Cervical pregnancy Aboubakr Elnashar

Benha university Hospital, Egypt ABOUBAKR ELNASHAR

CONENTS 1. INTRODUCTION

History

Define

Incidence

Cause

Risk Factors

Morbidity and Mortality

2. DIAGNOSIS

3. Differential diagnosis

4. TREATMENT

CONCLUSION

ABOUBAKR ELNASHAR

1. INTRODUCTION

History First report of a Cervical Pregnancy: 1860.

First described in the literature: 1911 (Parente et al, 1983).

First report of CEP diagnosed using US: 1978 (Raskin, 1978)

ABOUBAKR ELNASHAR

DEFINE:

Pregnancy implants in the lining of the endocervical

canal, below the level of the internal os.

Rubin pathological criteria (1911)

1) Cervical glands must be present opposite the

placental attachment

2) Attachment of the placenta to the cervix must be

intimate

3) The whole or a portion of the placenta must be

situated below the entrance of the uterine

vessels, or below the peritoneal reflection

of the anterior and posterior surface of the uterus

4) No fetal elements must be present in the corpus

uteri.

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

INCIDENCE

1% of ectopic pregnancies

1 in 9000 deliveries

More common in pregnancies achieved through

ART (Ginsburg, 1994).

0.1% of IVF pregnancies

3.7% of IVF ectopic gestations

ABOUBAKR ELNASHAR

CAUSE

Unknown

1. Rapid transport of the fertilized ovum into the

endocervical canal before it is capable of

nidation or because of an unreceptive

endometrium.

2. Damage to the cervix and endometrial lining

during operative uterine procedures

The more cephalad that the trophoblast is

implanted along the cervical canal, the greater is its

capacity to grow and hemorrhage.

ABOUBAKR ELNASHAR

RISK FACTOR

1. ART

2. Previous dilation and curettage.

3. Previous CS

4. Asherman syndrome

5. induced abortion

6. Endometritis, uterine fibroids

7. IUCD

8. Age between 35 and 40 y

9. Structural anomalies of the cervix or

body of the uterus

10. Grand multiparity, (Thomas et al, 1995; Jeng et al, 2007)

ABOUBAKR ELNASHAR

Morbidity and mortality

Although non-tubal ectopic pregnancies account

for only 5% of ectopic pregnancies, they are

responsible for significant morbidity (Condous, 2002)

Potentially life-threatening

Maternal mortality related to Cervical

Pregnancy has dropped from

40–45% to 0–6% in the past 50 ys (Wolcott, 1989)

ABOUBAKR ELNASHAR

2. DIAGNOSIS Early diagnosis

Important

{most cases of severe hge and need for

hysterectomy have occurred in pregnancies in the

late 1st and early 2nd T}.

To avoid complications and successful tt.

Correct diagnosis

Important

avoid interventions which could lead to severe hge

necessitating hysterectomy.

ABOUBAKR ELNASHAR

Symptoms

1. Painless vaginal bleeding: 90%

Massive hemorrhage: 30% (Ushakov, 1997).

2. Lower abdominal pain or cramps

30%

3. Pain without bleeding

rare.

ABOUBAKR ELNASHAR

Examination

1. Speculum examination

Distended, thin-walled cervix

Partially dilated external os

revealing fetal membranes or pregnancy tissue,

which appear blue or purple.

Infrequently, a cystic lesion on the cervical lip is

observed and represents trophoblastic invasion into

the cervical stroma.

ABOUBAKR ELNASHAR

Speculum appearance of

cervical pregnancy

presenting as a mass

at the external cervical os

ABOUBAKR ELNASHAR

2. Bimanual examination

Should be avoided until imaging studies have

excluded the diagnosis.

If bimanual examination is performed:

endocervical canal should not be explored as this

is likely to cause hemorrhage.

soft cervix that is disproportionately enlarged

compared to the uterus: "an hourglass“ shaped

uterus

As pregnancy progresses: Above the cervical

mass, a slightly enlarged uterine fundus can be felt.

By comparison, enlargement of the uterus without significant cervical enlargement is characteristic of intrauterine pregnancy, although the cervix softens and becomes mildly congested.

ABOUBAKR ELNASHAR

Investigations

1. Positive pregnancy test

2. Sonographic criteria

Accuracy: 87.5% [3].

An embryo or fetus in the intracervical area

Gestational sac:

below the level of the internal cervical os or uterine

arteries.

gestational sac or placenta within the cervix

● normal endometrial stripe

● hourglass (figure of eight) shaped uterus

ABOUBAKR ELNASHAR

Raskin (1978)

4 criteria:

1. enlargement of the cervix,

2. uterine enlargement

3. diffuse amorphous intrauterine echoes

4. absence of an intrauterine pregnancy.

Timor-Tritsch et al (1994) refined the criteria

5. placenta and entire chorionic sac containing

the pregnancy be below the internal cervical os

6. cervical canal must be dilated and barrel shaped

ABOUBAKR ELNASHAR

Ushakov’s sonographic criteria (1996)

1. GS: in the endocervical canal.

2. Presence of some intact cervical tissue between

the GS and the internal orifice.

3. Trophoblast invasion of the endocervical tissue.

4. Embryonal or fetal structures, in particular

pulsating heart, in the ectopic GS.

