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Cervical pregnancy
CURRENT OPINION "'-1• __ •
I
I
I
\..,lln1ca1 pro01ems
Cervical pregnancy Case presentation
8 hours later and there was no further bleeding. The specimens obtained by punch biopsy were diagnosed the following day as cervical pregnancy. The curettings revealed a decidual reaction. Problem: Discuss the management of this particular case? In addition, comment on the diagnosis, course, and management of cervical pregnancy in general.
M. W., a 34-year-o!d Negro female, gravida vii, para iv with 3 abortions, was admitted to the hospital on Nov. 24, 1964, with a chief complaint of profuse vaginal bleeding for 4 days. Her last normal menstrual period was Sept. 3, 1964. The breasts were tender. The vulva and vagina were free of disease. Pelvic examination revealed profuse bleeding from a soft, ragged, friable cervix. The uterus was slightly enlarged and firm. The adnexa were of normal size, freely movable, and not tender. The blood pressure was 90/58, pulse 96, and temperature 99.2° F. An intravenous infusion was started with oxytocin added. Several punch biopsies of the cervix were taken and, because of profuse hemorrhage, a pack was inserted against the cervix which slowed the bleeding somewhat. The patient's hemoglobin was 5 Gm., hematocrit 18 per cent, and white blood cell count 8,500 with a normal differential. The fibrinogen level was normal. The blood pressure dropped to 40/0 and she had signs of shock. Four units of blood were administered under pressure which raised the blood pressure to 110/70. In the operating room the pack was removed. All of the bleeding was coming from the lesion on the cervix. The internal os was tightly closed. With some difficulty the bleeding was controlled by multiple sutures. A minimal amount of tissue was curetted from the fundus of the uterus. Iodoform gauze was inserted against the cervix because of continued oozing. The pack was removed
Consultation
]. f.
Price, M.D. Philadelphia, Pennsylvania Assistant Director, Department of Obstetrics and Gynecology Misericordia Hospital This case is similar to a case of cervical pregnancy managed recently by Dr. Casimir \"{ anczyk and me. The case was quite frightening and provocative, stimulating us to review the literature and think of how we would manage a similar case in the future. We believe the patient presented received adequate therapy and fortunately the bleeding was controlled. We do suggest that a patient with a lesion as described, should have an immediate biopsy in the operating room and diagnosis by frozen section. The advent of the cryostat has made frozen section diagnosis completely satisfactory. The principle of the cryostat is that the cutting blade is kept at -20° C., therefore preventing the blade from melting the frozen tissue as it is cut. A thin slice of tissue is thereby obtained tantamount to tissue fixed in paraffin. This immediate diagnosis is important because the 134
Volume 99 Number 1
ragged friable cervix seen in cervical pregnancy mimics that of carcinoma of the cervix. With uncontrollable bleeding from the cervix, a simple hysterectomy would be indicated in cervical pregnancy, whereas internal iliac ligation and ovarian vessel ligation would be indicated in cervical carcinoma. In cervical carcinoma, simple hysterectomy is contraindicated, and irradiation or radical hysterectomy and node dissection could be performed more effectively after the patient's condition was stabilized. Cervical pregnancy may be defined as one in which the blastocyst implants in the cervical mucosa below the level of the internal os. In 1911, Rubin 1 set forth his criteria for the diagnosis of cervical pregnancy. These were: ( 1) cervical glands must be in close opposition to placental tissue; (2) there must be intimate attachment between the cervix and placenta; (3) the corpus must not contain fetal parts, and ( 4) the entire placenta must be attached below the entrance of the uterine vessels or peritoneal reflexion. Clinically, the diagnosis of cervical pregnancy is usually seen in grand multiparas with frequent pregnancies. There is painless bleeding with or without a history of amenorrhea. The pregnancy typically terminates in the first trimester. The cervix is frequently ragged and friable, or ballooning through which tissue or membranes may be seen on speculum examination. There is profuse hemorrhage on removal of tissue because of the deficient contractibility of the cervix. The internal os is closed and the uterus may be of hourglass shape, making it easy for the fundus to be mistaken for a fibroid. On dilatation and curettage minimal tissue is obtained from the fundus, which microscopically reveals a decidual reaction. The incidence of cervical pregnancy is unknown. There have been a little over 80 cases reported to date, but I'm sure a number have not been reported. We have had three cases in the past 15 years at our hospital which were not reported. One occurred in a woman who previously had had a subtotal hysterectomy.
