOI: 10.1148/rg.2015140202] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.
Collapse
Affiliation(s)
- Anjeza Chukus
- From the Department of Radiology, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140 (A.C., N.I.R.); Department of Radiology, George Washington University School of Medicine, Washington, DC (N.T.); and Department of Radiology, Miami Children's Hospital, Miami, Fla (R.R.)
| | | | | | | |
Collapse
|
11
|
Takeda A, Koike W, Hayashi S, Imoto S, Nakamura H. Cervico-isthmic pregnancy: early diagnostic imaging and successful dual therapy for uterine-sparing treatment. J Minim Invasive Gynecol 2015; 22:678-83. [PMID: 25623368 DOI: 10.1016/j.jmig.2015.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 01/20/2015] [Accepted: 01/21/2015] [Indexed: 11/29/2022]
Abstract
Cervico-isthmic pregnancy is a rare and potentially life-threatening form of ectopic gestation in which the blastocyst implants in the uterine cervico-isthmus between the histological and anatomical internal os, followed by subsequent extension to the lower uterine segment. Early diagnosis may allow a conservative therapeutic approach that avoids catastrophic hemorrhage requiring hysterectomy. Here we report the case of a 43-year-old primigravida woman whose cervico-isthmic pregnancy complicated by massive hematometra was diagnosed at 6 weeks gestation by multimodal imaging and successfully treated by hysteroscopic resection, securing adequate hemostasis, after transcatheter arterial chemoembolization.
Collapse
Affiliation(s)
- Akihiro Takeda
- Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan.
| | - Wataru Koike
- Department of Diagnostic Radiology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan
| | - Shotaro Hayashi
- Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan
| | - Sanae Imoto
- Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan
| | - Hiromi Nakamura
- Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu, Japan
| |
Collapse
|