Journal of South Asian Federation of Obstetrics and Gynaecology

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VOLUME 16 , ISSUE 3 ( May-June, 2024 ) > List of Articles


Case Series on Abnormal Low-lying Implantation of Ectopic Pregnancy: A Diagnostic and Management Dilemma

Ruby Bhatia, Kaveripatti K Aishwarya, Sukhbir P Kaur, Rahul Kalyanam

Keywords : Cesarean scar ectopic pregnancy, Diagnosis of ectopic pregnancy, Emergency peripartum hysterectomy, Low-lying implantation of ectopic pregnancy, Obstetric emergency

Citation Information : Bhatia R, Aishwarya KK, Kaur SP, Kalyanam R. Case Series on Abnormal Low-lying Implantation of Ectopic Pregnancy: A Diagnostic and Management Dilemma. J South Asian Feder Obs Gynae 2024; 16 (3):303-308.

DOI: 10.5005/jp-journals-10006-2407

License: CC BY-NC 4.0

Published Online: 29-04-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Introduction: Ectopic pregnancy occurs when implantation of a blastocyst takes place in a site other than the endometrium of the uterine cavity. Cesarean scar (CS) site ectopic has an incidence of 1 in 1,800, which occurs when a blastocyst implants in the anterior lower uterine segment at the site of the CS. Here we report a series of four rare cases of low-lying implantation ectopic pregnancy (LLIEP) and different treatment modalities performed in such scenarios. Case 1: A 28-year-old P2L2A1 presented to the emergency obstetrical unit with complaints of bleeding per vagina for 15 days. She provided a history of medical termination of pregnancy (MTP) pill intake at 1 month of gestation, followed by bleeding per vagina for 1 week. Dilatation and curettage were done on a private hospital patient, after which she continued to bleed for 10–12 days, associated with the passage of clots. Per abdomen examination, uterus was 12–14 weeks old, soft, non-tense, and non-tender. On p/s examination, 20-cc foul-smelling, blood-stained discharge was noted. The uterus was 12 weeks old, anteverted, tender, and mobile. A mass of 10 × 7 × 6 cm was felt in the anterior fornix, not separate from the uterus, extending into the right fornix. No fullness felt in the pouch of Douglas. Investigations: Hb-6.9 g/dL, Beta HCG-1250 IU/mL. A provisional diagnosis of septic incomplete abortion with severe anemia from two previous cesarean deliveries was made. Ultrasound revealed large vascular retained products of conceptions (RPOCs), but the exact location of RPOCs was not identified. Anterior myometrial wall thinning was noted. The patient was taken up for diagnostic laparoscopy with suction and evacuation under general anesthesia. On laparoscopy, dense adhesions are seen between the anterior abdominal walls, omentum, and anterior surface of the uterus until the fundus. The left side of the uterus could not be seen due to adhesions. Under vision suction, evacuation was started. There was torrential hemorrhage per vaginam. A decision for an emergency laparotomy was taken. A typical hourglass appearance of the uterus is noted. A small, non-pregnant firm fundus sits over the top of a large 10 × 8 × 7 cm lower uterine segment and a profusely thinned-out anterior wall. Myometrium was deficient on the anterior surface of the lower segment. Only the serosal layer was identified, through which products of conception were seen. A diagnosis of low-lying implantation of pregnancy was made. Cauliflower-shaped fungating growth was visualized after the serosal layer gave away. A lifesaving hysterectomy was done due to torrential bleeding. A cut section showed a non-pregnant fundus with a ballooned-out cervix. Histopathology confirmed the diagnosis of LIEEP. A total of six units of packed red cells and four frozen plasmas were transfused, and the patient was a maternal near-miss later discharged on day 7. Case 2: A 28-year-old G3P2L2 patient who had two previous lower segment cesarean section (LSCS) presented to us post-self-MTP pill intake with spotting pv at 9+5 weeks of gestation. Ultrasound revealed a type 1 CS ectopic pregnancy with a crown-rump length corresponding to 7+3 weeks and evidence of a fetal pole without cardiac activity in the lower uterine segment. β-hCG levels are 52,540 IU. Both medical and surgical options were explained to the patient, and she insisted on medical management. A multi-dose regimen of methotrexate was given, following which there was a significant fall in β-hCG levels. The patient came to the emergency room with torrential bleeding on day 19 in hypovolemic shock. Resuscitation and emergency lifesaving hysterectomy were done, and she was discharged on postoperative day 4. Case 3: A 37-year-old female G4P2L1A1 with 2 months of amenorrhea was referred in view of an ultrasound scan depicting pregnancy in the lower uterine segment with absent cardiac activity. Serum βhCG 6000 mIU/mL. Transvaginal sonography (TVS) depicted a gestational sac of diameter 12 mm in the lower uterine segment, eccentrically located in the anterior wall of the uterus, abutting the previous CS; the yolk sac and fetal pole were visualized; cardiac activity was absent; and a probable diagnosis of CS ectopic pregnancy was made. Medical management using a methotrexate regimen was chosen after informed consent, and 1 mg/kg (84 mg calculated dose) was administered intramuscularly on days 1, 3, 5, and 7 with folinic acid (0.1 mg/kg) on alternate days. Vital signs remained stable, and levels of βhCG declined. However, the patient's successive ultrasounds revealed an increase in MSD from 1.2 cm on day 0 to 1.7 cm on day 10, with the gestational sac protruding toward the endometrial cavity. Suction evacuation was done under ultrasound sonography (USG) guidance. At follow-up, βHCG was 36.1 and 1.4 mIU/mL after 1 and 2 weeks, respectively. Case 4: A 33-year-old, G3P2L2 31 weeks, presented with a complaint of bleeding per vaginam and fever since one day. The patient did not perceive fetal movements throughout the pregnancy. Ultrasonography done 2 days back depicted an intrauterine death at 20 weeks gestation. On per abdomen examination the uterus was 20 weeks, non tense, non tender and with no fetal heart sound. os was closed, cervix posterior, and uneffaced. A bedside ultrasonography reconfirmed intrauterine death at 20 weeks gestation. The lower uterine segment was distended, with the fetus primarily in the lower uterine segment. Cervical ripening and induction were done with dinoprostone gel 0.5 mg eight hourly for three doses, to which there was no response. On repeat examination, the cervix was high up, 10–20% effaced, loose hanging, 3 cm dilated, and the presenting part felt with the tip of the finger, which was soft placenta. The patient was taken up for a Cesarean section. There was a typical hourglass appearance of the uterus; an empty upper segment of the uterus was sitting on top of an overly distended Couvelaire lower uterine segment. A dead fetus of 20 weeks gestation was lying transversely in the leaves of the left broad ligament, while a separated placenta was lying in the lower uterine segment. The tissues were foul-smelling. A peripartum hysterectomy with repair of a broad ligament hematoma was done. Massive blood transfusions and intensive care unit (ICU) for 24 hours were given. The patient was discharged on POD 11. Low-lying implantation of ectopic pregnancy is a life-threatening cause of maternal morbidity and mortality. Currently, there are increasing trends in the incidence of LLIEP due to clinical suspicion and better diagnostic modalities. TVS, Color Doppler, and magnetic resonance imaging (MRI) remain gold standard modalities for the early diagnosis of LLIEP. Failure or delay in diagnosing it will lead to catastrophic complications, which can cause obstetric emergencies.

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