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Cervical pregnancy

This document discusses cervical pregnancy, beginning with an introduction covering the history, definition, incidence, causes, risk factors, and morbidity/mortality. It then covers diagnosis through physical exam, ultrasound criteria, and differential diagnosis compared to other conditions. The treatment section discusses both minimally invasive options like methotrexate injection or uterine artery embolization, as well as more invasive options like dilation and curettage or hysterectomy if bleeding cannot be controlled. Conservative treatment aims to preserve the uterus and can resolve most cases under 12 weeks, though bleeding may still require additional procedures like embolization.

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Cervical pregnancy Aboubakr Elnashar Benha university Hospital, EgyptABOUBAKR ELNASHAR
CONENTS 1.INTRODUCTION History Define Incidence Cause Risk Factors Morbidity and Mortality 2. DIAGNOSIS 3. Differential diagnosis 4. TREATMENT CONCLUSION ABOUBAKR ELNASHAR
1. INTRODUCTION History First report of a Cervical Pregnancy: 1860. First described in the literature: 1911 (Parente et al, 1983). First report of CEP diagnosed using US: 1978 (Raskin, 1978) ABOUBAKR ELNASHAR
DEFINE: Pregnancy implants in the lining of the endocervical canal, below the level of the internal os. Rubin pathological criteria (1911) 1) Cervical glands must be present opposite the placental attachment 2) Attachment of the placenta to the cervix must be intimate 3) The whole or a portion of the placenta must be situated below the entrance of the uterine vessels, or below the peritoneal reflection of the anterior and posterior surface of the uterus 4) No fetal elements must be present in the corpus uteri. ABOUBAKR ELNASHAR
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INCIDENCE 1% of ectopic pregnancies 1 in 9000 deliveries More common in pregnancies achieved through ART (Ginsburg, 1994). 0.1% of IVF pregnancies 3.7% of IVF ectopic gestations ABOUBAKR ELNASHAR
CAUSE Unknown 1. Rapid transport of the fertilized ovum into the endocervical canal before it is capable of nidation or because of an unreceptive endometrium. 2. Damage to the cervix and endometrial lining during operative uterine procedures The more cephalad that the trophoblast is implanted along the cervical canal, the greater is its capacity to grow and hemorrhage. ABOUBAKR ELNASHAR
RISK FACTOR 1. ART 2. Previous dilation and curettage. 3. Previous CS 4. Asherman syndrome 5. induced abortion 6. Endometritis, uterine fibroids 7. IUCD 8. Age between 35 and 40 y 9. Structural anomalies of the cervix or body of the uterus 10. Grand multiparity, (Thomas et al, 1995; Jeng et al, 2007) ABOUBAKR ELNASHAR
Morbidity and mortality Although non-tubal ectopic pregnancies account for only 5% of ectopic pregnancies, they are responsible for significant morbidity (Condous, 2002) Potentially life-threatening Maternal mortality related to Cervical Pregnancy has dropped from 40–45% to 0–6% in the past 50 ys (Wolcott, 1989) ABOUBAKR ELNASHAR
2. DIAGNOSIS Early diagnosis Important {most cases of severe hge and need for hysterectomy have occurred in pregnancies in the late 1st and early 2nd T}. To avoid complications and successful tt. Correct diagnosis Important avoid interventions which could lead to severe hge necessitating hysterectomy. ABOUBAKR ELNASHAR
Symptoms 1. Painless vaginal bleeding: 90% Massive hemorrhage: 30% (Ushakov, 1997). 2. Lower abdominal pain or cramps 30% 3. Pain without bleeding rare. ABOUBAKR ELNASHAR
Examination 1. Speculum examination Distended, thin-walled cervix Partially dilated external os revealing fetal membranes or pregnancy tissue, which appear blue or purple. Infrequently, a cystic lesion on the cervical lip is observed and represents trophoblastic invasion into the cervical stroma. ABOUBAKR ELNASHAR
Speculum appearance of cervical pregnancy presenting as a mass at the external cervical os ABOUBAKR ELNASHAR
2. Bimanual examination Should be avoided until imaging studies have excluded the diagnosis. If bimanual examination is performed:  endocervical canal should not be explored as this is likely to cause hemorrhage. soft cervix that is disproportionately enlarged compared to the uterus: "an hourglass“ shaped uterus As pregnancy progresses: Above the cervical mass, a slightly enlarged uterine fundus can be felt. By comparison, enlargement of the uterus without significant cervical enlargement is characteristic of intrauterine pregnancy, although the cervix softens and becomes mildly congested. ABOUBAKR ELNASHAR
