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CERVICAL ECTOPIC: CASE REPORT
Ling Yien Hii, Carol Lim, Soon Ruey
SABAH WOMEN’S AND CHILDREN’S HOSPITAL, KOTA KINABALU, SABAH
PRESENTED AT 10TH RCOG INTERNATIONAL SCIENTIFIC MEETING 6 – 8 JUNE 2012, BORNEO CONVENTION CENTRE KUCHING, KUCHING, SARAWAK, MALAYSIA
ABSTRACT
INTRODUCTION
MANAGEMENT
BACKGROUND
Cervical ectopic is a very rare form of extrauterine pregnancy which carries high morbidity
and mortality if misdiagnosed or undiagnosed. There is no definite recommended
treatment for the management of this entity. Recognition of risk factors and immediate
approach during emergency bleeding cervical ectopic are important in improving the
outcome of the problem.
Ectopic pregnancy (EP) has increased from previously 0.5% for the past 3 decades to 2% of
overall pregnancies lately, especially with higher rate of operative pelvic surgery and use of
assisted reproductive therapy. It remains as one of the most important causes for maternal
morbidity and mortality in early pregnancy. Cervical ectopic pregnancy (CEP) implants within
the cervical mucosal that lines the endocervical canal, constitutes 1 to 2% of total extrauterine
pregnancy. Few hypothesis about the occurrence of cervical ectopic postulated, possibly due to
too rapid transport of the blastocyts through immature endometrium for implantation or late
fertilization of the ovum takes place in the endocervical canal. 9 Because of the rare incidence,
majority of these cases associated with substandard care secondary to misdiagnosis or under
diagnosis, result in life threatening haemorrhage after the “usual” procedure.
treatment of CEPs, commonly there are high and low dose preparation. The route of
administration can be systemic via intramuscular, local injection into ectopic sac or a
combination of both. Sometimes, a local MTX injection can be carried out either by intraamniotic or intra-cervical administration. If embroyonic cardiac activity is detected, feticide can
be performed by intracardiac injection of potassium chloride, intra amniotic instillation MTX or
direct traumatic punctures under transvaginal ultrasound guidance by experienced personnel.
CASE
A 24 year-old multiparity who had two previous caesarean scars with irregular menses
was found pregnant during clinic checkup. She presented with prolonged per vaginal
bleeding prior to the appointment. Ultrasound examination revealed incomplete
miscarriage, she was therefore subjected to evacuation of conceptus. However it was
complicated by profused bleeding and required exploratory laparotomy, leading to
diagnosis of cervical ectopic. Patient was transferred to a tertiary hospital by emergency
retrieval team for further management. Suction and curettage was performed to
evacuate as much as possible the products of conception It was then followed by
insertion of Bakri balloon under ultrasound guidance. Postoperatively patient was given a
course of methotrexate for the remaining product of conceptus and no further vaginal
bleeding was observed. Bakri balloon was removed after 24 hours with antibiotic
coverage and patient recovered well.
CONCLUSION
Case of cervical ectopic can be managed conservatively as incomplete evacuation of
product of conceptus lead to massive haemorrhage. As in this patient, ultrasound
guidance of suction and curettage together with Bakri balloon insertion help in controlling
bleeding, while methotrexate is given to treat the remained tissue. Such management
helps to reduce the need for hysterectomy which carries more complication and morbidity
postoperatively.
Transvaginal cervical ectopic sac
with yolk sac
Transvaginal cervical ectopic
Cervix is a high vascularised area not only predisposed to implantation of fertilized ovum but
also vulnerable to torrential bleed after disruption of mucosal lining. Microscopically, only 20% of
cervix consists of smooth muscle, so the majority non contractile fibrous tissue has suboptimal
mechanical haemostatic manipulation and is insusceptible responding to uterotonic agent.
DIAGNOSIS
Historically, CEP diagnosed by retrospective histopathological confirmation after a curettage that
complicated by life threatening haemorrhage requiring hysterectomy to save life.1 Recognition
of risk factors, detailed clinical examination and use of transvaginal ultrasound imaging assist in
early detection of extrauterine pregnancy. Damage of the endometrial lining by previous
procedure is the main risk factor for EP, such as previous history of uterine curettage is found in
70% or more CEP1, insertion of intrauterine device (IUD) and in vitro fertilization. Other risk
factors include previous caesarean section or pelvic surgery, cervical endometriosis,
endomyometritis, Asherman’s syndrome, fibroids, uterine adhesion, history of exposure to
diethylstilbestrol, previous infective cervicitis such as gonorrhea or Chlamydia associated with
CEPs. 9 Increasing trend of invasive method in ART nowadays contributes to even higher
prevalence of CEP.