Clinical problems 135
The etiology is unknown. Schneider and Dreizin2 has postulated that the etiology may be based on an increased rate of travel or a decreased rate of ripening of the fertilized ovum. The cervix is in no way equipped to nourish the ovum nor to fulfill the demands of a growing fetus. For this reason it is considered a true ectopic pregnancy. The pathologic changes are based on the lack of a protective decidua basalis. There is haphazard advancement of the chorionic villi with the cervical tissue being thinned and destroyed. Early abortion is the rule because of destruction of the nutrient supply to the ovum. The course followed by the pregnancy may be one of three: It may expand into the cervical canal; it may rupture into the base of the broad ligament, beneath the bladder, or into the cul-de-sac with intraperitoneal hemorrhage; or it may rupture into the vagina. As previously stated, the tendency to hemorrhage is great because of the deficient contractibility of the cervix. Other conditions to be differentiated from cervical pregnancy are: simple incomplete abortion, attempted criminal abortion, ruptured tubal pregnancy, and, most important from the standpoint of management, carcinoma of the cervix. The prognosis may be grave since hemorrhage can be profuse. Studdiford 3 reported a mortality rate of 30 per cent in 1945, while Mayberger4 reported a 20 per cent mortality in 1958. Delayed hemorrhage may occur from 6 days to 6 weeks following removal of the products of conception. Treatment varies with the individual case. Of course, the administration of blood and therapy for shock will be necessary. As stated, immediate biopsy and frozen section should be performed to rule out carcinoma of the cervix. The bleeding area is tightly packed, until the patient can be brought to the operating room with blood running. The uterus and cervix is thoroughly curetted. An attempt is made to control the bleeding, by suturing the cervical branches of the uterine vessels and the bleeding area. If the bleeding cannot be controlled, a hysterectomy and/or ligation of the internal iliac
136 Clinical problems
:)cptt·rubet 1, !qtj7 '\tJL
vessels and ovanan vessels are performed depending on the age of the patient and hn desire for more children. REFERENCES
1. Rubin, C.: Surg., Gynec. & Obst. 13: 625, 1911. 2. Schneider, P., and Dreizin, D. H.: Am. J. Surg. 93: 27, 1957. 3. Studdiford, I. C.: AM. J. 0BST. & GYNEC. 49: 169, 1945. 4. Mayberger, H. W.: Obst. & Gynec. 11: 657, 1958.
Augusta Webster) M.D. Chicago, Illinois Professor) Department of Obstetrics and Gynecology Northwestern University Medical School Chairman) Department of Obstetrics Cook County Hospital The case presentation demonstrates most of the criteria for the diagnosis of cervical pregnancy. The history is that of a multigravid woman past 30 years of age with amenorrhea, sensitive breasts, and a sudden unprovoked vaginal hemorrhage. The examination reveals a bleeding, friable, ragged cervix surmounted by a "slightly enlarged and firm" corpus, with the vulva, vaginal vault, and adnexa all normal. The bleeding was observed to come from a cervical lesion and the internal os was closed. No mention is made of the external os but since the cervical lesion was visible to the examiner it is assumed that it was open. Cervical pregnancy is rare. Abortion and carcinoma are far more common and apparently both possibilities were considered. Oxytocin was given by intravenous drip presumably to treat an incomplete abortion. While this did no harm, oxytocics are powerless to control bleeding later proved to originate from the cervix. Danforth 1 has demonstrated that only 15 per cent of the nonpregnant cervix is composed of smooth muscle and that the remainder is primarily fibrous connective tissue. The contractile ability of the cervix, therefore, is minimaL Apparently when the cervix was inspected at the time of the initial vaginal examination
1
()h-.f.
