A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage

Case Report

A case report of cervical ectopic pregnancymisdiagnosed as cervical miscarriage

Ahmed S. Elagwany*, Tamer M. Abdeldayem

Department of Obstetrics and Gynecology, Alexandria University, Egypt

a r t i c l e i n f o

Article history:

Received 19 September 2013

Accepted 7 October 2013

Available online xxx

Keywords:

Cervical ectopic pregnancy

Ultrasound

Balloon tamponade

Cervical abortion

a b s t r a c t

Cervical pregnancy is a rare variety of ectopic gestation. The aetiology is obscure. Diagnosis

may be difficult unless the clinician/the radiologist is conscious of the entity. The evalu-

ation of first trimester vaginal bleeding or pelvic pain is an important task for the emer-

gency physician. The early identification of an ectopic pregnancy can help prevent

significant morbidity and mortality for patients seeking emergency care. We present the

case of a patient found to have a cervical ectopic pregnancy.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Cervical ectopic pregnancy is extremely rare, accounting for

less than 1% of all ectopic pregnancies. Its aetiology is still

unclear. However, there are reports of association with chro-

mosomal abnormalities as well as a prior history of pro-

cedures that damage the endometrial lining such as caesarean

section, intrauterine device, and in vitro fertilization.1

The important causes of first trimester bleeding are spon-

taneous abortion, ectopic pregnancy, and gestational tropho-

blastic disease. The clinical assessment of pregnancy outcome

is often unreliable, and ultrasound evaluation combined with

quantitative beta human chorionic gonadotropin (B-HCG) is

an established diagnostic tool in these patients. In the setting

of first trimester bleeding, it is important for physicians to

consider the diagnosis of ectopic pregnancy because signifi-

cant morbidity and mortality may result from a missed or

delayed diagnosis.2 We present the case of a cervical ectopic

pregnancy.

2. Case report

A 35-year-old female gravida three with a history of two

caesarean sections at full term and one spontaneous abortion

presented to our clinic with vaginal bleeding. The patient

underwent dilatation and curettage one week before for cer-

vical abortion in a district hospital. Ultrasound was done in

that hospital early in pregnancy with no suspicion of cervical

pregnancy. The patient was HCV positive. The patient was

complaining of vaginal bleeding since then.

On admission, vital signs were stable. HB was 7 g/dl.

Coagulation profile and liver function tests were in the normal

range. Transvaginal ultrasound (Fig. 1) showed a well-defined

uterus with echogenic tissues and fluid at the very lower

segment of the uterus essentially below the prior caesarean

section scars and in the cervix, colour Doppler showed active

blood flow around and in the tissues with high suspicion of

remnants of conception. Quantitative beta hCG was

4000 mLU/mL at this point. Speculum examination showed a

* Corresponding author. El-Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt. Tel.: þ20 1228254247.E-mail address: Ahmedsamyagwany@gmail.com (A.S. Elagwany).

Available online at www.sciencedirect.com

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Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed ascervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004

0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.10.004

copious amount of bleeding and clots and an enlarged tender

opened cervix with tissues protruding.

The patient was transferred to the operating theater for

evacuation under anaesthesia. Curettage of the remnants was

performed under ultrasound guidance, that revealed highly

adherent conceptus tissues (Fig. 2) with severe bleeding. So, a

diagnoses of cervical ectopic pregnancy was highly suspected.

Intracervical balloon tamponade with Foley’s catheter and

vaginal bilateral uterine artery ligationwere done. The balloon

was removed after 48 h without any recurrence in bleeding.

The tissues were sent to pathology, which confirmed

remnants of cervical ectopic pregnancy. Beta hCG was

500 mLU/mL on the day after the procedure and 30 mLU/mL

and 2 mLU/mL 2 weeks after. Follow up was done till B-hCG

reached zero after three weeks. Bleeding stopped completely

and the patient resumed her normal periods. Written

informed consent was obtained from the patient to publish

this case.

3. Discussion

The aetiology of cervical pregnancy is unknown, although it is

likely to result from a combination of factors, including local

cervical pathologymainly of iatrogenic origin such as previous

dilatation and curettage, Asherman’s syndrome, previous

Caesarean section, previous cervical or uterine surgery and

in vitro fertilization e embryo transfer.3

Presenting symptoms generally include vaginal bleeding

which is usually painless but may be coupled with abdominal

pain and urinary problems, particularly in more advanced

pregnancies. Findings at admission vary, but include an

enlarged, globular or distended cervix, which is often associ-

ated with external os dilatation.4

Diagnosis of cervical pregnancy requires visualization of

an intracervical ectopic gestational sac or trophoblastic mass.

Transvaginal ultrasound improves visualization in cases of

early cervical pregnancy. However, it is limited by a restricted

field of view inherent in the scanning technique. Trans-

abdominal imaging, although inferior in imaging detail, al-

lows visualization of the uterus, canal and vagina in a single

plane. It may be preferable in advanced cases of cervical

pregnancy. It has been suggested by Ushakov et al4 that

visualization of an intact part of the cervical canal between

the endometrium and gestational sac reflects an intracervical

placentation.

