- Email: [email protected]
Cervical pregnancy: A case report
CASE REPORT
Cervical Pregnancy: A Case Report From the Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL.
Trent R. Boyko, MD John F. O’Brien, MD
Received for publication January 2, 2001. Accepted for publication February 27, 2001. Address for reprints: Trent R. Boyko, MD, Questcare Emergency Physicians, 101 E. Park Boulevard, #911, Plano, TX 75074.
This is a case report of an uncommon but dangerous form of ectopic pregnancy. The incidence of cervical pregnancy may be increasing, and it should be included in the differential diagnosis of vaginal bleeding in pregnancy. Included in this case report are discussions of the incidence, causes, predisposing factors, diagnostics, and treatment options. [Boyko TR, O’Brien JF. Cervical pregnancy: a case report. Ann Emerg Med. August 2001;38:177-180.]
Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/115442 doi:10.1067/mem.2001.115442
INTRODUCTION
Cervical pregnancy is a rare and dangerous form of ectopic pregnancy. It is one of the most serious potential complications in obstetrics. One author was quoted as saying, “Most obstetricians would never see a cervical pregnancy and those who did encounter the complication would wish they had not.”1 Although the presentation may be dramatic, usually with severe and persistent vaginal bleeding, a clinical diagnosis may be difficult. The patient history, physical examination, and fetal ultrasound scan are essential in evaluating for cervical ectopic pregnancy. Aggressive resuscitation and surgical intervention are often necessary for successful treatment. We describe a patient with a cervical pregnancy who presented with massive, painless vaginal bleeding. Emergency physicians must consider cervical pregnancy in their differential diagnosis of vaginal bleeding. CASE REPORT
A 39-year-old woman, G2 P1 A1, was at a local tourist attraction when vaginal bleeding spontaneously developed. The hemorrhage was so remarkable that paramedics air transported her to our hospital for evaluation. On arrival, she was awake and alert but complained of being
AUGUST 2001
38:2
ANNALS OF EMERGENCY MEDICINE
1 7 7
CERVICAL PREGNANCY Boyko & O’Brien
dizzy. The patient had no abdominal pain and did not suspect she was pregnant. Her history was significant for one prior spontaneous abortion and one full-term pregnancy delivered by cesarean section. Her last menstrual period had been normal and had occurred approximately 6 weeks before this emergency department encounter. The patient was pale and diaphoretic on presentation but alert and cooperative. Initial vital signs were a pulse rate of 110 beats/min, respiratory rate of 22 breaths/min, and blood pressure of 124/72 mm Hg; she was also afebrile. Results of cardiac, lung, and abdominal examinations were normal. On pelvic examination, she was found to have massive vaginal bleeding. Her cervix appeared to be swollen; no products of conception were noted in the os. The external cervix was dilated to 1 cm. The urine β-human chorionic gonadotropin (β-hCG) test result was positive, and quantitative β-hCG was measured at 2,606 mIU/mL. Her initial hemoglobin level was 7.9 g/dL and subsequently decreased to 4.7 two hours after ED arrival. She also had episodes of remarkable hypotension, with systolic blood pressure as low as 50 mm Hg and a pulse rate of 140 to 150 beats/min, which were responsive to volume resuscitation with approximately 2 L of normal saline solution through 2 large-bore intravenous catheters. After the initial resuscitation, the patient underwent ultrasonographic examination and was found to have no visible gestational sac and retained products in a dilated endocervical canal. No free fluid was noted in the pouch of Douglas. Obstetric consultation was initiated early in the case. Because of the severity of hemorrhage, she was promptly taken to the operating room for dilatation and curettage (D&C) of a suspected incomplete abortion. Bleeding continued after the D&C, and a Foley catheter balloon was inserted in the cervical canal for temporary tamponade of ongoing bleeding. In the recovery room, the patient continued to have significant vaginal hemorrhage with hypotension and was subsequently taken back to the operating room for an emergency hysterectomy. The patient received a total of 8 L of normal saline solution, 12 units of packed RBCs, 4 units of fresh frozen plasma, and 10 units of platelets in her resuscitation and subsequent surgery. Histologic examination of the uterus showed retained products of conception, with the implantation site involving the lower uterine segment and upper endocervical canal at the internal cervical os. On postoperative day 3, the patient was doing well and was discharged home.
