Fig 2 - uploaded by Fu Tsai Kung
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The circled area with the letters a, b, and c inside indicate various low-lying-implantation ectopic pregnancy (LLIEP) anatomic locations: a ¼ cesarean scar pregnancy; b ¼ cervical-isthmus pregnancy; c ¼ cervical pregnancy.
Source publication
Objective: To describe the treatment outcomes of aberrant ectopic implantations in the lower segment of the uterus in a cohort population and to evaluate whether or not low-lying-implantation ectopic pregnancy (LLIEP), a new term, is appropriate to include in the traditional diagnoses of cervical pregnancy (CP), cesarean scar pregnancy (CSP), and o...
Context in source publication
Context 1
... the past few decades, the diagnosis of aberrant gestation in the lower segment of the uterus is based almost solely on ultrasound findings rather than surgical and anatomic examinations. CSP were often misdiagnosed as low intra- uterine pregnancies, CP, or miscarriage in progress [11,18]. In clinical practice, the ultrasound-based term of LLIEP is probably suitable for use in terms of clinical characteristics, response to treatment, and the final outcome after treatment. LLIEP represents a cluster of diagnoses, including CSP, CIP, and CP (Fig. ...
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Citations
... A large population of patients can be asymptomatic and have an atypical presentation or abnormal uterine bleeding, which may be painless. 2 All women with CSs are at a greater risk of ectopic gestation. The most probable route for the occurrence of low-lying implantation of ectopic is the entry of blastocysts into the scar myometrium through the microscopic dehiscent tract resulting from the trauma due to previous operative intervention. ...
... Tsai et al. have suggested that the term LLIEP can be used to include all the types of aberrant ectopic pregnancies in the lower uterine segment, which in turn reduces the dilemma, enables clinicians to simplify the diagnosis, and helps to provide apt treatment according to the condition of the patient. 2 Beta HCG can be used for confirmation of pregnancy, but the exponential increase in the levels of Beta HCG is almost the same as with intrauterine pregnancies. Ni Chin Tsai et al. have studied the trends of Beta HCG levels in 88 low implantation pregnancies and stated that there was no significant difference in Beta HCG levels between simple and complicated LLIEP. ...
... [11,12] CeSarean SCar pregnanCy Lower uterine pregnancy implantation may be on, in, or near the scar or may occupy the cervico isthmus space and not involve the scar at all. When the pregnancy implants in or on the CSD it is called CSP. [13,14] The precise etiology of CSP is not well understood. Pathology is complex and related to disrupted myometrium and surrounding vasculature. ...
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.
... Cervical pregnancy generally implants in the cervix only, and abnormal blood vessels dilate and meander, resulting in the swelling of the cervical canal. As the GS enlarges, it causes heavy bleeding, making it difficult to continue the pregnancy [5,6]. Cervico-isthmic pregnancy is considered to implant across the cervical canal and cervico-isthmus of the uterus between the histological and anatomical internal os [1,7]. ...
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.
... Cervical pregnancy (CP) and cesarean scar pregnancy (CSP) are a rare type of ectopic pregnancy and currently lacks consensus of optimal surgical or medical management [1,2]. While the mortality and morbidity rates have declined much in the past 20 years with early diagnosis, adequate blood transfusion, and control of infection [3], ectopic pregnancy with gestational trophoblast disease (GTD) is extremely rare. ...
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.
... From the resulting 60 publications fulfilling the inclusion criteria, 5 were excluded from the revision. In 5 of them the full text publication was impossible to obtain by our University Library (25,(28)(29)(30)(31). In one of them we were not able to contact with the first autho (25). ...
... In 5 of them the full text publication was impossible to obtain by our University Library (25,(28)(29)(30)(31). In one of them we were not able to contact with the first autho (25). Thus finally we have included 55 publications. ...
... The clinical symptoms of CP and CSP are similar [6]. Initially, patients may have no distinctive clinical presentation and often have mild vaginal bleeding, with or without vague abdominal pain. ...
Objectives:
To analyze the correlation between ultrasound typing and treatment modality of patients with an intrauterine ectopic pregnancy (cervical and cesarean scar).
Material and methods:
We retrospectively enrolled 65 patients diagnosed with cesarean scar pregnancy (CSP) or cervical pregnancy (CP) between February 2014 and May 2018. The cases were divided into two types according to the ultrasound presentation with a gestational sac (GS, type I) or a heterogeneous mass (HM, type II). Type I was further divided into type Ia (< 8 weeks) and type Ib (≥ 8 weeks); type II was defined as type IIa (with poor or no vascularity) and type IIb (with rich vascularity). Three treatment methods were applied in each group.