Investigations 1. Positive pregnancy test 2. Sonographic criteria Accuracy: 87.5% [3]. An embryo or fetus in the intracervical area Gestational sac: below the level of the internal cervical os or uterine arteries. gestational sac or placenta within the cervix ● normal endometrial stripe ● hourglass (figure of eight) shaped uterus ABOUBAKR ELNASHAR
Raskin (1978) 4 criteria: 1. enlargement of the cervix, 2. uterine enlargement 3. diffuse amorphous intrauterine echoes 4. absence of an intrauterine pregnancy. Timor-Tritsch et al (1994) refined the criteria 5. placenta and entire chorionic sac containing the pregnancy be below the internal cervical os 6. cervical canal must be dilated and barrel shaped ABOUBAKR ELNASHAR
Ushakov’s sonographic criteria (1996) 1. GS: in the endocervical canal. 2. Presence of some intact cervical tissue between the GS and the internal orifice. 3. Trophoblast invasion of the endocervical tissue. 4. Embryonal or fetal structures, in particular pulsating heart, in the ectopic GS. 5. Empty uterine cavity. 6. Endometrial decidualization. 7. Sand-glass shaped uterus. 8. Doppler detection of peritrophoblast arterial flow ABOUBAKR ELNASHAR
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3. MRI: unusual or complicated cases when the diagnosis is uncertain Rubin defined histologic criteria for cervical pregnancy, but a histologic diagnosis is not clinically practical since it requires hysterectomy. ABOUBAKR ELNASHAR
Abdominal MRI imaging of a cervical pregnancy. An empty uterine cavity a pregnancy (arrow) is present at the level of the cervix. ABOUBAKR ELNASHAR
3. DIFFERENTIAL DIAGNOSIS 1. Incomplete abortion that is proximal to the cervix. cardiac activity often seen in a cervical pregnancy with a visible embryo, but not in an incomplete abortion Gestational sac cervical pregnancy: regular contours incomplete abortion sac often has irregular contours that may change shape during the scan Cervical os closed in a cervical pregnancy open in an incomplete abortion (Jung, 2001; Sherer, 2008). ABOUBAKR ELNASHAR
Failed pregnancyCx ectopicCSP within the cervical canalanterior LUS1. Location normalthin2. Overlying anterior myometrium positivenegative3. Sliding organ sign* lack color flowvascular flow around and within the GS marked peritrophoblastic color Doppler flow around GS 4. Doppler not fixed in location, not growing ±growing5. Short follow up US *Gentle pressure with the TV probe: displace GS from its position within the endocervical canal ABOUBAKR ELNASHAR
2. Cesarean or hysterotomy scar pregnancy, gestational sac is in the anterior lower uterine segment uterine cavity and endocervical canal are empty ABOUBAKR ELNASHAR
CSP: at 6 w GS in the anterior LUS at the presumed site of the uterine scar empty endometrial (thin arrows) and cervical (long arrows) canals  thinning of the myometrium between GS and bladder (short arrows). ABOUBAKR ELNASHAR
2. Cervical abortion: an aborting intrauterine pregnancy that is trapped in the endocervical canal {resistance from the external cervical os}. some products of conception/blood clot in the uterine cavity the uterine cavity is enlarged compared to the cervix the internal cervical os is open gestational sac is flattened and has no or a minimal echogenic rim and contains no or a dead embryo ABOUBAKR ELNASHAR
Cervical ectopic pregnancy: Sagittal TAS of the midline uterus (A): GS centered in the endocervical canal, normal myometrial thickness between GS and bladder (arrow). Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C).ABOUBAKR ELNASHAR
Cervical ectopic pregnancy GS is seen within the cervical canal  myometrium is not thinned out as seen in LSCS scar pregnancy. ABOUBAKR ELNASHAR
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A) Thickened endometrium with a pseudo-GS (PS) B) GS below caesarian scar (CS) with a viable embryo C) CRL: 6,2mm D) low resistance blood flow around the gestational sacABOUBAKR ELNASHAR
Failed pregnancy TV color Doppler: sagittal midline cervix: avascular GS centered within the endocervical canal ABOUBAKR ELNASHAR
GS with a small embryonic pole with FHR 122bpm located in the cervix below the scar of the previous CS (vertical arrow). Cervix: closed, enlarged, and tender (horizontal arrow). Estimated gestational age based on LMP was 6w and 6d. ABOUBAKR ELNASHAR