& (~VJt(•C,
the friable lesion seen vvas thought to lw a carcinoma and consequently puuch biopsies were done. This producC'd even more serious bleeding ami dropped the blood pressure t[} 40/0. A pack was hastily placed against the bleeding cervix to temporarily stem the hemorrhage and the patient was taken to thC' operating room where the pack was removed and the bleeding controlled by multiple sutures. The internal os vvas dilated and the fundus curetted. Another pack \vas ~·inserted against the cervix to control the continued oozing." Had the bleeding not been controlled by the sutures a pack placed as described would have been inadequate. In order to control a hemorrhage a pack should be placed in the fundus, the cervical canal, and the vaginal vault so that counter pressure is firmly exerted. The minimal amount of tissue obtained from the fundus and the subsequent report of decidual reaction is the expected finding in cervical pregnancy. The punch biopsies were diagnosed as "cervical pregnancy." We do not know whether or not the diagnostic criteria as established by Rubin 2 were met. These are that: ( 1) cervical glands must be demonstrated opposite the placental attachment; (2) the attachment of the placenta to the cervix must be intimate; (3) the placenta must be either below the entrance of the uterine vessels or below the peritoneal reflection on the anterior and posterior surfaces of the uterus; and (4) fetal elements cannot be present in the corpus of the uterus. Cervical pregnancy has only been recorded three times in the past fifteen years at the Cook County Hospital. Two of the patients were on the gynecologic service and the admitting diagnosis was carcinoma. One was sent to the obstetric service with an admitting diagnosis of incomplete abortion. It seems probable that other patients with this entity have aborted early and these cases have gone unrecognized. This probability has been suggested by other observers. 3 - 5 The diagnosis is rarely made befon~ oneration and even then mav be mistaken for an incomplete abortion. A clinical diagnosis can be made by the ---
-
- .l-
-
-
-
'
Clinical problems 137
Volume 99 Number 1
thin-walled open external cervix and a closed internal os with a reiatively firm uterine fundus in the normal suprapubic position. There is usually, although not alvv·ays, brisk painless bleeding and an absence of uterine cramps. The products of conception are contained entirely within the cervix below a closed internal os. No fetal elements are found in the fundus. A tissue diagnosis as previously stated is conclusive. It seems appropriate to mention that cervicohysterosalpingography as recently described by Matracaru and associates 6 is not necessary for the diagnosis of cervical pregnancy. It can only serve as an interesting academic exercise to demonstrate graphically the characteristic hourglass shape of the uterus, the closed internal os, and dilated cervix. The risk of the upward spread of infection and of severe hemorrhage does not warrant the use of this procedure. The case presented was well managed with the exception of the timing of the punch biopsies which were done elsewhere than in the operating room and almost precipitated disaster by the bleeding produced. If the problem had been a carcinoma there would have been no need for
haste. The immediate problem was control of the hemorrhage and blood replacement. In the presence of a friable lesion the precaution of an adequately equipped operating room with good lights and available anesthesia is very desirable and permits one to obtain generous samples of tissue for study. The only treatment required in cervical pregnancy is removal of the conceptus by finger or gentle instrumental curettage and control of the bleeding. The fundus should also be explored, as was done in this instance. Sometimes tamponade of the uterus, cervix, and vagina is required and whole blood transfusion should be used as indicated. REFERENCES
1. Danforth, D. N.: AM. J. OssT. & GYNEC. 53: 541, 1947. 2. Rubin, I. C.: Surg., Gynec. & Obst. 13: 625, 1911. 3. Studdiford, I. C.: AM. J. OssT. & GYNEC. 49: 169, 1945. 4. Schneider, Paul, and Dreizin, David H.: Am. J. Surg. 93: 27, 1957. 5. Paalman, R. ]., and McElin, T. W.: AM. J. 0BST. & GYNEC. 77: 1261, 1959. 6. Matracaru, G., lacob, C., Constantinescu, Paula, Benescu, L., and Rogozeanu, E.: AM. ]. 0BST. & GYNEC. 94: 929, 1966.