1 7 8
DISCUSSION
Cervical pregnancy is defined as the implantation of a fertilized ovum in the endocervix. It is a rare form of ectopic pregnancy. With a reported incidence that ranges from 1:1,000 to 1:18,000,2 this entity represents less than 1% of all ectopic pregnancies.3 In the earliest recognized cases, mortality rates were reported to be between 40% and 45%. However, since 1954, no maternal deaths as a result of cervical pregnancy have been documented in the medical literature.3-6 Early recognition with the use of ultrasonographic scanning, as well as aggressive resuscitation, transfusion therapy, and improved surgical techniques, are partly responsible for this marked reduction in mortality. There have been no clear explanations for the occurrence of cervical pregnancy. However, several contributory factors have been proposed (Table 1).4,6-15 All predisposing factors point to the inability of the endometrium to accept implantation or to rapid transport of the fertilized ovum through the uterus. The strongest predisposing factor appears to include prior induced abortion with curettage, which is associated with a high incidence of subsequent cervical pregnancy.6 Rubin5 established rigid criteria for the diagnosis of cervical pregnancy in 1911, and these remain valid today (Table 2). Presentation is almost always during the first trimester, with prominent vaginal bleeding, but 1 case reports survival to 35 weeks’ gestational age and delivery of a living baby.8 The definition of a cervical pregnancy is the implantation of a fertilized ovum in the endocervix. Clinical, ultrasonographic, and histiopathologic criteria have been developed for the diagnosis of cervical pregnancy. Because histiopathologic criteria are based on surgical specimens,
Table 1.
Predisposing factors for cervical pregnancy. 1. Induced abortion with sharp curettage 2. Intrauterine devices 3. Asherman’s syndrome 4. History of cesarean section 5. Structural uterine and cervical anomalies 6. Uterine fibroids and malformation 7. Endometrial atrophy and chronic endometriosis 8. Abnormal transport and secondary attachment of the fertilized ovum 9. In vitro fertilization 10. Increased maternal age
ANNALS OF EMERGENCY MEDICINE
38:2 AUGUST 2001
CERVICAL PREGNANCY Boyko & O’Brien
clinical and ultrasonographic criteria are much more useful to the emergency physician. The most common clinical manifestation of cervical pregnancy is painless vaginal bleeding, usually occurring in the first trimester. Other clinical criteria involve closed internal os, partially open external os, products of conception confined within the endocervix, and a softened and disproportionately enlarged cervix.2,16,17 Ushakov et al12 noted in a group of patients (n=89) that vaginal bleeding was present in 91%, with associated abdominal cramps in 26% of patients. Approximately 29% had massive vaginal bleeding. The bleeding was described only as mild or spotting in 20% of the patients. In 7% of the patients, diagnosis was made by means of routine ultrasonographic scanning, and the patients were asymptomatic. Ultrasonographic criteria include the following12,16,18: intracervical localization of ectopic gestation; closed internal os; trophoblastic invasion in the endocervical tissue; empty uterine cavity; hourglass-shaped uterus; intracervical peritrophoblastic blood flow; and diffuse amorphous intrauterine echoes. In the review of the literature before ultrasonographic scanning by Ushakov et al,12 the correct clinical diagnosis was made in only 18% of cases (n=38). They found that this number steadily improved with the assistance of ultrasonographic scanning to approximately 87% in the 1990s. The management of cervical pregnancies depends on the clinical presentation. Hemodynamic stability and actual ongoing blood loss are the features that guide initial actions and definitive treatment. Along with the physical examination, initial evaluation should include a CBC count, blood type and screen, and quantitative β-hCG measurement. This, together with ultrasonographic evaluation, can help determine approximate gestational age and helps guide the physician in choosing appropriate therapy. Conservative management is the therapy of choice if the diagnosis can be made early before any complications. The main goal of conservative therapy is to
preserve the patient’s reproductive capability.11 Therapies that are considered conservative include those listed in Table 3.2,11-17,19-24 Although most treatments are surgical because of extensive hemorrhaging, on occasion, methotrexate may be used to cause fetal death and allow nonsurgical elimination of the pregnancy. Conservative treatment is often not successful for 2 main reasons: advanced gestational age and, more significantly, the anatomy of the cervix. The cervix itself is mostly fibrous connective tissue and composed of only 15% smooth muscle. It is thus unable to respond to mechanical hemostasis or uterotonic medications.14,17 Hysterectomy is performed if conservative treatment fails. In the past, as many as 70% of patients underwent hysterectomy for cervical pregnancy. A cervical pregnancy that is undetected until the second or third trimester usually requires hysterectomy. Cases of hysterectomy after D&C are reported in between 15% and 40% of cervical pregnancies.25,26 Other patients for whom hysterectomy should be considered are those older than 45 years and those who have completed their family or have associated uterine pathology.12,20 In summary, cervical pregnancy is a rare form of ectopic pregnancy, which usually presents with excessive firsttrimester vaginal bleeding. Clinical diagnosis is difficult, although a softened and disproportionately enlarged cervix in the appropriate clinical setting should increase suspicion. Past history of uterine manipulation (eg, D&C) or structural abnormalities increases the risk of cervical pregnancy. Ultrasonography is the most important diagnostic tool in cervical pregnancy. Management depends on clinical presentation. Hemodynamically stable patients may be treated conservatively, particularly with methotrexate administration or local excision and curettage. More aggressive surgical intervention may be
Table 3.
