- Email: [email protected]
A case of cervical pregnancy
July 1994 Am J Obstet Gynecol
Centini G., Rosignoli, and Severi
The occurrence of compression neuropathy involving the right peroneal nerve in this patient is of some interest. We hypothesize that, because she was righthanded, she may have exerted greater forces across the right knee, resulting in compression of the right peroneal nerve. Because electrodiagnostic testing was not performed on the left peroneal nerve, we are uncertain whether knee hyperflexion resulted in any subclinical compression on the left. The electrodiagnostic finding of a neurapraxic conduction block of the common peroneal nerve across the right knee > 7 days after injury indicated a good prognosis for recovery after myelin repair at the site of compression.
Our patient was recently delivered again, and this time was encouraged to use the method described (Fig. 2) to avoid peroneal nerve compression. There was no iryury to the common peroneal nerve during this delivery. REFERENCES 1. Koller RL, Blank NK. Strawberry pickers' palsy. Arch Neurol 1980;37:320. 2. Reif ME. Bilateral common peroneal nerve palsy secondary to prolonged squatting in natural childbirth. Birth 1988; 15:100-2.
A case of cervical pregnancy Giovanni Centini G., MD, Lucia Rosignoli, MD, and Filiberto M. Severi, MD Siena, Italy A cervical pregnancy diagnosed by transvaginal ultrasonography and successfully treated by aspiration and curettage is discussed: (AM J DBSTET GVNECOL 1994;171 :272-3.)
Key words: Cervical pregnancy, ectopic pregnancy, transvaginal ultrasonography Cervical pregnancy was first described by Rubin' in 1911 in a treatise on obstetric surgery. Rubin's criteria have been modified over the years, and cervical pregnancy is now also diagnosed on the basis of clinical signs. In the 1950s the need arose to distinguish cervical pregnancy from intrauterine miscarriage before surgery was undertaken. Until the introduction of ultrasonographic techniques, cervical pregnancy was generally diagnosed by postsurgical examination after initial misdiagnosis or late diagnosis; 90% of cases resulted in hysterectomy. In the others the products of conception were removed, and hemorrhaging was controlled by plugging the cervical canal, amputating the cervix, and ligating the cervical branches of the uterine arteries. At the end of the 1960s Kobayashi et al! outlined criteria for the diagnosis of cervical pregnancy by ultrasound. About 10 years later Raskin' reported the first case of cervical pregnancy diagnosed by ultrasonograFrom the Department of Obstetrics and Gynecology, University of Siena. Received for publication January 20, 1994; accepted January 31, 1994.
Reprint requests: Giovanni Centini, MD, Obstetrics and Gynecology Clinic, University of Siena, Via Mascagni 46, 53100 Siena, Italy Copyright © 1994 by Mosby-Year Book, Inc. 0002-9378/94 $3.00 + 0 6/1/54825
272
phy. The mortality related to cervical pregnancy has now dropped to almost zero from about 40% at the beginning of the century. Technical improvements in ultrasonography equipment, transvaginal examination, and ~-human chorionic gonadotropin (hCG) assay have led to much earlier and more reliable diagnosis of ectopic, including cervical, pregnancy. Early diagnosis is determinant for a favorable outcome. The many etiopathologic causes are outlined by Russel4 and include previous surgery of the lower uterus such as cesarean section and inflammatory conditions of the cervix and uterus. The frequency of cervical pregnancy is estimated at one in lOOO to 8000 pregnancies. 5 Case report The patient, a 36-year-old secundigravid woman, had undergone cesarean section at the twenty-sixth week of her previous pregnancy, less than a year earlier, because of gestational hypertension and preeclampsia. She came to our attention 5 weeks after her last menstrual bleeding with diffuse pains in the lower pelvis and spotting. There were no clinical signs of ectopic pregnancy, because pain to palpation was' normal. Ultrasonographic examination failed to reveal ectopic pregnancy, but ~-hCG was positive for pregnancy ..Ultrasono graphic markers of ectopic pregnancy were investigated with negative results.