I
I
I
\..,lln1ca1 pro01ems
Cervical pregnancy Case presentation
8 hours later and there was no further bleeding. The specimens obtained by punch biopsy were diagnosed the following day as cervical pregnancy. The curettings revealed a decidual reaction. Problem: Discuss the management of this particular case? In addition, comment on the diagnosis, course, and management of cervical pregnancy in general.
M. W., a 34-year-o!d Negro female, gravida vii, para iv with 3 abortions, was admitted to the hospital on Nov. 24, 1964, with a chief complaint of profuse vaginal bleeding for 4 days. Her last normal menstrual period was Sept. 3, 1964. The breasts were tender. The vulva and vagina were free of disease. Pelvic examination revealed profuse bleeding from a soft, ragged, friable cervix. The uterus was slightly enlarged and firm. The adnexa were of normal size, freely movable, and not tender. The blood pressure was 90/58, pulse 96, and temperature 99.2° F. An intravenous infusion was started with oxytocin added. Several punch biopsies of the cervix were taken and, because of profuse hemorrhage, a pack was inserted against the cervix which slowed the bleeding somewhat. The patient's hemoglobin was 5 Gm., hematocrit 18 per cent, and white blood cell count 8,500 with a normal differential. The fibrinogen level was normal. The blood pressure dropped to 40/0 and she had signs of shock. Four units of blood were administered under pressure which raised the blood pressure to 110/70. In the operating room the pack was removed. All of the bleeding was coming from the lesion on the cervix. The internal os was tightly closed. With some difficulty the bleeding was controlled by multiple sutures. A minimal amount of tissue was curetted from the fundus of the uterus. Iodoform gauze was inserted against the cervix because of continued oozing. The pack was removed
Consultation
]. f.
Price, M.D. Philadelphia, Pennsylvania Assistant Director, Department of Obstetrics and Gynecology Misericordia Hospital This case is similar to a case of cervical pregnancy managed recently by Dr. Casimir \"{ anczyk and me. The case was quite frightening and provocative, stimulating us to review the literature and think of how we would manage a similar case in the future. We believe the patient presented received adequate therapy and fortunately the bleeding was controlled. We do suggest that a patient with a lesion as described, should have an immediate biopsy in the operating room and diagnosis by frozen section. The advent of the cryostat has made frozen section diagnosis completely satisfactory. The principle of the cryostat is that the cutting blade is kept at -20° C., therefore preventing the blade from melting the frozen tissue as it is cut. A thin slice of tissue is thereby obtained tantamount to tissue fixed in paraffin. This immediate diagnosis is important because the 134
Volume 99 Number 1
ragged friable cervix seen in cervical pregnancy mimics that of carcinoma of the cervix. With uncontrollable bleeding from the cervix, a simple hysterectomy would be indicated in cervical pregnancy, whereas internal iliac ligation and ovarian vessel ligation would be indicated in cervical carcinoma. In cervical carcinoma, simple hysterectomy is contraindicated, and irradiation or radical hysterectomy and node dissection could be performed more effectively after the patient's condition was stabilized. Cervical pregnancy may be defined as one in which the blastocyst implants in the cervical mucosa below the level of the internal os. In 1911, Rubin 1 set forth his criteria for the diagnosis of cervical pregnancy. These were: ( 1) cervical glands must be in close opposition to placental tissue; (2) there must be intimate attachment between the cervix and placenta; (3) the corpus must not contain fetal parts, and ( 4) the entire placenta must be attached below the entrance of the uterine vessels or peritoneal reflexion. Clinically, the diagnosis of cervical pregnancy is usually seen in grand multiparas with frequent pregnancies. There is painless bleeding with or without a history of amenorrhea. The pregnancy typically terminates in the first trimester. The cervix is frequently ragged and friable, or ballooning through which tissue or membranes may be seen on speculum examination. There is profuse hemorrhage on removal of tissue because of the deficient contractibility of the cervix. The internal os is closed and the uterus may be of hourglass shape, making it easy for the fundus to be mistaken for a fibroid. On dilatation and curettage minimal tissue is obtained from the fundus, which microscopically reveals a decidual reaction. The incidence of cervical pregnancy is unknown. There have been a little over 80 cases reported to date, but I'm sure a number have not been reported. We have had three cases in the past 15 years at our hospital which were not reported. One occurred in a woman who previously had had a subtotal hysterectomy.