In fact, it is not surprised that CEP is often mistaken as incomplete miscarriage, cervical
abortion, prolapsed fibroid, or cervical cancer.8 Clinical presentation of CEP is similar to
intrauterine miscarriage: per vaginal bleed associated with abdominal pain. In certain case,
urinary symptoms secondary to mechanical irritation or compression of the urethra, maybe
found in CEP other than other site of EPs. Vaginal examination might reveal enlarged, bulging
and extended cervix till external cervical os. Transvaginal ultrasound is main diagnostic tool in
identifying more than 80% of CEPs.2 There are some sonographic features that helps to
distinguish CEP from other miscarriage in progress: empty uterus with “hour-glassed”
appearance, detected gestational sac below the uterine arteries with increased Doppler blood
flow around the gestational sac and opened external os but internal os is closed. There is
absence of “sliding sign” in CEP upon pressure applied by ultrasound probe. This helps to
differentiate from intrauterine pregnancy which is in the process of aborting through the cervix.
MANAGEMENT
In 1980’s, hysterectomy is commonly performed to save patient’s life when extensive bleeding
occur during dilatation and curettage for a presumed incomplete miscarriage in the actual case
of CEPs.1 Nowadays, collaboration of different entity of management help to preserve patient’s
fertility, especially for low parity young patients.
Left: Transabdominal view of uterus after suction curretage for cervical ectopic
Right: Post inflation of Bakri balloon at endocervical region with 60cc of normal saline at ectopic
site, uterine fundus is empty
Bakri Tamponade
Balloon Catheter
TEMPLATE DESIGN © 2008
www.PosterPresentations.com
Cervical Ripening
Balloon
Management of CEPs comprises of three major principles: systemic or local application of
methotrexate, mechanical termination of ectopic sac by curettage and haemostasis via
pharmacological, mechanical or operative procedure. Haemostasis is the most vital component
to determine whether the patient requires hysterectomy.
Expectant management is only applicable for patients who are haemodynamically stable and
asymptomatic during the first presentation, with the initial serum beta hCG less than 1000
mIU/ml. About 88% of patients have successful outcome. This is provided no sonographic
visualization of an ectopic gestation sac and the serial control serum beta hCG shows reducing
trend. Spontaneous abortion of cervical ectopic pregnancy is also possible but rare.
Methotrexate (MTX) is a folic acid antagonist, which inhibits DNA synthesis in rapidly growing
trophoblastic cells in cervical ectopic. No standardized protocol available for MTX regimen in
Exclusive operative method in the past tends to have higher failure rate, about 22% of the cases
ended up hysterectomy. Recent review of case series suggests that combination of medical and
uterine conservative procedures promote better outcome, with less drastic intervention, but
significant improvement in maternal consequences as compared to exclusive operative method.9
More importantly, fertility is preserved in such cases.
Mechanical evacuation of CEP is preferably performed by suction curettage than conventional
dilatation and curettage which is less bleeding and under better control, in term of avoiding
excessive curettage of uterine wall tissue. Sonographic guidance during the procedure helps to
ensure adequate removal of trophoblastic tissues at focused point. Haemostasis should be
applied towards the end of curettage to prevent further bleeding in view of structural potency for
cervical tissue to have extensive haemorrhage. It can be achieved by various means: Local
injection of vasopressin or carboprost, cervical cerclage, cervical stay sutures, mechanical
compression by uterine cavity tamponade balloon, uterine artery ligation, or embolization of the
descending branches of the uterine arteries. 3
Intracervical filtration of vasopressin or carboprost, cervical cerclage and cervical stay sutures
theoretically should be planned before the surgical removal of ectopic tissue, after confirmed
diagnosis of cervical ectopic.3 Risk of infections, necrosis of bladder or rectum caused by
erosion from the suture, uterine infarction and sciatic nerve injury can be occurred. However, a
trained person is needed to perform the procedure and it could be difficult if uncontrolled
bleeding obscures the anatomical view.
Uterine tamponade carries its intermediate role in controlling uterine haemorrhage between less
invasive method such as conventional uterine massage and uterotonic drugs and more invasive
methods such as uterine compression suture, uterine artery ligation and arterial embolisation,
before decision of hysterectomy. It seldom acts as monotherapy in the management of post
abortal haemorrhage but has significantly reduced maternal morbidity or mortality when
combined with other modalities of treatment. It is widely recognized as one of the life saving
measurement in acute uterine bleeding.
Concept of uterine tamponade has been introduced since 1980s which was started off with
uterine packing in controlling intractable uterine bleeding in postpartum and post abortal uterus.
6, 7 Practically, the mechanism of action is to exert external compression against intrauterine
wall to obliterate injured uterine vessel, promote platelet aggregation which release effective
vasoconstrictors then allow coagulation to act on time. Meanwhile, regular contraction of
smooth muscle maintains uterus in contracted state. Yet, introduction of vaginal pack blindly
into uterus can cause intrauterine infection or uterine perforation in vulnerable uterus.