Centini G., Rosignoli, and Severi
Volume 171, Number 1 Am J Obstet Gynecol
The following week the pain subsided and the patient was well. l3-hCG assays at 5 weeks 2 days and at 6 weeks were inconclusive, but the third sample was positive (1100 mIU/ml, radioimmunoassay). Ultrasonographic examination at 6 weeks 2 days clarified the situation by revealing a corpus luteum on the left, endometrial shedding, and a lozenge-shaped anechogenic area (like an exclamation mark) filling the cervical canal up to its opening into the uterus. A formation identified as the vitelline sac with an adjacent embryonic structure only it few millimeters in size and with scarcely perceptible cardiac activity was observed (Fig. I). This image was obtained transvaginally. The transabdominal picture did not give a clear image because the full bladder compressed the gestational chamber. At 6 weeks 4 days the products of conception were needle-aspirated, and careful curettage of the uterus and cervical canal was performed with the patient under total anesthesia. Transvaginal examination was performed immediately before and after the operation, with the patient still anesthesized, to check that the cervical canal had been completely cleared. Methotrexate therapy was not administered before or after the operation. Histologic examination of the tissue removed confirmed cervical pregnancy with endometrial shedding. There was slight but normal bleeding after the operation. Transvaginal ultrasonographic examination on the first day confirmed the return of the uterus to normal. The patient was discharged feeling well on the second day. Levels ofl3-hCG 10 days after the operation were negative. After 40 days normal menstrual bleeding recurred. Hysteroscopic examination after 3 months failed to reveal any structural anomalies of the cervical canal or uterus.
Comment The successful treatment of this case of cervical pregnancy is principally related to early diagnosis by transvaginal echotomography. Cervical implantation seemed
273
Fig. I. Transvaginal ultrasonographic image of cervical pregnancy.
to be related to prior surgical trauma, because the patient had undergone emergency cesarean section less than a year earlier. The hCG profile did not suggest ectopic pregnancy but normal pregnancy complicated by threatening miscarriage. The therapeutic approach used seems adequate if the condition is diagnosed before the ninth or tenth week. We emphasize the importance of transvaginal ultrasonographic examination .in the first week of pregnancy when there is bleeding. REFERENCES I. Rubin IC. Cervical pregnancy. Surg Cynecol Obstet 1911; 16:625. 2. Kobayashi M, Hillman LM, Fillist LP. Ultrasound, an aid in the diagnosis of ectopic pregnancy. AM J OBSTET CYNECOL 1969; 103: 11 3 J. 3. Raskin M . Diagnosis of cervical pregnancy by ultrasound: a case report. AM J OBSTET CYNECOL 1978;130:234 . 4. Russel JB. The etiology of ectopic pregnancy. Clin Obstet CynecoI1987;30:181. 5. Bayless RB. Nontubal ectopic pregnancy. Clin Obstet Cynecol 1987 ;30: 19 J.
Centini G., Rosignoli, and Severi
The occurrence of compression neuropathy involving the right peroneal nerve in this patient is of some interest. We hypothesize that, because she was righthanded, she may have exerted greater forces across the right knee, resulting in compression of the right peroneal nerve. Because electrodiagnostic testing was not performed on the left peroneal nerve, we are uncertain whether knee hyperflexion resulted in any subclinical compression on the left. The electrodiagnostic finding of a neurapraxic conduction block of the common peroneal nerve across the right knee > 7 days after injury indicated a good prognosis for recovery after myelin repair at the site of compression.
Our patient was recently delivered again, and this time was encouraged to use the method described (Fig. 2) to avoid peroneal nerve compression. There was no iryury to the common peroneal nerve during this delivery. REFERENCES 1. Koller RL, Blank NK. Strawberry pickers' palsy. Arch Neurol 1980;37:320. 2. Reif ME. Bilateral common peroneal nerve palsy secondary to prolonged squatting in natural childbirth. Birth 1988; 15:100-2.
A case of cervical pregnancy Giovanni Centini G., MD, Lucia Rosignoli, MD, and Filiberto M. Severi, MD Siena, Italy A cervical pregnancy diagnosed by transvaginal ultrasonography and successfully treated by aspiration and curettage is discussed: (AM J DBSTET GVNECOL 1994;171 :272-3.)
Key words: Cervical pregnancy, ectopic pregnancy, transvaginal ultrasonography Cervical pregnancy was first described by Rubin' in 1911 in a treatise on obstetric surgery. Rubin's criteria have been modified over the years, and cervical pregnancy is now also diagnosed on the basis of clinical signs. In the 1950s the need arose to distinguish cervical pregnancy from intrauterine miscarriage before surgery was undertaken. Until the introduction of ultrasonographic techniques, cervical pregnancy was generally diagnosed by postsurgical examination after initial misdiagnosis or late diagnosis; 90% of cases resulted in hysterectomy. In the others the products of conception were removed, and hemorrhaging was controlled by plugging the cervical canal, amputating the cervix, and ligating the cervical branches of the uterine arteries. At the end of the 1960s Kobayashi et al! outlined criteria for the diagnosis of cervical pregnancy by ultrasound. About 10 years later Raskin' reported the first case of cervical pregnancy diagnosed by ultrasonograFrom the Department of Obstetrics and Gynecology, University of Siena. Received for publication January 20, 1994; accepted January 31, 1994.
