Nikola Alexander Letham and Christopher Morosky
History of present illness
A 39-year-old gravida 5, para 3 woman presents to the emergency room 7 weeks after her last menstrual period with complaints of vaginal spotting and a positive pregnancy test at home 4 days ago. The patient also complains of fatigue and some mild nausea. She denies pelvic pain, cramping or recent trauma.
Her previous obstetrical history includes a preterm spon- taneous vaginal delivery at 36 weeks followed by two term Cesarean deliveries, and then afirst-trimester termination with dilation and curettage. Her medical and surgical histories are otherwise unremarkable.
This is an unplanned and undesired pregnancy. Her inten- tion is to pursue termination. She also desires a reliable form of contraception, and is open to surgical sterilization.
Physical examination
General appearance:Alert woman who is in no apparent distress
Vital signs:
Temperature: 37.2°C Pulse: 61 beats/min
Blood pressure: 113/74 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 100% on room air
Cardiovascular:Regular rate and rhythm without murmurs, rubs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, nontender and nondistended, no guarding or rebound, normal active bowel sounds
Pelvic:
External genitalia: Normal appearing with no lesions or masses
Bimanual exam: Shows uterus 8-weeks’sized, anteverted, nontender, no pelvic masses
Speculum exam: Shows closed cervix, no lesions, a small amount of old dark blood is present in the vagina, no active bleeding
Laboratory studies:
Quantitative beta-hCG: 36 345 mIU/mL Hb: 12.6 g/dL
Ht: 37.6%
Blood type: O positive
Imaging:A transvaginal ultrasound reveals a single gestational sac within the lower uterine segment with an hourglassing portion of the sac within the upper portion of the cervix (Fig. 30.1). Within the gestational sac is a single embryo measuring six weeks andfive days by crown rump length measurement. Cardiac activity is present. The remainder of the endometrial stripe is thin and normal in appearance
How would you manage this patient?
The patient was discharged from the emergency room with the diagnosis of a threatened abortion. At her obstetrical follow-up appointment two days later, she underwent a repeat transva- ginal ultrasound and the images confirmed the diagnosis of a cervical ectopic pregnancy.
In discussing the options for management, the patient elected to undergo hysterectomy. Her decision-making was guided by a desire to have the pregnancy terminated in a controlled setting in order to mitigate the risk of significant blood loss. This also accomplished her desired surgical sterilization.
The patient underwent an uncomplicated total abdominal hysterectomy. Histologic examination of the surgical specimen confirmed the diagnosis of a cervical pregnancy (Fig. 30.2). At her six week follow-up visit she was completely recovered and without complication.
Cervical pregnancy
Ectopic pregnancies account for approximately 2% of all preg- nancies. The fallopian tube is the location of the majority (93–98%) of ectopic pregnancies. The remainder of ectopic locations can be divided between the cervix, interstitium, ovary, Cesarean section scar, or the abdomen. Cervical preg- nancies account for less than 1% of all ectopic pregnancies.
The frequency has been reported from 1 in 10 000 to 1 in 50 000 pregnancies [1]. The rate, however, is higher in patients undergoing in-vitro fertilization, where it accounts for up to 3.5% of ectopic pregnancies.
Due to their extremely low incidence, risk factors for cer- vical pregnancies have been difficult to determine. Two series found 50–70% of patients with cervical pregnancies have had a previous curettage [1,2]. Another very small series showed that 75% of the patients have had a previous Cesarean delivery [3].
Additional possible risk factors include Asherman syndrome and diethylstilbestrol (DES) exposure.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
The presentation of a cervical pregnancy is fairly uniform, with 92% of patients presenting with vaginal bleeding, which is often painless. Thirty percent of women also experience abdominal cramping [1]. On speculum examination the cervical os is typically closed, but there may be dilation with products of conception visible. The differential diagnosis in this setting also includes a threatened, incomplete, or inevit- able miscarriage. Any tissue in the cervix should not be
disturbed until an ultrasound evaluation of the cervix has been performed. Furthermore, products of conception in the lower uterine segment and cervix should not be disturbed in a setting that is not set up to handle significant acute hemorrhage.
Patients should have emergent access to the operating room where aspiration and additional surgical measures can be performed if increased bleeding is encountered.
As in our patient, differentiating a cervical pregnancy from a threatened, incomplete, or inevitable abortion can be diffi- cult. Ultrasoundfindings are the most important indicator of a cervical pregnancy. Ultrasoundfindings that are characteristic of a cervical ectopic pregnancy include:
1. A gestational sac or placenta in the cervix.
2. Dopplerflow around the sac in the cervix.
3. An otherwise normal endometrial stripe.
4. An hourglass orfigure of eight membranes, caused by ballooning of the cervix to accommodate the pregnancy.
5. A barrel-shaped cervix.
Any time there is fetal cardiac activity noted within the cervix, the diagnosis of a cervical pregnancy should be considered.
Diagnosis by ultrasound is correct in nearly 90% of cases of cervical pregnancies. In cases where the diagnosis is unclear, further evaluation may be performed with MRI. In reviewing the ultrasound images of our patient, all of the abovefindings were present on her initial and follow-up ultrasounds.