Conservative treatments. Table 2.
Diagnostic criteria for cervical pregnancy. 1. Cervical glands must be present opposite the placental attachment. 2. The attachment of the placenta to the cervix must be intimate. 3. The placenta must be below the peritoneal reflection of the anterior and posterior surfaces of the uterus. 4. Fetal elements must not be present within the uterine cavity.
AUGUST 2001
38:2
ANNALS OF EMERGENCY MEDICINE
1. Local excision and curettage 2. Curettage with compression of the cervix or tamponade with packing 3. Cervical cerclage 4. Curettage and tamponade with Foley catheter placed in the cervical canal 5. Ligation of the descending branches of the uterine artery 6. Angiographic uterine artery embolization 7. Intracervical injection of prostaglandins 8. Methotrexate administration 9. Potassium chloride administered as an intra-amniotic injection
1 7 9
CERVICAL PREGNANCY Boyko & O’Brien
required, with hysterectomy still occasionally necessary if more conservative measures fail. REFERENCES 1.
Baptisti A, Cervical pregnancy. Obstet Gynecol. 1953;1:353-358.
2. Yankowitz J, Leake J, Huggins G, et al. Cervical ectopic pregnancy: review of the literature and report of a case treated by single-dose methotrexate therapy. Obstet Gynecol Surv. 1990;45:405-414. 3. Marcovici I, Rosenzweig BA, Brill AI, et al. Cervical pregnancy: case reports and a current literature review. Obstet Gynecol Surv. 1994;49:49-55. 4. Studdiford WE. Cervical pregnancy: a partial review of the literature and a report of two probable cases. Am J Obstet Gynecol. 1945;49:169. 5.
Rubin I. Cervical pregnancy. Surg Gynecol Obstet. 1911;13:625-633.
6. Parente JT, Ou CS, Levy J, et al. Cervical pregnancy analysis: a review and report of five cases. Obstet Gynecol. 1983;62:79-82. 7. Shinagawa S, Nagayama M. Cervical pregnancy as a possible sequela of induced abortion. Am J Obstet Gynecol. 1969;105:282-284. 8.
Dees HC. Cervical pregnancy associated with uterine leiomyomas. South Med J. 1966;59:900.
9.
Fahmy K, Zikry AM, Hassan S. Cervical pregnancy. Int Surg. 1971;55:127-130.
