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• W2000063871 abstract "Of all forms of ectopic gestation, the possibility of fertility catastrophe is highest with a cervical pregnancy. Though rare, it is a potentially life-threatening condition. In the past it was diagnosed late, after there was profuse hemorrhage from the cervix and it usually required hysterectomy. With ultrasound, diagnosis can be made earlier and conservative management attempted in order to preserve the reproductive potential. Methotrexate has been used both systemically and intra-amniotically to treat cervical ectopic gestation conservatively (1). Case 1: A 32 years old multiparous lady presented at 8 weeks amenorrhea with profuse and painless vaginal bleeding for 1 day. There was no history of passage of products of conception. Urine for hCG was positive. Per-speculum examination revealed a hypertrophied congested posterior cervical lip with flattened external os. Per-vaginam examination showed a normal sized uterus with a ballooned cervix. Transvaginal ultrasound showed the presence of a gestational sac 30 mm×28 mm in the cervical canal containing a fetal node with cardiac activity. Uterine cavity was empty (1, 2). Trans-abdominal ultrasound showing empty uterine cavity with a dilated cervical canal containing the gestational sac. Transvaginal scan showing the fetal node within the gestational sac. Patient was not bleeding actively and was given 50 mg methotrexate intramuscularly. On Day 3, sonography showed a viable pregnancy. The same day, the gestational sac was aspirated and 50 mg methotrexate instilled intra-amniotically under sonographic guidance (Fig. 3). Repeat sonography on Day 5 showed a shrunken gestational sac (20 mm×24 mm) with absent cardiac activity (Fig. 4) which persisted for the next few days. Evacuation of products of conception from the cervical canal was done on Day 11. Hemostatic sutures were applied in the bed of the gestational sac. A Foley's catheter was placed in the cervical canal and balloon inflated to compress the bed of the evacuated gestational sac and achieve hemostasis. Foley's catheter was removed after 2 days. There was no bleeding. On follow up she had normal menstrual cycles. Trans-abdominal scan showing the needle within the gestational sac for instilling methotrexate intra-amniotically. Appearance of fibrosis in the gestational sac two days after instillation of methotrexate. The cardiac activity had also disappeared. Case 2: A 26 years old, second gravida lady presented with mild vaginal bleeding for 1 week preceded by 6 weeks amenorrhea. Urine for hCG was positive. Per-speculum examination revealed minimal bleeding per vaginam. The cervix was ballooned and congested. Bimanual examination revealed the external os to be open with a 5×5 cm soft mass palpable within the cervical canal and normal sized uterus. Sonography showed a gestational sac of 25 mm diameter in the cervical canal with trophoblastic invasion of endocervical tissue and an empty uterus. Fetal node was present with no cardiac activity. She was given 50 mg methotrexate intramuscularly. On day 6, she expelled the products of conception spontaneously with minimal bleeding per vaginam. Day 10 sonography showed a normal sized uterus with empty cervical canal. She had subsequent regular menstrual cycles. Case 3: A 32 years old multiparous lady presented with 6 weeks amenorrhea followed by excessive painless vaginal bleeding for 23 days. There was no history of expulsion of products of conception. Urine for hCG was positive. The patient was pale, had tachycardia and hypotension. Per-speculum examination revealed a ballooned cervix which was bleeding profusely. A fleshy red mass of 2×1 cm size was protruding through the external os. On bimanual examination, the uterus was of 8 weeks size. Under anesthesia, products of conception were removed from the cervical canal. Oxytocics was given but she continued to bleed profusely from the cervix. A diagnosis of cervical pregnancy was entertained and hysterectomy was performed to control the hemorrhage. She received 12 units of blood transfusion. Post-operative period was uneventful. Histopathological examination confirmed cervical pregnancy. Cervical pregnancy occurs when the fertilized ovum implants in the cervical canal. Usually the initial clinical diagnosis is of incomplete or inevitable abortion. However, profuse and painless vaginal bleeding during early pregnancy, which was seen in two of these cases, should alert the clinician about the possibility of a cervical pregnancy; whereas an intrauterine pregnancy in the process of abortion is almost always accompanied by pain. Early and accurate diagnosis is possible with the help of ultrasonography. The sonographic diagnosis of cervical pregnancy was first reported in 1978 (2). Subsequently, various criteria for sonographic diagnosis of cervical pregnancy have been proposed and include intracervical localization of gestational sac, closed internal cervical os and trophoblastic invasion to the endocervical tissue. Additional signs are empty uterine cavity and demonstration of fetal structures and cardiac activity within the gestational sac located in the cervical canal (1). Treatment of cervical pregnancy depends upon the timing of diagnosis of cervical pregnancy and desire to preserve future fertility. Various conservative surgical and medical management options have been reported (1). Medical management includes systemic methotrexate, local methotrexate and local KCl injections (3, 4). A combination of systemic and intra amniotic methotrexate has been advocated in the presence of cardiac activity (4). Medical management has been associated with a significantly lower hysterectomy rate (2%) as compared to hysterectomy rate of 15% in the conservative surgical group (5). Also, the risk of major hemorrhage was less in the medical group. The first patient had a viable pregnancy and required both systemic and intra-amniotic methotrexate whereas in the second case systemic methotrexate alone sufficed. Both patients had a favorable outcome. The third patient was hemodynamically unstable and hysterectomy had to be performed to control hemorrhage. Conservative management is a reasonable option but it should be attempted only after hospitalization and with careful supervision, as unsuccessful treatment or profuse hemorrhage may necessitate a hysterectomy anytime. Angiographic embolization as an option to control hemorrhage in medically treated patients of cervical pregnancy has also been described (4)." @default.
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• W2000063871 date "2001-07-01" @default.
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• W2000063871 title "Cervical pregnancy and therapeutic options" @default.
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• W2000063871 doi "https://doi.org/10.1034/j.1600-0412.2001.800715.x" @default.
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