Early correct diagnosis is extremely important. In an insti- tutional review at McGill University, 12 cervical pregnancies were analysed [1]. Of the presenting patients, seven were initially misdiagnosed as threatened abortions, inevitable abortions, ruptured ovarian cysts, or an ectopic pregnancy. These misdiagnosed patients were treated primarily with curettage,
Fig. 30.2 Surgical specimen confirmed the diagnosis of a cervical pregnancy.
Fig. 30.1 Transvaginal ultrasound revealing a single gestational sac within the lower uterine segment with an hourglassing portion of the sac within the upper portion of the cervix.
laparotomy, or laparoscopy. All of the misdiagnosed patients encountered increased bleeding, resulting in four patients under- going total abdominal hysterectomy andfive patients receiving blood transfusions. Of the patients that were correctly diagnosed, none required a hysterectomy or a blood transfusion. These patients were successfully treated with methotrexate initially, followed by differing combinations of potassium chloride, uterine artery embolization, and curettage.
Treatment recommendations for cervical pregnancies are based upon case reports and small case series. The majority of the literature favors medical management for nonemergent cases of cervical pregnancies, particularly when the patient desires future fertility. Methotrexate is largely recommended, and when fetal cardiac activity is present concurrent feticide with intra-amniotic injection of potassium chloride (KCl) (1–5 mL of 20% solution) was found to greatly improve the efficacy of the methotrexate [3]. Transcervical injection of the KCl preparation, rather than injection through the cervical os, is recommended in order to decrease the risk of bleeding.
Methotrexate has been administered intravenously, intramus- cularly, and intramniotically. No clear difference in efficacy has been established between these treatment regimens, although no direct comparative date is available.
A review of available case reports of cervical pregnancies that were managed with various treatment regimens of methotrexate showed that the best candidates for medical management were those cervical pregnancies less than 9 weeks’
gestation, with a beta-human chorionic gonadotropin (beta- hCG) level of less than 10 000 mIU/mL, and absent fetal cardiac activity [4]. After medical treatment, a decrease in the beta-hCG should be noticed on average within 14 days. Some authors use a cutoffof a 15% decrease, and if the cutoffis not met, a second dose of methotrexate may be given [3]. On average the beta-hCG values reached zero with a median of 68 days. The echogenic lesion in the cervical region will persist, and in a review it was noted to resolve with a median time of 86 days [4]. It is important to note that in the appropriately counseled patient who strongly desires a trial of medical man- agement to avoid surgical intervention, the administration of methotrexate outside of these parameters is not unreasonable.
These patients should understand that they are likely at a higher risk of failure for such medical management and may experience acute onset of heavy vaginal bleeding if the preg- nancy tissue begins to abort vaginally.
For acutely hemorrhaging patients and those failing med- ical management, surgical intervention should be performed.
Dilation and curettage has very limited success, with a high rate of hysterectomy (40–70%) as well as blood transfusion [1]. Recommendations vary and data is limited, but many authors recommend attempting to decrease blood flow to the uterus prior to attempting any form of instrumentation.
Hemostatic options include uterine artery embolization, placement of a transvaginal cervical cerclage, or transvaginal
ligation of the cervical branches of the uterine artery with suture [2,5,6]. Other suggestions are the placement of a Foley balloon or other hemostatic material within the cervix following curettage and the use of uterotonic or vasoconstrict- ing agents.
Hysterectomy may be performed primarily or after failure of other treatments. Due to the increased vascularflow to the cervix, hysterectomy can also be complicated by significant bleeding. Hemostatic measures such as uterine artery emboli- zation or hypogastric artery ligation have been used to limit the blood loss during hysterectomy for cervical pregnancies.
Radical dissection of surrounding pelvic organs, such as the bladder and rectum, is occasionally required, and consider- ation should be given to preoperative consultation with pelvic surgical specialists. After being counseled about the option of medical management with methotrexate, our patient elected to undergo primary hysterectomy given her increased risks for failure (an elevated beta-hCG level and present fetal cardiac activity), as well as her desire to undergo sterilization.
In conclusion, cervical pregnancies are a rare manifestation of ectopic pregnancy. They are often misdiagnosed as spon- taneous abortions or intrauterine pregnancies. In this setting, the risk of hysterectomy and transfusion is greatly increased when patients undergo dilation and curettage. Careful atten- tion to specific ultrasound characteristics optimizes the proper early diagnosis of cervical pregnancies. Stable patients can be treated medically, with surgical management reserved for acutely hemorrhaging patients, those failing conservative man- agement, and those who are poor candidates for medical management and not desiring future fertility.
Key teaching points
Any pregnancy seen on ultrasound within the lower uterine segment should be viewed with suspicion for being a cervical pregnancy. Hourglass membranes and cardiac activity in the lower uterine segment should increase this suspicion.
Misdiagnosis of a cervical pregnancy followed by dilation and curettage greatly increases the risk of emergency hysterectomy and the need for blood transfusion.
In the stable patient with a cervical pregnancy, medical management should be the preferred course of treatment.
Ideal candidates for medical management are those less than 9 weeks’gestation with a beta-human chorionic gonadotropin level below 10 000mIU/mL and absent fetal cardiac activity.
Transcervical intra-amniotic injection of potassium chloride (KCl) can be performed in addition to
methotrexate therapy when fetal cardiac activity is present.
If surgical intervention is necessary there is a high risk of hemorrhage, and measures to prevent or manage such should be anticipated.
Case 30: Unanticipated ultrasoundfindings at follow-up prenatal visit
References
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