10. Iffy I. Contribution to the etiology of ectopic pregnancy. Obstet Gynaecol Br Commonwealth. 1961;8:441. 11. Acosta DA. Cervical pregnancy—a forgotten entity in family practice. J Am Board Fam Pract. 1997;10:290-295. 12. Ushakov FB, Elchalal U, Aceman PJ, et al. Cervical pregnancy: past and future. Obstet Gynecol Surv. 1996;52:45-59. 13. Sonmez AS, Kafkasli A, Sarac K, et al. Cervical pregnancy: can age and parity be predisposing factors? Acta Obstet Gynecol Scand. 1994;73:734-736. 14. Traina V, Pinto V, Marinaccio M, et al. Exocervical pregnancy. Arch Gynecol Obstet. 1997;259:205-207. 15. Frates MC, Benson CB, Doubilet PM, et al. Cervical ectopic pregnancy: results of conservative treatment. Radiology. 1994;191:773-775. 16. Poon KF, Chan LKC, Tan HK, et al. Cervical ectopic pregnancy—a case report. Singapore Med J. 1997;38:27-28. 17. Sepulveda WH, Vinals F, Donetch G, et al. Cervical pregnancy: a case report. Arch Gynecol Obstet. 1993;252:155-157. 18. Kobayashi M, Hellman LM, Fillist LP. Ultrasound: an aid in the diagnosis of ectopic pregnancy. Am J Obstet Gynecol. 1969;103:1131-1140. 19. Hajenius PJ, Roos D, Ankum WM, et al. Are human chorionic gonadotropin clearance curves of use in monitoring methotrexate treatment in cervical pregnancy? Fertil Steril. 1998;70:362-365. 20. Dall P, Pfisterer J, Du Bois A, et al. Therapeutic strategies in cervical pregnancy. J Obstet Gynecol Reprod Biol. 1994;56:195-200. 21. Palazzetti PL, Cipriano L, Spera G, et al. Hysterectomy in women with cervical pregnancy complicated by life-threatening bleeding: a case report. Clin Exp Obstet Gynecol. 1997;24:74-75. 22. Okeahialam MG, Tuffnell DJ, Donovan PO, et al. Cervical pregnancy managed by suction evacuation and balloon tamponade. Eur J Obstet Gynecol Reprod Biol. 1998;79:89-90. 23. Cosin JA, Bean M, Grow D, et al. The use of methotrexate and arterial embolization to avoid surgery in a case of cervical pregnancy. Fertil Steril. 1997;67:1169-1171. 24. Centini GG, Rosignoli L, Severi M. A case of cervical pregnancy. Am J Obstet Gynecol. 1994;171:272-273. 25. Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and report of two cases treated conservatively. Ultrasound Obstet Gynecol. 1996;8:373380. 26. Van de Meerssche M, Verdonk P, Jacquemyn Y, et al. Cervical pregnancy: three case reports and a review of the literature. Hum Reprod. 1995;10:1850-1855.
1 8 0
ANNALS OF EMERGENCY MEDICINE
38:2 AUGUST 2001
Cervical Pregnancy: A Case Report From the Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL.
Trent R. Boyko, MD John F. O’Brien, MD
Received for publication January 2, 2001. Accepted for publication February 27, 2001. Address for reprints: Trent R. Boyko, MD, Questcare Emergency Physicians, 101 E. Park Boulevard, #911, Plano, TX 75074.
This is a case report of an uncommon but dangerous form of ectopic pregnancy. The incidence of cervical pregnancy may be increasing, and it should be included in the differential diagnosis of vaginal bleeding in pregnancy. Included in this case report are discussions of the incidence, causes, predisposing factors, diagnostics, and treatment options. [Boyko TR, O’Brien JF. Cervical pregnancy: a case report. Ann Emerg Med. August 2001;38:177-180.]
Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/115442 doi:10.1067/mem.2001.115442
INTRODUCTION
Cervical pregnancy is a rare and dangerous form of ectopic pregnancy. It is one of the most serious potential complications in obstetrics. One author was quoted as saying, “Most obstetricians would never see a cervical pregnancy and those who did encounter the complication would wish they had not.”1 Although the presentation may be dramatic, usually with severe and persistent vaginal bleeding, a clinical diagnosis may be difficult. The patient history, physical examination, and fetal ultrasound scan are essential in evaluating for cervical ectopic pregnancy. Aggressive resuscitation and surgical intervention are often necessary for successful treatment. We describe a patient with a cervical pregnancy who presented with massive, painless vaginal bleeding. Emergency physicians must consider cervical pregnancy in their differential diagnosis of vaginal bleeding. CASE REPORT
A 39-year-old woman, G2 P1 A1, was at a local tourist attraction when vaginal bleeding spontaneously developed. The hemorrhage was so remarkable that paramedics air transported her to our hospital for evaluation. On arrival, she was awake and alert but complained of being