Cervical pregnancy (1) an hourglass uterine shape (2) ballooned cervical canal (3) gestational tissue at the level of the cervix (black arrow) (4) absent intrauterine gestational tissue (white arrows) (5) portion of the endocervical canal seen interposed between the gestation and the endometrial canal ABOUBAKR ELNASHAR
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4. TREATMENT Dependent on 1. Gestational age 2. Stability of the patient 3. Patient interest in retaining future fertility 4. Resources 5. Expertise of the practice treating the patient. ABOUBAKR ELNASHAR
TT must address the serious danger of uncontrollable hge Curettage local prostaglandin injection, hysteroscopic resection angiographic UAE uterine artery ligation Cervicotomy intracervical injections of vasoconstrictive agents Shirodkar-type cervical cerclage When there are so many options, it indicates that there is no ideal management regimen. ABOUBAKR ELNASHAR
≤9 w gestational age and without fetal cardiac activity: systemic chemotherapy with MTX alone either single dose regimens: 50 mg/m2) or multiple dose regimens MTX: 1 mg/kg on days 1, 3, 5 and 7 Folinic acid rescue (leucovorin) 0.1 mg/kg on days 2, 4, 6 and 8 { ameliorate MTX side effects}. ABOUBAKR ELNASHAR
If MTX is unsuccessful: UAE minimizes the risk of hge Curettage was then performed to ensure the eradiation of the pregnancy. ABOUBAKR ELNASHAR
For patients who are no longer interested in fertility: hysterectomy is an option if they are diagnosed with an actively bleeding cervical pregnancy ABOUBAKR ELNASHAR
I. Minimally invasive Conservative management is feasible for many women Methotrexate  1st -line therapy in stable women (Verma, 2011; Zakaria, 2011). ABOUBAKR ELNASHAR
1. Direct injection into GS, alone or with systemic doses (Jeng, 2007; Kirk, 2006). Multidose MTX therapy with intraamniotic and/or intrafetal injection of local KCL (intracardiac injection of 5 mEq) when fetal cardiac activity is present (Verma, 2009). If β-hCG levels do not decline more than 15% after 1 w, a 2nd dose of MTX can be given. Song and associates (2009) described management of 50 cases and observed that sonographic resolution lagged far behind serum β-hCG regression. ABOUBAKR ELNASHAR
More advanced gestations where fetal cardiac activity is present: 1. combined treatment with both M multidose MTX and intraamniotic and/or intrafetal injection of KCL: prompt fetal death: facilitate pregnancy resorption, which can take a few months Intrasac injection in the operating room {there is a risk of hge when the sac collapses}. A 2022 gauge needle is advanced transvaginally into the GS and fetal thorax under US using a needle guide attachment. When the tip of the needle is in the embryo, KCL (1 to 5 mL of 20% KCL solution) is injected until there is cessation of cardiac activity. ABOUBAKR ELNASHAR
Heavy vaginal bleeding when the pregnancy is involuting may require 1. intraarterial embolization to control hge. 2. If this is not successful: A. dilation and evacuation is the next step: B. hysterectomy is a last resort. ABOUBAKR ELNASHAR
Results 1. Ablation of the ectopic gestation 2. Preservation of the uterus in 80% 3. Resolution and uterine preservation are achieved for gestations < 12 ws in 91% of cases (Kung, 1997). ABOUBAKR ELNASHAR
2. Foley catheter In the event of hemorrhage 26F Foley catheter with a 30-mL balloon placed intracervically and inflated: hemostasis by vessel tamponade and to monitor uterine drainage. Remains inflated for 24 to 48 h gradually decompressed over a few days (Ushakov, 1997). ABOUBAKR ELNASHAR
3. Uterine artery embolization Indication: 1. As an adjunct to medical or surgical therapy 2. As a response to bleeding or 3. As a preprocedural preventive tool (Hirakawa, 2009; Nakao, 2008; Zakaria, 2011). methotrexate infusion combined with UAE (Xiaolin, 2010). ABOUBAKR ELNASHAR
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II. Systemic 1. Single-dose IM MTX  Dose between 50 and 75 mg/m2 BSA Higher failure (Hung et al, 1996) G age > 9 w, β-hCG levels > 10,000 mIU/mL CRL10 mm Fetal cardiac activity. For this reason, many induce fetal death with intracardiac or intrathoracic injection of KCl ABOUBAKR ELNASHAR
Contraindications of systemic MTX for the tt of any ectopic pregnancy (ACOG, 2009) 1. hCG ≥5000 mIU/ mL 2. Embryonic cardiac activity very commonly found with cervical pregnancies, are relative ABOUBAKR ELNASHAR
No visible cardiac activity: Single dose of MTX no advantage in the use of a multipledose regimen (Kirk et al, 2006)  local MTX or KCl injection with or without interval curettage. If such techniques are not available: multiple-dose systemic MTX is an alternative. ABOUBAKR ELNASHAR