Multiple revision and innovation have been ongoing for years, use of various type of hydrostatic
balloon catheter has replaced uterine packing nowadays. Condom catheter, Foley’s catheter,
Rusch catheter, Bakri balloon, BT balloon and Sengstaken – Blakemore oesophageal tube have
been used in several case series that eventually achieve satisfactory haemostasis.5 Use of
cervical ripening balloon will be another alternative especially in achieving localized haemostasis
in endocervical region. Hydrostatic balloons are preferred as the contour of the balloon adapts
the unique configuration of the semi rigid uterine cavity to tamponade uterine bleeding.
Use of uterine tamponade device requires minimal training which can be also performed by
trained medical staffs, particularly for those originate from low resources setting or without
surgical facilities. It has important role in preventing further volume loss during transporting
patient to tertiary health centre or while waiting for optimization of patient haemodynamic status
before proceed to further invasive procedures. Sometimes, it is known as a ‘test’ in given period
of interval to decide whether subsequent intervention is necessary. Concurrent uterotonic agent
and tamponade balloon are recommended to serve dual mechanism, which is sustaining the
uterus at contracted state and blockage of exposed raw vessels area. There is no clear
recommendation about the duration of balloon tamponade should be left in situ, usually is
according to instruction by manufacturer, ranged from minimum 4 hours till maximum have to
remove after 24 hours.5 A course of antibiotic would be considered as prophylaxis for uterine
infection. Ideally, removal of hydrostatic balloon should be done during daytime with presence of
senior staffs and availability of operative theatre, which further intervention might be necessary.
In some advanced health centre, embolization of uterine arteries service is available. However, well
trained profession is required in the procedure. In general, recent case reviews demonstrate that
CEPs can be managed efficiently by above minimally invasive procedure, provided the diagnosis is
made earlier. 4
CONCLUSION
As in this case, patient’s past surgical history provided vital piece of information, there is high
suspicious index of possible cervical pathology after two previous caesarean sections. Her irregular
menstrual pattern was unable to provide further information about gestational age. Presumed
“incomplete miscarriage” earlier on subjected patient for usual evacuation of retained product of
conceptus (POC). Diagnosis was established during laparotomy with direct visualisation of
abnormal anterior cervix. Process of resuscitation and stabilization might be difficult if patient
developed circulatory collapse without anticipation of extensive haemorrhage before procedure.
Haemostasis by vaginal pack did provide short tamponade effect during patient transfer. Use of
uterotonic agent may be considered in this case as well. Before retrieval of patient to the tertiary
hospital, pre-transfer resuscitation and stabilisazation are mandatory with large bore intravenous
assess and adequate blood product to standby before proceeding for major operation. In view of
disruption of ectopic sac by previous curettage and high vascularised cervical canal post cervical
implantation, gentle suction and curettage was performed under ultrasound guidance to evacuate as
much conceptus as possible by focusing on the exact implantation site. Ideally, Doppler ultrasound
will be helpful in that situation.
Previous uterine surgery again increases the possibility of adherent product of conceptus which
makes full evacuation hazardous. In this case, minimal POC is felt adherent after suction curettage
at anterior endocervix. The tamponade method in this case is achieved by insertion of Bakri balloon
under ultrasound guidance. The design of Bakri balloon carries few advantages as it follows the
contour of the uterine cavity and silicone material causes less allergic reaction as compare to
traditional latex material. Cervical ripening balloon is another better choice as it anchores around
cervical region.
Single dose of intramuscular MTX was given for the patient after procedure to regress the remaining
trophoblastic tissue. She recovered well after the procedure, Bakri balloon was removed with
caution after 24 hours in situ without recurrent bleeding reported. Patient was under close follow up
for her serum beta hCG monitoring after discharge from hospital, with initial post operative reading
650 mIU/ml decrease to 1.3 mIU/ml after 2 weeks.
There is no standardized protocol in management of cervical ectopic pregnancy. In general,
successful treatment of CEP can be achieved by means of surgical curettage followed by adequate
local haemostasis and use of systemic methotrexate.7, 9 Successful haemostasis is the main
modality to avoid hysterectomy. Balloon tamponade is the common practice among other mode of
local haemostasis. Exclusive conservative treatment with methotrexate is reserved for cases
fulfilled the defined preconditions. There is still inadequate review about weigh between giving MTX
before the curettage procedure or after the procedure. Nevertheless, identification of risk factors
and early diagnosis of cervical ectopic pregnancy by mode of transvaginal ultrasound with or without
Doppler study is important to plan for subsequent intervention.
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