Back to Search Results

1/1/2014

Diagnosis and Management of Cervical Ectopic Pregnancy

Author: Paula Amato, MD

Editor: Katherine Rivlin, MD

Registered users can also download a PDF or listen to a podcast of this Pearl.
Log in now, or create a free account to access bonus Pearls features.

Download Listen

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. Clinical signs may include a soft, disproportionately large or barrel-shaped cervix. The differential diagnosis are 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 completely 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 gentle pressure is applied to the cervix with the vaginal transducer). The presence of cardiac activity or peritrophoblastic blood flow to the cervix helps to differentiate this condition from incomplete abortion. Once cervical pregnancy is thought likely, 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, and often a combination of therapies is required. If the patient is hemodynamically stable, providers may consider medical management with systemic single dose or multi-dose methotrexate (MTX). .However, MTX alone has been associated with lower success rates compared to dilation and curettage (D&C), D&C plus uterine artery embolization (UAE), and UAE alone. The risk of MTX failure must be weighed against the risk of hemorrhage with surgical management of cervical pregnancies. MTX may be administered for cervical pregnancy in the presence of factors which may be relatively contraindicated in tubal ectopic pregnancy, such as cardiac activity, advanced gestational age, a gestational sac >4 cm, and βhCG level >5,000 mIU/ml. Systemic MTX plus a double balloon catheter, serving as a tamponade, has also yielded good results.  

If fetal cardiac activity is present, intra-amniotic injection of potassium chloride has been associated with successful avoidance of hysterectomy in 80% of cases. D&C alone carries a significant risk of severe hemorrhage, though D&C should be considered following adjunctive measures such as MTX injection or uterine artery embolization. UAE may be useful preoperatively to help prevent surgical hemorrhage or in the management of acute heavy bleeding.

In patients who are hemodynamically unstable or fail medical management, surgical therapy is indicated in the form of  dilation and curettage. In addition to UAE, options that may reduce the risk of hemorrhage include 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 patients who have completed childbearing.

Further reading:

 

Original approval January 2014; Revised May 2017, Reaffirmed November 2018, Revised July 2020; Minor Revision January 2022; Revised September 2023

 

********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2023 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved.  No re-print, duplication or posting allowed without prior written consent.

 

Back to Search Results