AUGUST 2001
38:2
ANNALS OF EMERGENCY MEDICINE
1 7 7
CERVICAL PREGNANCY Boyko & O’Brien
dizzy. The patient had no abdominal pain and did not suspect she was pregnant. Her history was significant for one prior spontaneous abortion and one full-term pregnancy delivered by cesarean section. Her last menstrual period had been normal and had occurred approximately 6 weeks before this emergency department encounter. The patient was pale and diaphoretic on presentation but alert and cooperative. Initial vital signs were a pulse rate of 110 beats/min, respiratory rate of 22 breaths/min, and blood pressure of 124/72 mm Hg; she was also afebrile. Results of cardiac, lung, and abdominal examinations were normal. On pelvic examination, she was found to have massive vaginal bleeding. Her cervix appeared to be swollen; no products of conception were noted in the os. The external cervix was dilated to 1 cm. The urine β-human chorionic gonadotropin (β-hCG) test result was positive, and quantitative β-hCG was measured at 2,606 mIU/mL. Her initial hemoglobin level was 7.9 g/dL and subsequently decreased to 4.7 two hours after ED arrival. She also had episodes of remarkable hypotension, with systolic blood pressure as low as 50 mm Hg and a pulse rate of 140 to 150 beats/min, which were responsive to volume resuscitation with approximately 2 L of normal saline solution through 2 large-bore intravenous catheters. After the initial resuscitation, the patient underwent ultrasonographic examination and was found to have no visible gestational sac and retained products in a dilated endocervical canal. No free fluid was noted in the pouch of Douglas. Obstetric consultation was initiated early in the case. Because of the severity of hemorrhage, she was promptly taken to the operating room for dilatation and curettage (D&C) of a suspected incomplete abortion. Bleeding continued after the D&C, and a Foley catheter balloon was inserted in the cervical canal for temporary tamponade of ongoing bleeding. In the recovery room, the patient continued to have significant vaginal hemorrhage with hypotension and was subsequently taken back to the operating room for an emergency hysterectomy. The patient received a total of 8 L of normal saline solution, 12 units of packed RBCs, 4 units of fresh frozen plasma, and 10 units of platelets in her resuscitation and subsequent surgery. Histologic examination of the uterus showed retained products of conception, with the implantation site involving the lower uterine segment and upper endocervical canal at the internal cervical os. On postoperative day 3, the patient was doing well and was discharged home.
1 7 8
DISCUSSION
Cervical pregnancy is defined as the implantation of a fertilized ovum in the endocervix. It is a rare form of ectopic pregnancy. With a reported incidence that ranges from 1:1,000 to 1:18,000,2 this entity represents less than 1% of all ectopic pregnancies.3 In the earliest recognized cases, mortality rates were reported to be between 40% and 45%. However, since 1954, no maternal deaths as a result of cervical pregnancy have been documented in the medical literature.3-6 Early recognition with the use of ultrasonographic scanning, as well as aggressive resuscitation, transfusion therapy, and improved surgical techniques, are partly responsible for this marked reduction in mortality. There have been no clear explanations for the occurrence of cervical pregnancy. However, several contributory factors have been proposed (Table 1).4,6-15 All predisposing factors point to the inability of the endometrium to accept implantation or to rapid transport of the fertilized ovum through the uterus. The strongest predisposing factor appears to include prior induced abortion with curettage, which is associated with a high incidence of subsequent cervical pregnancy.6 Rubin5 established rigid criteria for the diagnosis of cervical pregnancy in 1911, and these remain valid today (Table 2). Presentation is almost always during the first trimester, with prominent vaginal bleeding, but 1 case reports survival to 35 weeks’ gestational age and delivery of a living baby.8 The definition of a cervical pregnancy is the implantation of a fertilized ovum in the endocervix. Clinical, ultrasonographic, and histiopathologic criteria have been developed for the diagnosis of cervical pregnancy. Because histiopathologic criteria are based on surgical specimens,
Table 1.
