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CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 38-40

Cervical pregnancy: A rare case


Department of Obstetrics and Gynaecology, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission20-Oct-2020
Date of Decision12-Dec-2020
Date of Acceptance04-Jan-2021
Date of Web Publication30-Mar-2021

Correspondence Address:
Dr. Mooga Swetcha
Department of Obstetrics and Gynecology, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_18_20

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  Abstract 


Cervical pregnancy is a rare form of ectopic pregnancy. Incidence is <1% of all ectopic pregnancies. It is defined as pregnancy that is implanted in the cervical canal below the internal os with cervical glands noted histologically. It is a rare variant of ectopic pregnancy and the diagnosis may be missed unless the clinician and the radiologist are aware of this entity. Here, we present a case of cervical pregnancy in a 26-year-old female G3P2L2 who was diagnosed as missed abortion and was planned for termination of pregnancy. During suction evacuation, she had severe uncontrolled bleeding. Laparotomy revealed the presence of an ectopic cervical pregnancy for which hysterectomy had to be done. Thus, this case illustrates the importance of its early and accurate diagnosis in order to avoid complications and for planning appropriate management accordingly.

Keywords: Cervical pregnancy, ectopic pregnancy, hysterectomy


How to cite this article:
Swetcha M, Nalini Y L, Ramana Bai P V, Rani S, Lakshmi D V. Cervical pregnancy: A rare case. MRIMS J Health Sci 2021;9:38-40

How to cite this URL:
Swetcha M, Nalini Y L, Ramana Bai P V, Rani S, Lakshmi D V. Cervical pregnancy: A rare case. MRIMS J Health Sci [serial online] 2021 [cited 2021 Apr 14];9:38-40. Available from: http://www.mrimsjournal.com/text.asp?2021/9/1/38/312496




  Introduction Top


The majority of ectopic pregnancies are found within some part of the  Fallopian tube More Details. Increasingly, more ectopic pregnancies are found in other locations within the abdomen and pelvis. Cervical pregnancy is one of those rare nontubal ectopic pregnancies where pregnancy is implanted within the cervix below the internal os. It accounts for <1% of all ectopic pregnancies.[1] The cervical glands are noted histologically opposite the placental attachment site and by all or part of the placenta found below the entrance of the uterine vessels or below the peritoneal reflection on the anterior uterus. Predisposing risk factors include assisted reproductive techniques and prior uterine curettage.[2],[3] The diagnosis may not be suspected until the patient undergoes suction curettage with a resultant torrential hemorrhage. However, cervical pregnancy can be identified based on transvaginal ultrasound. Management of cervical ectopic pregnancies includes medical treatment with methotrexate and surgical dilation and curettage, in case if the bleeding is uncontrolled by conservative methods hysterectomy may be required.[4],[5]


  Case Report Top


A 26-year-old G3P2L2= gravid with two previous lower segment cesarean section (LSCS) with history of 2 months of amenorrhea, complaints of bleeding per vaginum for 2 days. Her urine pregnancy test was positive. Obstetric history first and second pregnancies were term cesarean section; last childbirth was 2 years. Ultrasound revealed a single intrauterine fetus corresponding to 7 weeks without cardiac activity suggestive of missed miscarriage. On examination, her vitals were stable, but marked pallor was present. Per speculum examination showed soft cervix, pinhole os, and healthy vagina. On bimanual vaginal examination uterus was retroverted, 8 weeks size, mobile, and B/L fornices free. Suction evacuation was attempted under anesthesia, during which she had torrential bleeding, which was not controlled by uterotonics. Simultaneous resuscitation was done. Blood was transfused as per requirement, vaginal packing was done. Cervical pregnancy or scar pregnancy was suspected and planned for emergency laparotomy and prior consent for hysterectomy was taken. Laparotomy revealed the presence of ballooning of the cervix. Hysterectomy was done, an incision made over the anterior part of the cervix revealed products of conception. Cervical pregnancy was diagnosed and as the intractable bleeding was continued we proceeded with hysterectomy. Hemostasis was secured, the abdomen was closed in layers. Histopathology report confirmed the diagnosis of cervical ectopic pregnancy. The patient was discharged on the 7th POD after suture removal in satisfactory condition. After 1 month, she came for follow-up, having no complaints and was healthy.


  Discussion Top


Cervical pregnancy was first described in 1817 and first named as such in 1860.[6] In 1911, Rubin defined the anatomical and histological criteria for the diagnosis of cervical pregnancy.[7]

  • The cervical glands must be opposite to the attachment of the trophoblast/placenta
  • Attachment of trophoblast must be below the level of entrance of uterine vessels to the uterus or anterior peritoneal reflection
  • Fetal elements (products of conception) must be absent from the corpus uteri.


