A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage
 

A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage

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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 evaluation of first ...

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 evaluation of first trimester vaginal bleeding or pelvic pain is an important task for the emergency 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.




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A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage Document Transcript

  • A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage
  • Case Report A case report of cervical ectopic pregnancy misdiagnosed 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 journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3 Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed as cervical 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 ligation were 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 pathology mainly 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. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e32 Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed as cervical 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 case report and literature review. Ultrasound Obstet Gynecol. 2002;19:297e301. 2. Tayal VS, Cohen H, Norton HJ. Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy. Acad Emerg Med. 2004;11:912e917. 3. Honey L, Leader A, Claman P. Uterine artery embolizationda successful treatment to control bleeding cervical pregnancy with a simultaneous intrauterine gestation. Hum Reprod. 1999;14:553e555. 4. Ushakov FB, Elchalal V, Aceman PJ. Cervical pregnancy: past and future. Obstet Gynecol Sur. 1996;52:45e59. 5. Benson CB, Doubilet PM. Strategies for conservative treatment of cervical ectopic pregnancy. Ultrasound Obstet Gynecol. 1996;8:371e372. 6. Spitzer D, Steiner M, Graf A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection. Hum Reprod. 1997;12:860e866. 7. Cosin JA, Bean M, Grow D. The use of methotrexate and arterial embolisation in a case of cervical pregnancy. Fertil Steril. 1997;67:1169e1171. 8. Kung FT, Chang JC, Tsai YC. Subsequent reproduction and obstetric outcome after methotrexate treatment of cervical pregnancy: a review of original literature and international collaborative follow-up. Hum Reprod. 1997;12:591e595. 9. Yitzhak M, Orvieto R, Nitke S. Cervical pregnancyda conservative stepwise approach. Hum Reprod. 1999;14:847e849. 10. Kung FT, Chang SY. Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies. Am J Obstet Gynecol. 1999;181:1438e1444. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3 3 Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004
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