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Diagnosis and Management of Cervical Ectopic Pregnancy

Author: Paula Amato, MD

Editor: Katherine Rivlin, MD

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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.

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


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