Predisposing factors for cervical pregnancy. 1. Induced abortion with sharp curettage 2. Intrauterine devices 3. Asherman’s syndrome 4. History of cesarean section 5. Structural uterine and cervical anomalies 6. Uterine fibroids and malformation 7. Endometrial atrophy and chronic endometriosis 8. Abnormal transport and secondary attachment of the fertilized ovum 9. In vitro fertilization 10. Increased maternal age
ANNALS OF EMERGENCY MEDICINE
38:2 AUGUST 2001
CERVICAL PREGNANCY Boyko & O’Brien
clinical and ultrasonographic criteria are much more useful to the emergency physician. The most common clinical manifestation of cervical pregnancy is painless vaginal bleeding, usually occurring in the first trimester. Other clinical criteria involve closed internal os, partially open external os, products of conception confined within the endocervix, and a softened and disproportionately enlarged cervix.2,16,17 Ushakov et al12 noted in a group of patients (n=89) that vaginal bleeding was present in 91%, with associated abdominal cramps in 26% of patients. Approximately 29% had massive vaginal bleeding. The bleeding was described only as mild or spotting in 20% of the patients. In 7% of the patients, diagnosis was made by means of routine ultrasonographic scanning, and the patients were asymptomatic. Ultrasonographic criteria include the following12,16,18: intracervical localization of ectopic gestation; closed internal os; trophoblastic invasion in the endocervical tissue; empty uterine cavity; hourglass-shaped uterus; intracervical peritrophoblastic blood flow; and diffuse amorphous intrauterine echoes. In the review of the literature before ultrasonographic scanning by Ushakov et al,12 the correct clinical diagnosis was made in only 18% of cases (n=38). They found that this number steadily improved with the assistance of ultrasonographic scanning to approximately 87% in the 1990s. The management of cervical pregnancies depends on the clinical presentation. Hemodynamic stability and actual ongoing blood loss are the features that guide initial actions and definitive treatment. Along with the physical examination, initial evaluation should include a CBC count, blood type and screen, and quantitative β-hCG measurement. This, together with ultrasonographic evaluation, can help determine approximate gestational age and helps guide the physician in choosing appropriate therapy. Conservative management is the therapy of choice if the diagnosis can be made early before any complications. The main goal of conservative therapy is to
preserve the patient’s reproductive capability.11 Therapies that are considered conservative include those listed in Table 3.2,11-17,19-24 Although most treatments are surgical because of extensive hemorrhaging, on occasion, methotrexate may be used to cause fetal death and allow nonsurgical elimination of the pregnancy. Conservative treatment is often not successful for 2 main reasons: advanced gestational age and, more significantly, the anatomy of the cervix. The cervix itself is mostly fibrous connective tissue and composed of only 15% smooth muscle. It is thus unable to respond to mechanical hemostasis or uterotonic medications.14,17 Hysterectomy is performed if conservative treatment fails. In the past, as many as 70% of patients underwent hysterectomy for cervical pregnancy. A cervical pregnancy that is undetected until the second or third trimester usually requires hysterectomy. Cases of hysterectomy after D&C are reported in between 15% and 40% of cervical pregnancies.25,26 Other patients for whom hysterectomy should be considered are those older than 45 years and those who have completed their family or have associated uterine pathology.12,20 In summary, cervical pregnancy is a rare form of ectopic pregnancy, which usually presents with excessive firsttrimester vaginal bleeding. Clinical diagnosis is difficult, although a softened and disproportionately enlarged cervix in the appropriate clinical setting should increase suspicion. Past history of uterine manipulation (eg, D&C) or structural abnormalities increases the risk of cervical pregnancy. Ultrasonography is the most important diagnostic tool in cervical pregnancy. Management depends on clinical presentation. Hemodynamically stable patients may be treated conservatively, particularly with methotrexate administration or local excision and curettage. More aggressive surgical intervention may be
Table 3.
Conservative treatments. Table 2.
Diagnostic criteria for cervical pregnancy. 1. Cervical glands must be present opposite the placental attachment. 2. The attachment of the placenta to the cervix must be intimate. 3. The placenta must be below the peritoneal reflection of the anterior and posterior surfaces of the uterus. 4. Fetal elements must not be present within the uterine cavity.
AUGUST 2001
38:2
ANNALS OF EMERGENCY MEDICINE
1. Local excision and curettage 2. Curettage with compression of the cervix or tamponade with packing 3. Cervical cerclage 4. Curettage and tamponade with Foley catheter placed in the cervical canal 5. Ligation of the descending branches of the uterine artery 6. Angiographic uterine artery embolization 7. Intracervical injection of prostaglandins 8. Methotrexate administration 9. Potassium chloride administered as an intra-amniotic injection
1 7 9
CERVICAL PREGNANCY Boyko & O’Brien
required, with hysterectomy still occasionally necessary if more conservative measures fail. REFERENCES 1.
Baptisti A, Cervical pregnancy. Obstet Gynecol. 1953;1:353-358.
