Teoh Jessica, Rajendran Sumathi, Gupta Sarika
Women and Babies Department Royal Prince Alfred Hospital Camperdown New South Wales Australia.
Sydney Ultrasound for Women Sydney New South Wales Australia.
Australas J Ultrasound Med. 2023 Feb 27;26(3):199-202. doi: 10.1002/ajum.12337. eCollection 2023 Aug.
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.
早期妊娠超声必须满足客观标准才能安全诊断流产。低位妊娠囊的鉴别诊断包括流产的宫颈阶段以及宫颈和剖宫产瘢痕部位的异位妊娠。误诊可能导致严重的母体发病率。我们描述了一名36岁初产妇的妊娠情况，其低位妊娠囊的超声表现符合流产标准；然而，刮宫时出现了宫颈大出血。妊娠6周6天时的超声显示宫内妊娠，存活情况不明。11天后复查超声，根据两次扫描之间没有进展且无胚胎心跳，确诊为流产。可见塌陷的妊娠囊位于宫颈内口水平，有蜕膜反应和滋养层周围血流。在妊娠囊下方，可见少量血管的滋养层样组织开始扩张宫颈管上段：妊娠囊的滑动征阳性，宫颈管上段内容物的滑动征阴性。可见宫颈间质围绕着扩张的组织。患者接受刮宫术，术中出血2000毫升，需要输血以及进行药物和手术治疗，包括宫腔内放置Foley导管。组织病理学证实为妊娠组织，宫颈上皮有破坏，但无真正的浸润。建议患者在未来妊娠时到专业的产科影像机构进行早期超声检查以确定孕周。目前的文献中未描述低位妊娠囊流产且伴有滋养层延伸至宫颈管的高危特征的病例。我们建议保持高度警惕，排除鉴别诊断，因为大多数女性没有异位妊娠的危险因素。这些病例应建议进行手术治疗。