2. IM multidose MTX alone Often adequate for tt of very early cervical pregnancies without fetal cardiac activity [24]. MTX IM rather than IV {IM is more convenient and there are no data indicating that one route is superior to the other}. The multidose MTX drug protocol is the same as that used in patients with tubal ectopic pregnancy ABOUBAKR ELNASHAR
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Evolution of serum β-hCG during multidose MTX Both patients were followed with serial serum β-hCG measurements. Arrows indicate injections of methotrexate (MTX) 50 mg/m2. ABOUBAKR ELNASHAR
Success rate overall: 55-83% With cardiac pulsation: 40% Without cardiac pulsation: 91% {37, 42}. Conservative treatment with methotrexate chemotherapy of patients with either viable, or nonviable cervical pregnancies at <12 weeks’ gestation, carries a 91% success rate for preservation of the uterus. The structure of the cervix was restored and menstruation returned for all patients in whom the uterus was preserved after treatment (Fu-Tsai Kung, 1999). Resolution of the cervical mass on sonography lagged far behind resolution of the serum HCG level. The cervical mass evolved from a gestational sac into a mixed echoic lesion on serial TVS (Song et al, 2009). ABOUBAKR ELNASHAR
On day 2 after systemic methotrexate administration (7 MHz probe). A) Color doppler flow showing remnant trophoblastic perfusion; B) endometrial cavity filled with a central anechogenic area suggestive of blood and a thinner surrounding endometrium ABOUBAKR ELNASHAR
On day 45 (7 MHz probe). Normal cervix. ABOUBAKR ELNASHAR
III. Surgical therapy 1. Dilation and evacuation Suction curettage favored in rare cases of a heterotopic pregnancy composed of a cervical and a desired uterine pregnancy (Moragianni, 2012). A key point: not attempt cervical dilation before initiation of the passage of an appropriately sized suction canula. Dilation can disrupt implantation and immediately lead to heavy vaginal bleeding. Complication high incidence of severe hge ABOUBAKR ELNASHAR
Cervical pregnancy at the time of dilatation and curettage ABOUBAKR ELNASHAR
Before curretage intraoperative bleeding may be lessened by 1. Preoperative UAE 2. Transvaginal ligation of the cervicovaginal branches of the uterine artery done by deviating the cervix to one side and placing a suture at 3 and 9 o'clock on the lateral side of the cervix. The suture is placed high just below the lateral vaginal fornix, similar to sutures placed for hemostasis during cold knife conization. use 20 polyglactin (Vicryl) ABOUBAKR ELNASHAR
3. Vasopressin injection 20 to 30 mL of vasopressin (0.5 U/mL) solution with a 1.5inch 21 gauge needle circumferentially deep into the dense cervical stroma. 4. Shirodkar cerclage placed at the internal cervical os to compress feeding vessels (Davis, 2008; De La Vega, 2007; Trojano, 2009; Wang, 2011). ABOUBAKR ELNASHAR
Infiltration of the cervical stroma with dilute vasopressin around the cervical pregnancy Initiation of suction curettage without cervical dilation Foley catheter balloon tamponade of the cervical implantation site after curettage ABOUBAKR ELNASHAR
Placement of a cerclage-type suture high on the cervical portio ABOUBAKR ELNASHAR
 Following curettage 1. Foley balloon is placed to tamponade bleeding size 26 Foley catheter with a 30 mL balloon into the dilated cervix, with the tip extending into the uterine cavity. Sterile water (as much as 95 mL) is used to inflate the balloon for 24 to 48 h. 2. A purse string suture can be placed around the external cervical os and tied after inflation of the balloon to prevent expulsion. 3. After 24 to 48 h, the balloon is gradually deflated over a period of hours to days and removed, but may be reinflated at any time if bleeding picks up or recurs. The catheter also allows constant uterine drainage.ABOUBAKR ELNASHAR
4. injection of prostaglandin F2α. { increase uterine contractions, promote vasoconstriction, and therefore, reduce hemorrhage. ABOUBAKR ELNASHAR
Additional measures that can be employed in women who continue to bleed: Hemostatic sutures locally in the cervix Angiographic embolization, Bilateral internal iliac artery ligation Bilateral uterine artery ligation. Hysteroscopic resection with a resectoscope has also been reported to be successful in one case ABOUBAKR ELNASHAR
