Ectopic Pregnancy: A Clinical Casebook

12. Cervical Pregnancy

Abdulrahman Alserri  and Togas Tulandi 

(1)

McGill University Health Center, 687 Pine Ave West, H3A 1A1 Montreal, QC, Canada

Abdulrahman Alserri

Email: binserri@gmail.com

Togas Tulandi (Corresponding author)

Email: togas.tulandi@mcgill.ca

Keywords

Cervical pregnancyCervical ectopic pregnancyMethotrexateMultidose methotrexate

Case Study

A 35-year-old gravida 3, para 1, aborta 1 woman presented with painless vaginal bleeding 5 weeks after treatment with in vitro fertilization (IVF) with a single embryo transfer. Past history revealed a suction curettage for a miscarriage at 6 gestational weeks and a cesarean delivery. A speculum examination showed an abnormally enlarged cervix with minimal fresh bleeding seen at the external cervical os. The serum β-human chorionic gonadotropin (hCG) level was 9112 IU/L and transvaginal ultrasound demonstrated a gestational sac within the body of the cervix with a yolk sac and a fetal pole with cardiac activity (Fig. 12.1). The diagnosis was cervical ectopic pregnancy (CEP) . Other blood tests including liver and renal function tests were within normal limits.

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Fig. 12.1

A sagittal ultrasound image of a uterus with a cervical pregnancy

My Management

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Diagnosis and Assessment

CEP is defined as a pregnancy that implants in the surface of the endocervical canal [1]. Its incidence is approximately 1 in 9000 pregnancies and accounts for 0.15 % of all ectopic pregnancies [2]. Our patient had several risk factors for cervical pregnancy including a history of a previous curettage, which is present in 50–70 % of patients with cervical pregnancy, and a history of a previous cesarean delivery, found in 16.7–37.5 % of patients with cervical pregnancy and pregnancy after IVF. Cervical pregnancy accounts for 0.1 % of all IVF pregnancies and 3.7 % of all IVF ectopic pregnancies. Other risk factors specific to cervical pregnancy include previous instrumentation or trauma to the cervix and Asherman’s syndrome [25].

Classically, cervical pregnancy presents as painless vaginal bleeding after a period of amenorrhea in 90.1 % of cases. On speculum examination, a disproportionately enlarged and softened cervix is seen [6]. Differential diagnosis include incomplete abortion, placenta previa, carcinoma of the cervix, and degenerating leiomyoma [6].

The first ultrasound of cervical pregnancy was reported by Raskin in 1978 [7]. Almost a decade later, Ushakov described the ultrasound criteria of cervical pregnancy . They arep: gestational sac in the endocervix, intact cervical canal above the gestational sac, closed internal cervical os, trophoblastic invasion of the endocervix by Doppler ultrasound, the presence of embryo/fetal structures/cardiac activity, empty uterine cavity, endometrial decidualization, and hourglass uterus [2]. Cervical pregnancy can be differentiated from an aborting intrauterine pregnancy that is stuck in the cervical canal by a “sliding sac sign.” The sac that slides with slight pressure of the endovaginal probe to the cervix suggests no intimate attachment between the gestational sac and the endocervical tissue. When available, an MRI can be used to confirm the diagnosis (Fig. 12.2).

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Fig. 12.2

A sagittal magnetic resonance imaging of the pelvis with a cervical pregnancy

In the past, CEPs were diagnosed late and many women ended up with hysterectomies as a consequence of catastrophic bleeding. Increased awareness and ultrasound examination provide means for early diagnosis and lead to decreased morbidity and mortality.

Management

Following the establishment of a diagnosis of cervical pregnancy, treatment should be immediately started.

Medical Management

In stable patients, medical treatment with methotrexate is preferable. Most of the data on cervical pregnancy are derived from case series, and most experts advocate treatment with multidose methotrexate regimen. Due to the high risk of severe bleeding from cervical pregnancy leading to hysterectomy, we advise against single-dose methotrexate regimen and local injection of methotrexate for the treatment of CEP. We recommend administering methotrexate 1 mg/kg body weight intramuscularly on days 1, 3, 5, and 7 alternating with leucovorin 0.1 mg/kg body weight intramuscularly on day 2, 4, 6, and 8. In general, the effectiveness of methotrexate alone to treat CEP is reduced when serum β-hCG level > 10,000 IU/L, gestational age > 9 weeks, presence of fetal cardiac activity, and crown-rump length (CRL)  > 10 mm [8].