Clinical problems 135
The etiology is unknown. Schneider and Dreizin2 has postulated that the etiology may be based on an increased rate of travel or a decreased rate of ripening of the fertilized ovum. The cervix is in no way equipped to nourish the ovum nor to fulfill the demands of a growing fetus. For this reason it is considered a true ectopic pregnancy. The pathologic changes are based on the lack of a protective decidua basalis. There is haphazard advancement of the chorionic villi with the cervical tissue being thinned and destroyed. Early abortion is the rule because of destruction of the nutrient supply to the ovum. The course followed by the pregnancy may be one of three: It may expand into the cervical canal; it may rupture into the base of the broad ligament, beneath the bladder, or into the cul-de-sac with intraperitoneal hemorrhage; or it may rupture into the vagina. As previously stated, the tendency to hemorrhage is great because of the deficient contractibility of the cervix. Other conditions to be differentiated from cervical pregnancy are: simple incomplete abortion, attempted criminal abortion, ruptured tubal pregnancy, and, most important from the standpoint of management, carcinoma of the cervix. The prognosis may be grave since hemorrhage can be profuse. Studdiford 3 reported a mortality rate of 30 per cent in 1945, while Mayberger4 reported a 20 per cent mortality in 1958. Delayed hemorrhage may occur from 6 days to 6 weeks following removal of the products of conception. Treatment varies with the individual case. Of course, the administration of blood and therapy for shock will be necessary. As stated, immediate biopsy and frozen section should be performed to rule out carcinoma of the cervix. The bleeding area is tightly packed, until the patient can be brought to the operating room with blood running. The uterus and cervix is thoroughly curetted. An attempt is made to control the bleeding, by suturing the cervical branches of the uterine vessels and the bleeding area. If the bleeding cannot be controlled, a hysterectomy and/or ligation of the internal iliac
136 Clinical problems
:)cptt·rubet 1, !qtj7 '\tJL
vessels and ovanan vessels are performed depending on the age of the patient and hn desire for more children. REFERENCES
1. Rubin, C.: Surg., Gynec. & Obst. 13: 625, 1911. 2. Schneider, P., and Dreizin, D. H.: Am. J. Surg. 93: 27, 1957. 3. Studdiford, I. C.: AM. J. 0BST. & GYNEC. 49: 169, 1945. 4. Mayberger, H. W.: Obst. & Gynec. 11: 657, 1958.
Augusta Webster) M.D. Chicago, Illinois Professor) Department of Obstetrics and Gynecology Northwestern University Medical School Chairman) Department of Obstetrics Cook County Hospital The case presentation demonstrates most of the criteria for the diagnosis of cervical pregnancy. The history is that of a multigravid woman past 30 years of age with amenorrhea, sensitive breasts, and a sudden unprovoked vaginal hemorrhage. The examination reveals a bleeding, friable, ragged cervix surmounted by a "slightly enlarged and firm" corpus, with the vulva, vaginal vault, and adnexa all normal. The bleeding was observed to come from a cervical lesion and the internal os was closed. No mention is made of the external os but since the cervical lesion was visible to the examiner it is assumed that it was open. Cervical pregnancy is rare. Abortion and carcinoma are far more common and apparently both possibilities were considered. Oxytocin was given by intravenous drip presumably to treat an incomplete abortion. While this did no harm, oxytocics are powerless to control bleeding later proved to originate from the cervix. Danforth 1 has demonstrated that only 15 per cent of the nonpregnant cervix is composed of smooth muscle and that the remainder is primarily fibrous connective tissue. The contractile ability of the cervix, therefore, is minimaL Apparently when the cervix was inspected at the time of the initial vaginal examination
1
()h-.f.