The technique begins with circumferential infiltration of the cervical stroma around the cervical pregnancy with a hemostatic vasoconstricting agent, such as 20 mL of dilute vasopressin (20 units diluted within 50 mL of injectable normal saline) to a depth reachable with a 1 1/2 inch, 21 gauge needle This is followed by the placement of an untied cervical suture high around the cervical portio, using a McDonald cerclage technique . This stitch is left in place ready to tie, if necessary, to temporarily occlude the descending cervical branches of the uterine arteries should bleeding occur during the procedure. Then, without cervical canal dilation (the canal is already open containing the pregnancy) an appropriately sized suction curettage (diameter in millimeters equal to the gestational age in weeks), attached to suction, is rotated and slowly passed through the cervical canal and into the endometrial cavity ABOUBAKR ELNASHAR
Immediately postcurettage a cervical canal balloon, such as a 30 mL balloon foley catheter, is placed against the cervical canal placental bed and inflated to permit a tamponade effect within the cervical canal . The balloon must be inflated within the cervical canal and not within the endometrial cavity. The balloon tamponade is left in place for approximately 24 hours, then slowly deflated, in anticipation of no cervical bleeding. Should such bleeding occur the balloon is reinflated for later removal. Pain control may be needed because of balloon catheter postprocedure cervical canal distention, but in my experience this has been unnecessary. A key point with this suction evacuation is to not attempt cervical dilation before initiation of the passage of an appropriately sized suction canula. The cervical canal is already dilated by the cervical implantation, and further dilation can lead to immediate and profuse cervical bleeding. Sharp curettage is to be avoided. ABOUBAKR ELNASHAR
During the treatment of these 13 women, no procedure lasted more than 15 minutes, and no immediate intraoperative nor delayed postoperative bleeding occurred. The cerclage suture was never tied but remained in place until after the curettage, ready to be tied should immediate intraoperative bleeding occur. The cerclage suture was removed followed the curettage and placement of the balloon tamponade. Despite not encountering intraoperative bleeding, the balloon tamponade was used in all cases with the anticipation that as the effect of the hemostatic cervical infiltration weaned, bleeding from the cervical placental bed would occur. ABOUBAKR ELNASHAR
2. Cervicotomy. ABOUBAKR ELNASHAR
3. Hysterectomy Indication 1. bleeding uncontrolled by conservative methods. 2. women who have completed their families or have additional uterine pathology and do not want to assume the risk of hemorrhage, which can occur in the course of conservative surgery or medical therapy. {close proximity of the ureters to the ballooned cervix} urinary tract injury rates are of concern with hysterectomy. ABOUBAKR ELNASHAR
Cervical pregnancy treated by hysterectomy ABOUBAKR ELNASHAR
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FUTURE 1. Spontaneous pregnancies after conservative management of cervical pregnancy (2). 2. increased incidence of cervical insufficiency in subsequent pregnancies. 3. increased incidence of preterm labor. 4. UAE may affect future fertility decreased fertility and limited ovarian reserve. ABOUBAKR ELNASHAR
COCLUSIONS CEP is the rarest type of ectopic pregnancy There is a high rate of incorrect diagnosis. The most common misdiagnosis is cervical miscarriage. CEP is a challenging to manage and diagnose. Preservation of fertility is dependent on early recognition and tt. Severe hge is the main risk of CEP. Due to the low incidence of CEP, there is a strong argument for referral to specialist tertiary referral units. These units will have more experience in managing such cases and will be able to offer a variety of treatment options. What will be successful tt for one CEP may fail for another. ABOUBAKR ELNASHAR
No RCT to suggest which tt modality is superior.: TT should be individualised Medical rather than surgical tt is recommended (Grade 2C). Multidose, systemic MTX IM. If fetal cardiac activity is present: inject MTx or KCL into the gestational sac/embryo. Nonsurgical tt should be the initial option Successful tt may be achieved by means of a combination of systemic and local MTX and local hemostasis. ABOUBAKR ELNASHAR
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