Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 6  |  Page : 741-743  

Cervical ectopic pregnancy: A case report of missed diagnosis


1 Department of Pathology, R. N. Cooper Hospital, Mumbai, Maharashtra, India
2 Department of Gynecology and Obstetrics, R. N. Cooper Hospital, Mumbai, Maharashtra, India

Date of Web Publication16-Nov-2016

Correspondence Address:
Richa D Patel
Department of Pathology, R. N. Cooper Hospital, Mumbai - 400 056, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.194201

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  Abstract 

Cervical pregnancy is a rare form of ectopic pregnancy with an estimated incidence of 0.1-1% of all ectopic pregnancies. It is defined as a pregnancy that implants in the cervical canal below the internal os and within the cervical mucosa. Treatment varies from conservative management to hysterectomy depending on the clinical presentation and the time of diagnosis. Diagnosis may be missed unless the clinician and the radiologist are aware of this entity. We present a case of cervical pregnancy in a 30-year-old female who was diagnosed outside as missed abortion and was referred for termination of pregnancy. During suction evacuation, she had severe uncontrollable bleeding. Laparotomy revealed the presence of an ectopic cervical pregnancy for which hysterectomy had to be done. We present this case to highlight the importance of correct diagnosis in these cases to avoid such a catastrophe.

Keywords: Cervical pregnancy, ectopic pregnancy, hysterectomy


How to cite this article:
Khatib Y, Khashikar A, Wani R, Patel RD. Cervical ectopic pregnancy: A case report of missed diagnosis. Med J DY Patil Univ 2016;9:741-3

How to cite this URL:
Khatib Y, Khashikar A, Wani R, Patel RD. Cervical ectopic pregnancy: A case report of missed diagnosis. Med J DY Patil Univ [serial online] 2016 [cited 2024 Mar 28];9:741-3. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2016/9/6/741/194201


  Introduction Top


In an ectopic pregnancy, the fertilized ovum is implanted at a site other than the normal uterine cavity. Although the majority of the ectopic pregnancies are tubal, other rare sites described are ovary, cervix, and primary abdominal pregnancy. Cervical pregnancy has an incidence of 1:16,000-1:18,000 of all pregnancies. [1] The exact cause is not known but is attributed to previous cesarean section, abortion, dilatation and curettage, use of the prior intrauterine contraceptive device (IUCD), in vitro fertilization, scars, and Asherman syndrome. [2],[3]

Clinical and histopathological criterions have been described to diagnose this rare entity. We report a rare case of cervical pregnancy in a 30-year-old female who came with a history of 2 prior cesarean sections and had to be treated with an emergency hysterectomy.


  Case Report Top


A 30-year-old female, gravida 5, para 4 with a previous history of 2 cesarean sections and one spontaneous abortion, diagnosed outside as missed abortion was referred for evacuation of the uterus. She complained of 3 months of amenorrhea with altered vaginal bleeding. On examination, her abdomen was soft; cervical os was closed, and no bleeding on per speculum examination, uterus was 8-10 weeks on bimanual examination. Her urine pregnancy test was positive and ß-human chorionic gonadotropins (hCG) was 1373.83 IU/ml.

Her ultrasound reports impression was of missed abortion. Sonologist suggested a correlation with other reports (hCG/histopathology) for final diagnosis [Figure 1] and [Figure 2]. On the basis of the low hCG for this gestation and uterus being smaller than weeks of gestation and ultrasonography report, the clinical diagnosis of missed abortion was made. She was taken up for suction evacuation. During the procedure profuse uncontrollable bleeding started before complete evacuation. At this stage, a differential diagnosis of scar injury, the cervical phase of incomplete abortion, cervical pregnancy, and the very rare occurrence of intra scar pregnancy was considered. Hence, decision for exploratory laparotomy was taken, and blood products were arranged.
Figure 1: Transabdominal sonography showing bulky cervix with gestational sac

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Figure 2: Transvaginal sonography with color Doppler showing gestational sac, fetal parts, and placental tissue with increased vascularity

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Intraoperative findings revealed just bulky uterus, no hemoperitoneum and ballooned cervicoisthmic region, supporting a clinical diagnosis of cervical pregnancy with hemorrhage. With informed consent, obstetric hysterectomy was done conserving the ovaries.

Grossly, the uterus and cervix measured 9 cm × 3.5 cm × 1.5 cm. The fundus and the body were relatively of normal size, but the cervix was greatly dilated with eroded and irregular walls. On cut section, the products were seen infiltrating the entire cervical wall and extending into the ectocervix [Figure 3]. Microscopic examination showed the presence of chorionic villi and the trophoblastic tissue infiltrating into the cervical wall in juxtaposition to the endocervix [Figure 4]. Based on the gross and the microscopic features as per Rubins criterion, the diagnosis of cervical pregnancy was confirmed. [4]
Figure 3: Gross hysterectomy specimen showing cervical pregnancy extending up to ectocervix

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Figure 4: Chorionic villi and trophoblastic tissue in juxtaposition to the endocervical glands (H and E, ×100)

