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Diagnosis and Management of Cervical Ectopic Pregnancy

1/1/2014 - Paula Amato, MD

 

Editor:  Martin E. Olsen, MD

Cervical ectopic pregnancy is the rare implantation of a pregnancy in the endocervical canal and accounts for less than 1% of all ectopic pregnancies. Patients usually present with vaginal bleeding, which can be profuse and is often painless. Other clinical signs may include a soft, disproportionately large cervix and an hourglass-shaped uterus. If a physical exam is performed, the cervix may be bigger than the uterine fundus. The differential diagnosis also includes incomplete abortion and pregnancy implanted in a cesarean or hysterotomy scar.

Transvaginal ultrasound is an important component of the diagnosis. Sonographic criteria include an empty uterus, an enlarged barrel-shaped cervix, a gestational sac within the cervical canal with or without cardiac activity, peritrophoblastic Doppler blood flow to the cervix, and an absent “sliding sign” (the intracervical sac fails to slide along the cervical canal when the vaginal transducer is used to apply gentle pressure to the cervix). The presence of cardiac activity or peritrophoblastic blood flow to the cervix is strongly suggestive of a cervical ectopic pregnancy. Once cervical pregnancy is a leading diagnosis, subsequent bimanual examination should be avoided.

Early diagnosis and treatment is critical to avoid serious complications such as severe hemorrhage and the need for hysterectomy. The most appropriate treatment depends on the clinical presentation. If the patient is hemodynamically stable, medical management with systemic single dose or multi-dose methotrexate (MTX) is the therapy of choice. Although cardiac activity is a relative contraindication to MTX treatment, in cases of cervical ectopic, the risk of MTX failure must be weighed against the significant risk of hemorrhage with surgical management. Advanced gestational age, a gestational sac >4 cm, βhCG level >5,000 mIU/ml, and fetal cardiac activity are associated with a higher failure rate of MTX.

If fetal cardiac activity is present, intra-amniotic injection of potassium chloride injection has been associated with successful avoidance of hysterectomy in 80% of cases. Dilation and curettage is a surgical option, but carries a significant risk of severe hemorrhage. Preoperative uterine artery embolization (UAE) may be useful to help control hemorrhage or in the management of bleeding complications.

In patients who are hemodynamically unstable or fail medical management, surgical therapy is indicated and requires dilation and curettage. In addition to UAE, the risk of hemorrhage may also be reduced by transvaginal ligation of the cervical branches of the uterine arteries, cervical cerclage, or intracervical vasopressin injection. Postoperative bleeding can often be controlled with tamponade using a Foley catheter, hemostatic sutures in the implantation site, UAE, bilateral uterine or internal iliac artery ligation, or hysterectomy. Data on future pregnancy outcomes after cervical ectopic pregnancy are limited. Hysterectomy may be considered as an initial option in women who have completed their childbearing.

Further reading:

  1. Hosni MM, Herath PP, Mumtaz. Diagnostic and therapeutic dilemmas of cervical ectopic pregnancy. Obstet Gynecol Surv. 2014;69:261-76.
  2. Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100:638-44.
  3. Zakaria MA, Abdallah ME, Shavell VI, Berman JM, Diamond MP, Kmak DC. Conservative management of cervical ectopic pregnancy: utility of uterine artery embolization. Fertil Steril 2011;95:872-6.

Original approval January 2014; Revised November 2015; Revised May 2017.

 

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