Methotrexate can be administered alone or in conjunction with other medical or surgical measures. Despite a few reports of local KCl injection in the presence of fetal cardiac activity, the possible risks of local KCl injection outweigh its advantage. Furthermore, in our experience, all fetal cardiac activity will eventually cease with multidose methotrexate treatment.

Mifepristone (RU 486) is an anti-progesterone with an anti-decidual effect. In a case series of four patients with cervical pregnancy treated with a single-dose methotrexate (MTX) and mifepristone, three patients required additional treatments including UAE, dilatation and curettage, and misoprostol. The efficacy of this treatment protocol is questionable [9].

Surgical Management

Surgical management should be used only for patients with severe bleeding or when medical treatment combined with UAE has failed. Instead of surgery, it is best to perform UAE after methotrexate treatment if needed. Performing UAE before methotrexate administration is not recommended; it might decrease the delivery of methotrexate to the tissue due to decreased blood supply. Furthermore, methotrexate treatment in most cases will be successful without the need of UAE. UAE as an adjuvant treatment has also been successful in treating CEP in different situations including acute/semi-acute bleeding, before curettage to minimize bleeding, and after failed medical treatment with methotrexate [410].

In women who wish to preserve their fertility and require surgery due to massive bleeding , the surgical treatment consists of curettage preceded by ligation of the descending branch of uterine artery and followed by tamponading with either a Foley catheter inserted into the endocervical canal or a cervical cerclage and vaginal packing. The Foley catheter has to be sutured to the cervix to allow its retention. If time allows, selective UAE should be performed before curettage to minimize bleeding keeping in mind that UAE may have a detrimental effect on fertility. Today, hypogastric artery ligation or hysterectomies are rarely needed.

Outcome

After starting the multidose methotrexate treatment, the patient’s serum β-hCG levels rose to 11,514 IU/L on day 3 then started to fall thereafter. Her day 7 β-hCG was 6000 IU/L. She experienced no bleeding since her admission and repeat ultrasound showed an arrested fetal cardiac activity and shrinkage of the gestational sac. She was discharged on day 7 after receiving her last methotrexate dose and was followed up weekly as an outpatient. The serum β-hCG levels continued to decrease, and at 4 weeks of follow-up the hCG levels were undetectable and the cervical ectopic had completely resolved on ultrasound. She was then discharged from follow-up and advised to be followed up closely in future Pregnancies.

Clinical Pearls/Pitfalls

·               Painless vaginal bleeding after a period of amenorrhea is highly suspicious of cervical pregnancy especially in the presence of risk factors.

·               Early diagnosis and treatment can be lifesaving and reduces morbidity.

·               Ultrasound is the mainstay of diagnosis of CEP.

·               Patients with the diagnosis of CEP should be admitted and treated initially as inpatients.

·               In stable patients, conservative medical management with multidose methotrexate is preferable.

·               Prompt surgical management is required when CEP presents with life-threatening bleeding.

·               Although rare, it is important to counsel patients about the possible need for hysterectomy when treating CEP as a lifesaving measure.

References

1.

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2.

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4.

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7.

Raskin MM. Diagnosis of cervical pregnancy by ultrasound: a case report. Am J Obstet Gynecol. 1978;130(2):234–5.PubMed

8.

Hung TH, Shau WY, Hsieh TT, Hsu JJ, Soong YK, Jeng CJ. Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: a quantitative review. Hum Reprod. 1998;13(9):2636–42.CrossRefPubMed

9.

Gómez García MT, Aguarón Benitez G, Barberá Belda B, Callejón Rodríguez C, González Merlo G. Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol. 2012;165(1):77–81. doi:10.1016/j.ejogrb.2012.06.024. Epub 2012 Jul 7.CrossRefPubMed

10.

Martinelli P, Maruotti GM, Oppedisano R, Agangi A, Mazzarelli LL, Votino C, et al. Is uterine artery embolization for cervical ectopic pregnancy always safe? J Minim Invasive Gynecol. 2007;14(6):758–63.CrossRefPubMed