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  Discussion Top


Cervical pregnancy was first described in 1817 and first named as such in 1860. [5] In 1911, Rubin defined the anatomical and histological criteria for the diagnosis of cervical pregnancy. [4]

  1. The cervical glands must be opposite the attachment of the trophoblast/placenta.
  2. Attachment of trophoblast must be below the level of entrance of uterine vessels to the uterus or anterior peritoneal reflection.
  3. Fetal elements (products of conception) must be absent from the corpus uteri.
However, these criteria can be applied only on a hysterectomy specimen as done in our case. Palmaan and McElin had proposed clinical criteria for diagnosing this condition. [6]

  1. Uterine bleeding without cramping pain following a period of amenorrhea.
  2. Hourglass-shaped uterus.
  3. Partly open external os.
  4. Closed internal os.
  5. Products of conception entirely confined within the cervix and firmly attached to the endocervix.
The exact cause of cervical pregnancy is not known. The accelerated migration of the fertilized ovum through the uterus and the change in the ability of the endometrial lining to accept implantation and damage to the endometrial canal may all be the contributing factors. Studies have shown a history of dilatation and curettage, IUCD use, pelvic inflammatory disease, and previous cesarean sections as predisposing factors in cases of cervical pregnancy as was seen in the present case. [2]

The patients with cervical pregnancy present with painless first trimester vaginal bleeding, although some cases have presented with cramping pain and are often misdiagnosed as abortion. On examination, there is soft distended cervix which is disproportionally enlarged compared to the uterus, a partially opened external cervical os. and profuse hemorrhage on manipulation of the cervix. However, these classical signs were not seen in our case. [5]

With high index of suspicion, sonography can suggest this rare diagnosis. On ultrasound if the gestational sac is present in the cervix with trophoblastic invasion of the cervical wall and an intact part of the cervical canal exists between the gestational sac and the uterine endometrium. However, this was missed in the initial report, and retrospective review of the plates did suggest some of these sonologic features. [7]

A mere presence of gestational sac in the cervix could also indicate the cervical stage of abortion, which can be ascertained by demonstration of sliding sign on ultrasound. [7]

Management of the cervical ectopic pregnancy is dependent on several factors such as patients gestational age, fetal cardiac activity, stability of the patient, patient's interest in retaining future fertility, and the availability of resources and expertise of the practicing gynecologist. Several treatment choices are available. Conservative management is ideal for patients with <9 weeks of gestational age and the absence of fetal cardiac activity. It includes systemic methotrexate therapy in single dose or multiple dose regimens. [7]

Advanced gestational age, presence of fetal cardiac activity, failure of conservative management, and active profuse bleeding necessitate surgical interventions which includes curettage with Foley catheter tamponade, local prostaglandin injections, angiographic uterine artery embolization, bilateral uterine or iliac artery ligation, Shirodkar type cervical cerclage, cervicotomy, and hysterectomy for patients who are no longer interested in retaining their fertility. [7],[8] Our patient was ideal for conservative management, but as the diagnosis was missed preoperatively and picked up intraoperatively when the patient started bleeding profusely, the decision of obstetric hysterectomy was taken.

To conclude, it should be understood that the cervical ectopic pregnancies though rare, do occur, and their incidence is increasing. A high index of suspicion, clinicosonological correlation, especially in cases with previous uterine scars can pick up this rare entity preoperatively. If diagnosed early conservative management can be offered; however, missed diagnosis can lead to high morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rock JA, Damario MA. Ectopic pregnancy. In: Rock JA, Jones HW 3 rd , editors. TeLinde's Operative Gynaecology. 9 th ed. USA: Lippincott Williams & Wilkins; 2003. p. 507-36.  Back to cited text no. 1
    
2.
Kaur Pandher D, Shehgal A. Diagnosis and management of cervical ectopic pregnancy - Report of three cases. Nepal Med Coll J 2009;11:64-5.  Back to cited text no. 2
    
3.
Weibel HS, Alserri A, Reinhold C, Tulandi T. Multidose methotrexate treatment of cervical pregnancy. J Obstet Gynaecol Can 2012;34:359-62.  Back to cited text no. 3
    
4.
Rubin IC. Cervical pregnancy. Surg Gynecol Obstet 1911;13: 625-33.  Back to cited text no. 4
    
5.
Leeman LM, Wendland CL. Cervical ectopic pregnancy. Diagnosis with endovaginal ultrasound examination and successful treatment with methotrexate. Arch Fam Med 2000;9:72-7.  Back to cited text no. 5
    
6.
Paalman RJ, McElin TW. Cervical pregnancy; review of the literature and presentation of cases. Am J Obstet Gynecol 1959;77:1261-70.  Back to cited text no. 6
    
7.
Rizk B, Holliday CP, Owens S, Abuzeid M. Cervical and cesarean scar ectopic pregnancies: Diagnosis and management. Middle East Fertil Soc J 2013;18:67-73.  Back to cited text no. 7
    
8.
Yitzhak M, Orvieto R, Nitke S, Neuman-Levin M, Ben-Rafael Z, Schoenfeld A. Cervical pregnancy - A conservative stepwise approach. Hum Reprod 1999;14:847-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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