2. Yankowitz J, Leake J, Huggins G, et al. Cervical ectopic pregnancy: review of the literature and report of a case treated by single-dose methotrexate therapy. Obstet Gynecol Surv. 1990;45:405-414. 3. Marcovici I, Rosenzweig BA, Brill AI, et al. Cervical pregnancy: case reports and a current literature review. Obstet Gynecol Surv. 1994;49:49-55. 4. Studdiford WE. Cervical pregnancy: a partial review of the literature and a report of two probable cases. Am J Obstet Gynecol. 1945;49:169. 5.
Rubin I. Cervical pregnancy. Surg Gynecol Obstet. 1911;13:625-633.
6. Parente JT, Ou CS, Levy J, et al. Cervical pregnancy analysis: a review and report of five cases. Obstet Gynecol. 1983;62:79-82. 7. Shinagawa S, Nagayama M. Cervical pregnancy as a possible sequela of induced abortion. Am J Obstet Gynecol. 1969;105:282-284. 8.
Dees HC. Cervical pregnancy associated with uterine leiomyomas. South Med J. 1966;59:900.
9.
Fahmy K, Zikry AM, Hassan S. Cervical pregnancy. Int Surg. 1971;55:127-130.
10. Iffy I. Contribution to the etiology of ectopic pregnancy. Obstet Gynaecol Br Commonwealth. 1961;8:441. 11. Acosta DA. Cervical pregnancy—a forgotten entity in family practice. J Am Board Fam Pract. 1997;10:290-295. 12. Ushakov FB, Elchalal U, Aceman PJ, et al. Cervical pregnancy: past and future. Obstet Gynecol Surv. 1996;52:45-59. 13. Sonmez AS, Kafkasli A, Sarac K, et al. Cervical pregnancy: can age and parity be predisposing factors? Acta Obstet Gynecol Scand. 1994;73:734-736. 14. Traina V, Pinto V, Marinaccio M, et al. Exocervical pregnancy. Arch Gynecol Obstet. 1997;259:205-207. 15. Frates MC, Benson CB, Doubilet PM, et al. Cervical ectopic pregnancy: results of conservative treatment. Radiology. 1994;191:773-775. 16. Poon KF, Chan LKC, Tan HK, et al. Cervical ectopic pregnancy—a case report. Singapore Med J. 1997;38:27-28. 17. Sepulveda WH, Vinals F, Donetch G, et al. Cervical pregnancy: a case report. Arch Gynecol Obstet. 1993;252:155-157. 18. Kobayashi M, Hellman LM, Fillist LP. Ultrasound: an aid in the diagnosis of ectopic pregnancy. Am J Obstet Gynecol. 1969;103:1131-1140. 19. Hajenius PJ, Roos D, Ankum WM, et al. Are human chorionic gonadotropin clearance curves of use in monitoring methotrexate treatment in cervical pregnancy? Fertil Steril. 1998;70:362-365. 20. Dall P, Pfisterer J, Du Bois A, et al. Therapeutic strategies in cervical pregnancy. J Obstet Gynecol Reprod Biol. 1994;56:195-200. 21. Palazzetti PL, Cipriano L, Spera G, et al. Hysterectomy in women with cervical pregnancy complicated by life-threatening bleeding: a case report. Clin Exp Obstet Gynecol. 1997;24:74-75. 22. Okeahialam MG, Tuffnell DJ, Donovan PO, et al. Cervical pregnancy managed by suction evacuation and balloon tamponade. Eur J Obstet Gynecol Reprod Biol. 1998;79:89-90. 23. Cosin JA, Bean M, Grow D, et al. The use of methotrexate and arterial embolization to avoid surgery in a case of cervical pregnancy. Fertil Steril. 1997;67:1169-1171. 24. Centini GG, Rosignoli L, Severi M. A case of cervical pregnancy. Am J Obstet Gynecol. 1994;171:272-273. 25. Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and report of two cases treated conservatively. Ultrasound Obstet Gynecol. 1996;8:373380. 26. Van de Meerssche M, Verdonk P, Jacquemyn Y, et al. Cervical pregnancy: three case reports and a review of the literature. Hum Reprod. 1995;10:1850-1855.
1 8 0
ANNALS OF EMERGENCY MEDICINE
38:2 AUGUST 2001