Reprint requests: Giovanni Centini, MD, Obstetrics and Gynecology Clinic, University of Siena, Via Mascagni 46, 53100 Siena, Italy Copyright © 1994 by Mosby-Year Book, Inc. 0002-9378/94 $3.00 + 0 6/1/54825
272
phy. The mortality related to cervical pregnancy has now dropped to almost zero from about 40% at the beginning of the century. Technical improvements in ultrasonography equipment, transvaginal examination, and ~-human chorionic gonadotropin (hCG) assay have led to much earlier and more reliable diagnosis of ectopic, including cervical, pregnancy. Early diagnosis is determinant for a favorable outcome. The many etiopathologic causes are outlined by Russel4 and include previous surgery of the lower uterus such as cesarean section and inflammatory conditions of the cervix and uterus. The frequency of cervical pregnancy is estimated at one in lOOO to 8000 pregnancies. 5 Case report The patient, a 36-year-old secundigravid woman, had undergone cesarean section at the twenty-sixth week of her previous pregnancy, less than a year earlier, because of gestational hypertension and preeclampsia. She came to our attention 5 weeks after her last menstrual bleeding with diffuse pains in the lower pelvis and spotting. There were no clinical signs of ectopic pregnancy, because pain to palpation was' normal. Ultrasonographic examination failed to reveal ectopic pregnancy, but ~-hCG was positive for pregnancy ..Ultrasono graphic markers of ectopic pregnancy were investigated with negative results.
Centini G., Rosignoli, and Severi
Volume 171, Number 1 Am J Obstet Gynecol
The following week the pain subsided and the patient was well. l3-hCG assays at 5 weeks 2 days and at 6 weeks were inconclusive, but the third sample was positive (1100 mIU/ml, radioimmunoassay). Ultrasonographic examination at 6 weeks 2 days clarified the situation by revealing a corpus luteum on the left, endometrial shedding, and a lozenge-shaped anechogenic area (like an exclamation mark) filling the cervical canal up to its opening into the uterus. A formation identified as the vitelline sac with an adjacent embryonic structure only it few millimeters in size and with scarcely perceptible cardiac activity was observed (Fig. I). This image was obtained transvaginally. The transabdominal picture did not give a clear image because the full bladder compressed the gestational chamber. At 6 weeks 4 days the products of conception were needle-aspirated, and careful curettage of the uterus and cervical canal was performed with the patient under total anesthesia. Transvaginal examination was performed immediately before and after the operation, with the patient still anesthesized, to check that the cervical canal had been completely cleared. Methotrexate therapy was not administered before or after the operation. Histologic examination of the tissue removed confirmed cervical pregnancy with endometrial shedding. There was slight but normal bleeding after the operation. Transvaginal ultrasonographic examination on the first day confirmed the return of the uterus to normal. The patient was discharged feeling well on the second day. Levels ofl3-hCG 10 days after the operation were negative. After 40 days normal menstrual bleeding recurred. Hysteroscopic examination after 3 months failed to reveal any structural anomalies of the cervical canal or uterus.
Comment The successful treatment of this case of cervical pregnancy is principally related to early diagnosis by transvaginal echotomography. Cervical implantation seemed
273
Fig. I. Transvaginal ultrasonographic image of cervical pregnancy.
to be related to prior surgical trauma, because the patient had undergone emergency cesarean section less than a year earlier. The hCG profile did not suggest ectopic pregnancy but normal pregnancy complicated by threatening miscarriage. The therapeutic approach used seems adequate if the condition is diagnosed before the ninth or tenth week. We emphasize the importance of transvaginal ultrasonographic examination .in the first week of pregnancy when there is bleeding. REFERENCES I. Rubin IC. Cervical pregnancy. Surg Cynecol Obstet 1911; 16:625. 2. Kobayashi M, Hillman LM, Fillist LP. Ultrasound, an aid in the diagnosis of ectopic pregnancy. AM J OBSTET CYNECOL 1969; 103: 11 3 J. 3. Raskin M . Diagnosis of cervical pregnancy by ultrasound: a case report. AM J OBSTET CYNECOL 1978;130:234 . 4. Russel JB. The etiology of ectopic pregnancy. Clin Obstet CynecoI1987;30:181. 5. Bayless RB. Nontubal ectopic pregnancy. Clin Obstet Cynecol 1987 ;30: 19 J.