& (~VJt(•C,
the friable lesion seen vvas thought to lw a carcinoma and consequently puuch biopsies were done. This producC'd even more serious bleeding ami dropped the blood pressure t[} 40/0. A pack was hastily placed against the bleeding cervix to temporarily stem the hemorrhage and the patient was taken to thC' operating room where the pack was removed and the bleeding controlled by multiple sutures. The internal os vvas dilated and the fundus curetted. Another pack \vas ~·inserted against the cervix to control the continued oozing." Had the bleeding not been controlled by the sutures a pack placed as described would have been inadequate. In order to control a hemorrhage a pack should be placed in the fundus, the cervical canal, and the vaginal vault so that counter pressure is firmly exerted. The minimal amount of tissue obtained from the fundus and the subsequent report of decidual reaction is the expected finding in cervical pregnancy. The punch biopsies were diagnosed as "cervical pregnancy." We do not know whether or not the diagnostic criteria as established by Rubin 2 were met. These are that: ( 1) cervical glands must be demonstrated opposite the placental attachment; (2) the attachment of the placenta to the cervix must be intimate; (3) the placenta must be either below the entrance of the uterine vessels or below the peritoneal reflection on the anterior and posterior surfaces of the uterus; and (4) fetal elements cannot be present in the corpus of the uterus. Cervical pregnancy has only been recorded three times in the past fifteen years at the Cook County Hospital. Two of the patients were on the gynecologic service and the admitting diagnosis was carcinoma. One was sent to the obstetric service with an admitting diagnosis of incomplete abortion. It seems probable that other patients with this entity have aborted early and these cases have gone unrecognized. This probability has been suggested by other observers. 3 - 5 The diagnosis is rarely made befon~ oneration and even then mav be mistaken for an incomplete abortion. A clinical diagnosis can be made by the ---
-
- .l-
-
-
-
'
Clinical problems 137
Volume 99 Number 1
thin-walled open external cervix and a closed internal os with a reiatively firm uterine fundus in the normal suprapubic position. There is usually, although not alvv·ays, brisk painless bleeding and an absence of uterine cramps. The products of conception are contained entirely within the cervix below a closed internal os. No fetal elements are found in the fundus. A tissue diagnosis as previously stated is conclusive. It seems appropriate to mention that cervicohysterosalpingography as recently described by Matracaru and associates 6 is not necessary for the diagnosis of cervical pregnancy. It can only serve as an interesting academic exercise to demonstrate graphically the characteristic hourglass shape of the uterus, the closed internal os, and dilated cervix. The risk of the upward spread of infection and of severe hemorrhage does not warrant the use of this procedure. The case presented was well managed with the exception of the timing of the punch biopsies which were done elsewhere than in the operating room and almost precipitated disaster by the bleeding produced. If the problem had been a carcinoma there would have been no need for
haste. The immediate problem was control of the hemorrhage and blood replacement. In the presence of a friable lesion the precaution of an adequately equipped operating room with good lights and available anesthesia is very desirable and permits one to obtain generous samples of tissue for study. The only treatment required in cervical pregnancy is removal of the conceptus by finger or gentle instrumental curettage and control of the bleeding. The fundus should also be explored, as was done in this instance. Sometimes tamponade of the uterus, cervix, and vagina is required and whole blood transfusion should be used as indicated. REFERENCES
1. Danforth, D. N.: AM. J. OssT. & GYNEC. 53: 541, 1947. 2. Rubin, I. C.: Surg., Gynec. & Obst. 13: 625, 1911. 3. Studdiford, I. C.: AM. J. OssT. & GYNEC. 49: 169, 1945. 4. Schneider, Paul, and Dreizin, David H.: Am. J. Surg. 93: 27, 1957. 5. Paalman, R. ]., and McElin, T. W.: AM. J. 0BST. & GYNEC. 77: 1261, 1959. 6. Matracaru, G., lacob, C., Constantinescu, Paula, Benescu, L., and Rogozeanu, E.: AM. ]. 0BST. & GYNEC. 94: 929, 1966.