Results:
Of included cases, there were 53 CSP and 12 CP. There was no significant difference between Type I and Type II groups in any variable. The beta human chorionic gonadotropin (β-hCG) level and gestational age of type IIb were significantly higher compared to type IIa (p < 0.05). There was a positive correlation between ultrasound categories and treatment methods (rs = 0.723, p = 0.000). Analysis of CSP cases of initial treatment failure indicated success rate of initial dilation and curettage (D&C) was dependent upon ultrasonic types, mean sac diameter, gestational age, hCG level, and number of cesarean sections.
Conclusions:
The features of ultrasound imaging might provide an additional reference for the selection of clinical treatment methods.
... Cervical pregnancy (CP) and cesarean scar pregnancy (CSP), defined as low-lying-implantation ectopic pregnancies (LLIEP), are rare conditions of aberrant intrauterine implantation in the lowest portion of the uterus. 1 CP, first reported in 1978, 2 has an incidence of about 1 in 9000 deliveries. 3 Risk factors for CP include previous dilation and curettage, previous cesarean delivery, previous myomectomy and uterine structural abnormalities. ...
... To avoid the misdiagnosis, during a vaginal ultrasound, the physician may apply gentle pressure on the cervix using the ultrasound probe to rule out "abortion in progress with abortus retained by a resistant external os," also referred to as the "sliding sign". 1 Besides, there would be no vascular flow surrounding the gestational tissue in an aborting IUP on Doppler imaging. ...
... Although there are questions regarding whether the presence of fetal cardiac activity in LLIEP affects the treatment outcomes, GA, operation time and blood loss amount did not differ significantly between LLIEP with and without a fetal heartbeat. 1 Our cohort exhibited no significant difference in the distribution of fetal heartbeat presence between simple and complicated LLIEP (Table 3). In another cohort of 58 women 14 with CSP, the presence of cardiac activity did not differ significantly between the bleeding and control groups, providing further evidence that fetal cardiac activity did not affect the prognosis of women with LLIEP in the first trimester. ...
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.
... The number of reported cases of Cesarean scar pregnancy (CSP) has increased in the last 10 years because of the increase in Cesarean sections number and the improvement in ultrasound detection in the first trimester [3,[10][11][12][13][14]. Cervico-isthmic implantation is also viewed as a variation of EP [9,[15][16][17]. Some authors associate this localization with CSP as pregnancy located below the internal os [15,17]. ...
... In recent years the number of reports of livebirth delivery has increased although this situation is always connected with high risk of bleeding and hysterectomy [2,13,17,[22][23][24][25]. Unfortunately, in clinical practice the majority of clinicians have very limited experience and confidence in the differential diagnosis of this pathology and treatment is at the physicians' discretion [16]. Literature about non-tubal EP has been restricted to small case reports and series, with limited data on optimal treatment protocols [1]. ...
... According to the retrospective data ultrasound protocols the sensitivity of routine pelvic ultrasound examination for LIP diagnostics amounted to 54% (prior to hospital admission the diagnosis was confirmed by US in 20 cases: 10 in the 1 st group and 10 in the 2 nd group). US criteria for CSP (LIP) are well-known: location of "empty" uterus and "empty" cervical canal; visualization of gestation sac/trophoblast in scar/isthmus; myometrial thinning of anterior wall of uterus (1-3 mm); gestation sac located in the "niche" surrounded by myometrium/fibrose tissue separated from cavum uterus; hypervascular pattern with trophoblastic blood flow into scar with positive test for β-HCG; negative "sliding-sign"; placental bulge, placental lacunae [13,15,16,26]. ...
... A mayor altura más síntomas, pues la erosión de los vasos sanguíneos por el trofoblasto es mayor. (3) Algunos autores, (7,8) señalan que los factores de riesgo asociados son: síndrome de Asherman, cesárea previa, exposición a dietilestilbestrol, dispositivo intrauterino, leiomiomatosis, anormalidades estructurales y fertilización in vitro. ...
Cervical ectopic pregnancy accounts for about 0.1% of all ectopic pregnancies. The incidence is estimated at 1: 2500 to 1: 98,000 pregnancies. It is a strange phenomenon; however, morbidity and mortality from this cause are high, but early diagnosis can help reducing. It is extremely dangerous because the trophoblast can reach the uterine vessels through the thin cervical wall and cause a severe and incoercible hemorrhage that, even today, usually ends in mutilating surgeries that will limit future reproduction. At present, no clear criteria in the literature help decision-making. We report a case of cervical pregnancy successfully treated by total abdominal hysterectomy and subsequent follow-up in the Intensive Care Unit. We present some criteria that could help timely diagnosing this devastating entity to reduce morbidity and mortality and improve the later reproductive possibilities of women.
... Ultrasound assessment of the relationship between the gestational sac of a CSP and the endometrial line (the COS) may help to determine whether a cesarean scar pregnancy will progress towards a less severe form of morbidity adherential process, amenable to postnatal treatment, and successful pregnancy outcome [5]. The differential diagnosis should be made with cervico-isthmic implantation of pregnancy, cervical ectopic pregnancy and spontaneous miscarriage in progress [6]. ...