Ultrasound criteria for the diagnosis of cervical pregnancy[1]

  • Gestational sac or placental tissue visualized within the cervix cardiac motion noted below the level of the internal os
  • No intrauterine pregnancy
  • Hourglass uterine shape with ballooned cervical canal
  • No movement of the sac with pressure from the transvaginal probe (i.e., no “sliding sign” that is typically seen with incomplete abortions)
  • Closed internal os.


The exact cause of cervical pregnancy is not known. The patients with cervical pregnancy present with painless first trimester vaginal bleeding, although some cases have presented with cramping pain and are often misdiagnosed as abortion. On examination, there is soft distended cervix which is disproportionally enlarged compared to the uterus, a partially opened external cervical os and profuse hemorrhage on the manipulation of the cervix.[6] However, these findings were not seen in our case. And with high index of suspicion, sonography can help in this rare diagnosis. However, this was missed in the initial report of our case. Management of the cervical ectopic pregnancy is dependent on several factors such as patients gestational age, fetal cardiac activity, the stability of the patient, patient's interest in retaining future fertility, and the availability of resources and expertise of the practicing gynecologist.[8]

Medical management with methotrexate can be considered for cervical pregnancy. Surgical methods should be reserved for those women suffering from life-threatening bleeding. Early, accurate diagnosis is the key factor in conservative management. Gestational age <12 weeks, the absence of fetal cardiac activity, and lower serum beta-human chorionic gonadotropin (β-hCG) levels are associated with more successful conservative management. Higher risks of systemic MTX treatment failure in those with a gestational age >9 weeks, β-hCG levels >10,000 mIU/mL, crown-rump length >10 mm, and fetal cardiac activity.[4] To resolve fetal cardiac activity, a sonographically guided fetal intracardiac injection of 2 mL (2 mEq/mL) potassium chloride solution can be given. As an adjunct to medical or surgical therapy, uterine artery embolization has been described either as a response to bleeding or as a preprocedural preventive tool. Furthermore, in the event of hemorrhage, a 26F Foley catheter with a 30-mL balloon can be placed intracervically and inflated to attain hemostasis, it is inflated for 24–48 h and is gradually decompressed over a few days.[4] If cervical curettage is planned, intraoperative bleeding may be lessened by preoperative UAE, by intracervical vasopressin injection, or by a cerclage placed at the internal cervical os to compress feeding vessels,[4] lateral cervical suture placement to ligate the lateral cervical vessels.[1] When none of these methods is successful then we proceed with hysterectomy. In our case, as the diagnosis was missed preoperatively and picked up intraoperatively when the patient started bleeding profusely, since our patient comes under high-risk category with two previous LSCS scars with torrential bleeding. Hence, it was decided to proceed with hysterectomy. To conclude, cervical pregnancy is a rare variant of ectopic pregnancy and a high index of suspicion, clinicosonological correlation, especially in cases with previous uterine scars can pick up this rare entity preoperatively and if diagnosed early conservative management can be offered. However, missed diagnosis can lead to high rates of morbidity and mortality and this case illustrates the importance of its early and accurate diagnosis to avoid the catastrophe.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: A 10 year population-based study of 1800 cases. Hum Reprod 2002;17:3224-30.  Back to cited text no. 1
    
2.
Ginsburg ES, Frates MC, Rein MS, Fox JH, Hornstein MD, Friedman AJ. Early diagnosis and treatment of cervical pregnancy in an in vitro fertilization program. Fertil Steril 1994;61:966-9.  Back to cited text no. 2
    
3.
Schorge J, Schaffer J, Halvorson L, Hoffman B, Bradshaw K, Cunningham F. Williams gynecology. J Midwifery Womens Health 2010;55:e59-e59.  Back to cited text no. 3
    
4.
Kung FT, Lin H, Hsu TY, Chang CY, Huang HW, Huang LY, et al. Differential diagnosis of suspected cervical pregnancy and conservative treatment with the combination of laparoscopy-assisted uterine artery ligation and hysteroscopic endocervical resection. Fertil Steril 2004;81:1642-9.  Back to cited text no. 4
    
5.
Leeman LM, Wendland CL. Cervical ectopic pregnancy. Diagnosis with endovaginal ultrasound examination and successful treatment with methotrexate. Arch Fam Med 2000;9:72-7.  Back to cited text no. 5
    
6.
Rizk B, Holliday CP, Owens S, Abuzeid M. Cervical and cesarean scar ectopic pregnancies: Diagnosis and management. Middle East Fertil Soc J 2013;18:67-73.  Back to cited text no. 6
    
7.
Spitzer D, Steiner H, Graf A, Zajc M, Staudach A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection. Hum Reprod 1997;12:860-6.  Back to cited text no. 7
    
8.
Berek JS. Nontubal ectopic pregnancy. In: Berek and Novak's Gynecology. 15th ed.Wolters Kluwer, Lippincott Williams, Philadelphia;2012. p. 642-3.  Back to cited text no. 8
    




 

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