Differentiation of a true cervical pregnancy from an isth-

micocervical pregnancy is important and requires demon-

stration of a closed internal os. The internal os (on a coronal

view) is said to be at the level of the insertion of the uterine

arteries. Thus, if the internal os cannot itself be visualized, the

sac should be below the uterine artery insertion, which should

be identifiable.4

Early cervical pregnancy may be mistaken for the cervical

stage of miscarriage where the abortus is retained by a resis-

tant external os, thereby ballooning out the cervical canal. The

larger or globular uterus compared to the hourglass configu-

ration in cervical pregnancy is particularly helpful. The

‘sliding sign’ which occurs when the gestational sac of an

abortus slides against the endocervical canal following gentle

pressure by the sonographer and which will not be seen in an

implanted cervical pregnancy may also assist in the differ-

entiation.5 Local endocervical tissue invasion by the tropho-

blast is also important in cervical pregnancy and it may be

possible to identify the site with ultrasound. The hyperechoic

trophoblastic ring will be thicker in the area of invasion. It

may be more difficult to visualize the remaining thinned

cervical wall. Low resistance placental blood flow due to the

trophoblastic villi, termed peritrophoblastic arterial flow, has

been useful in the diagnosis of tubal ectopic pregnancy using

Fig. 1 e Ultrasound picture showing remnants of

conception intra cervical.

Fig. 2 e Remnants of conception after curettage.

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Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed ascervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004

colour flow Doppler and may be useful in both diagnosis and

monitoring of treatment in cervical.4,6 The low resistance flow

may be detected in an intracervical position confirming the

site of implantation. A non-viable sac passing through the

cervix will have no peritrophoblastic flow.7

Following diagnosis, conservative medical and/or surgi-

cal management is generally undertaken in an attempt to

avoid hysterectomy and preserve fertility. Over the last

decade, therapeutic regimes including chemotherapy, Foley

catheter tamponade, curettage and local prostaglandin in-

jection and arterial embolization have been pursued with a

consequent reduction in the number of hysterectomies

performed.4,8

Methotrexate is the most commonly used systemic

agent, although the drug has also been administered intra-

muscularly, intravenously, intracervically and intra-

amniotically. The presence of a viable foetus or advanced

gestational age have been associated with higher rates of

treatment failure.9 If there is an increase in bleeding or

reappearance of vaginal bleeding during methotrexate

treatment, further intervention with intra-arterial emboli-

zation is warranted. Arterial embolization has been used to

control bleeding to enable the maintenance of a concurrent

intrauterine heterotopic pregnancy in the presence of a

cervical pregnancy.7,10

In the case of cervical pregnancy, it may also be preferable

to wait for at least 6 months before conceiving to minimize

any effect. Furthermore, it may be important to watch for

possible increased risk of preterm labour or incompetent

cervix, which are not due to the cervical pregnancy itself but

rather its predisposing factors.10

In conclusion, early diagnosis of cervical pregnancy with

the use of ultrasound and utilization of conservative treat-

ment regimens has decreased associated morbidity and

improved the possibility of on-going fertility in affected

patients.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Gun M, Mavrogiogis M. Cervical ectopic pregnancy: a casereport and literature review. Ultrasound Obstet Gynecol.2002;19:297e301.

2. Tayal VS, Cohen H, Norton HJ. Outcome of patients with anindeterminate emergency department first-trimester pelvicultrasound to rule out ectopic pregnancy. Acad Emerg Med.2004;11:912e917.

3. Honey L, Leader A, Claman P. Uterine artery embolizationdasuccessful treatment to control bleeding cervical pregnancywith a simultaneous intrauterine gestation. Hum Reprod.1999;14:553e555.

4. Ushakov FB, Elchalal V, Aceman PJ. Cervical pregnancy: pastand future. Obstet Gynecol Sur. 1996;52:45e59.

5. Benson CB, Doubilet PM. Strategies for conservativetreatment of cervical ectopic pregnancy. Ultrasound ObstetGynecol. 1996;8:371e372.

6. Spitzer D, Steiner M, Graf A. Conservative treatment ofcervical pregnancy by curettage and local prostaglandininjection. Hum Reprod. 1997;12:860e866.

7. Cosin JA, Bean M, Grow D. The use of methotrexate andarterial embolisation in a case of cervical pregnancy. FertilSteril. 1997;67:1169e1171.

8. Kung FT, Chang JC, Tsai YC. Subsequent reproduction andobstetric outcome after methotrexate treatment of cervicalpregnancy: a review of original literature and internationalcollaborative follow-up. Hum Reprod. 1997;12:591e595.

9. Yitzhak M, Orvieto R, Nitke S. Cervical pregnancydaconservative stepwise approach. Hum Reprod.1999;14:847e849.

10. Kung FT, Chang SY. Efficacy of methotrexate treatment inviable and nonviable cervical pregnancies. Am J ObstetGynecol. 1999;181:1438e1444.

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Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed ascervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004

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