Cervical pregnancy

1. Cervical pregnancy
Aboubakr Elnashar
Benha university Hospital, EgyptABOUBAKR ELNASHAR

2. CONENTS
1.INTRODUCTION
History
Define
Incidence
Cause
Risk Factors
Morbidity and Mortality
2. DIAGNOSIS
3. Differential diagnosis
4. TREATMENT
CONCLUSION
ABOUBAKR ELNASHAR

3. 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

4. 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.
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5. ABOUBAKR ELNASHAR

6. 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
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7. 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.
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8. 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)
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9. 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)
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10. 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.
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11. Symptoms
1. Painless vaginal bleeding: 90%
Massive hemorrhage: 30%
(Ushakov, 1997).
2. Lower abdominal pain or cramps
30%
3. Pain without bleeding
rare.
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12. 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.
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13. Speculum appearance of
cervical pregnancy
presenting as a mass
at the external cervical os
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14. 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.
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15. 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
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16. 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
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17. 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
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18. ABOUBAKR ELNASHAR

19. 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.
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20. Abdominal MRI imaging of a cervical pregnancy.
An empty uterine cavity
a pregnancy (arrow) is present at the level of the
cervix.
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21. 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

22. 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
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23. 2. Cesarean or hysterotomy scar pregnancy,
gestational sac is in the anterior lower uterine
segment
uterine cavity and endocervical canal are empty
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24. 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

25. 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
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26. 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

27. Cervical ectopic pregnancy
GS is seen within the
cervical canal
 myometrium is not thinned
out as seen in LSCS scar
pregnancy. ABOUBAKR ELNASHAR

28. ABOUBAKR ELNASHAR

29. 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

30. Failed pregnancy TV color Doppler: sagittal midline
cervix: avascular GS centered within the endocervical
canal ABOUBAKR ELNASHAR

31. 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.
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32. 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
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33. ABOUBAKR ELNASHAR

34. 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

35. 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

36. ≤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

37. If MTX is unsuccessful:
UAE minimizes the risk of hge
Curettage was then performed to ensure the
eradiation of the pregnancy.
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38. For patients who are no longer interested in
fertility:
hysterectomy is an option if they are diagnosed
with an actively bleeding cervical pregnancy
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39. I. Minimally invasive
Conservative management is feasible for many
women
Methotrexate
 1st -line therapy in stable women
(Verma, 2011; Zakaria, 2011).
ABOUBAKR ELNASHAR

40. 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

41. 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

42. 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

43. 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

44. 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).
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45. 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

46. ABOUBAKR ELNASHAR

47. 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

48. 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

49. 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

50. 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
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51. ABOUBAKR ELNASHAR

52. ABOUBAKR ELNASHAR

53. 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.
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54. 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).
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55. 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
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56. On day 45 (7 MHz probe). Normal cervix.
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57. 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
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58. Cervical pregnancy at the time of dilatation and
curettage
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59. 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)
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60. 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

61. 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
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62. Placement of a cerclage-type suture high
on the cervical portio
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63.  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

64. 4. injection of prostaglandin F2α.
{ increase uterine contractions, promote
vasoconstriction, and therefore, reduce
hemorrhage.
ABOUBAKR ELNASHAR

65. 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

66. 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
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67. 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

68. 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.
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69. 2. Cervicotomy.
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70. 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.
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71. Cervical pregnancy treated by hysterectomy
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72. ABOUBAKR ELNASHAR

73. 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

74. 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

75. 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.
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76. Thanks
ABOUBAKR ELNASHAR