5. Empty uterine cavity.

6. Endometrial decidualization.

7. Sand-glass shaped uterus.

8. Doppler detection of peritrophoblast arterial flow

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

3. MRI:

unusual or complicated cases when the diagnosis

is uncertain Rubin defined histologic criteria for cervical pregnancy, but a histologic

diagnosis is not clinically practical since it requires hysterectomy.

ABOUBAKR ELNASHAR

Abdominal MRI imaging of a cervical pregnancy.

An empty uterine cavity

a pregnancy (arrow) is present at the level of the

cervix. ABOUBAKR ELNASHAR

3. DIFFERENTIAL DIAGNOSIS

1. Incomplete abortion that is proximal to the cervix.

cardiac activity often seen in a cervical pregnancy with a visible

embryo, but not in an incomplete abortion

Gestational sac

cervical pregnancy: regular contours

incomplete abortion sac often has irregular

contours that may change shape during the scan

Cervical os

closed in a cervical pregnancy

open in an incomplete abortion (Jung, 2001; Sherer, 2008).

ABOUBAKR ELNASHAR

Failed pregnancy Cx ectopic CSP

within the cervical canal anterior LUS 1. Location

normal thin 2. Overlying anterior

myometrium

positive negative 3. Sliding organ sign*

lack color flow vascular flow

around and within

the GS

marked

peritrophoblastic

color Doppler flow

around GS

4. Doppler

not fixed in

location, not

growing

±growing 5. Short follow up

US

*Gentle pressure with the TV probe: displace GS from its

position within the endocervical canal

ABOUBAKR ELNASHAR

2. Cesarean or hysterotomy scar pregnancy,

gestational sac is in the anterior lower uterine

segment

uterine cavity and endocervical canal are empty

ABOUBAKR ELNASHAR

CSP: at 6 w

GS in the anterior LUS at the presumed site of the uterine scar

empty endometrial (thin arrows) and cervical (long arrows)

canals

thinning of the myometrium between GS and bladder (short

arrows). ABOUBAKR ELNASHAR

2. Cervical abortion:

an aborting intrauterine pregnancy that is trapped

in the endocervical canal {resistance from the

external cervical os}.

some products of conception/blood clot in the

uterine cavity

the uterine cavity is enlarged compared to the

cervix

the internal cervical os is open

gestational sac is flattened and has no or a

minimal echogenic rim and contains no or a

dead embryo

ABOUBAKR ELNASHAR

Cervical ectopic pregnancy:

Sagittal TAS of the midline

uterus (A): GS centered in the

endocervical canal, normal

myometrial thickness between

GS and bladder (arrow). Sagittal

and TVS of the endocervical

canal (B and C) with vascular

flow around and within the GS

on color Doppler ( C). ABOUBAKR ELNASHAR

Cervical ectopic pregnancy

GS is seen within the

cervical canal

myometrium is not thinned

out as seen in LSCS scar

pregnancy. ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

A) Thickened endometrium with a pseudo-GS (PS)

B) GS below caesarian scar (CS) with a viable embryo

C) CRL: 6,2mm

D) low resistance blood flow around the gestational sac ABOUBAKR ELNASHAR

Failed pregnancy TV color Doppler: sagittal midline

cervix: avascular GS centered within the endocervical

canal ABOUBAKR ELNASHAR

GS with a small embryonic pole with FHR 122bpm located in the

cervix below the scar of the previous CS (vertical arrow).

Cervix: closed, enlarged, and tender (horizontal arrow).

Estimated gestational age based on LMP was 6w and 6d.

ABOUBAKR ELNASHAR

Cervical pregnancy

(1) an hourglass uterine shape

(2) ballooned cervical canal

(3) gestational tissue at the level of the cervix (black arrow)

(4) absent intrauterine gestational tissue (white arrows)

(5) portion of the endocervical canal seen interposed between

the gestation and the endometrial canal ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

4. TREATMENT Dependent on

1. Gestational age

2. Stability of the patient

3. Patient interest in retaining future fertility

4. Resources

5. Expertise of the practice treating the patient.

ABOUBAKR ELNASHAR

TT must address the serious danger of

uncontrollable hge

Curettage

local prostaglandin injection,

hysteroscopic resection

angiographic UAE

uterine artery ligation

Cervicotomy

intracervical injections of vasoconstrictive

agents

Shirodkar-type cervical cerclage

When there are so many options, it indicates

that there is no ideal management regimen.

ABOUBAKR ELNASHAR

≤9 w gestational age and without fetal cardiac

activity:

systemic chemotherapy with MTX alone

either

single dose regimens: 50 mg/m2) or

multiple dose regimens

MTX: 1 mg/kg on days 1, 3, 5 and 7

Folinic acid rescue (leucovorin) 0.1 mg/kg on

days 2, 4, 6 and 8

{ ameliorate MTX side effects}.

ABOUBAKR ELNASHAR

If MTX is unsuccessful:

UAE minimizes the risk of hge

Curettage was then performed to ensure the

eradiation of the pregnancy.

ABOUBAKR ELNASHAR

For patients who are no longer interested in

fertility:

hysterectomy is an option if they are diagnosed

with an actively bleeding cervical pregnancy

ABOUBAKR ELNASHAR

I. Minimally invasive

Conservative management is feasible for many

women

Methotrexate

1st -line therapy in stable women (Verma, 2011; Zakaria, 2011).

ABOUBAKR ELNASHAR

1. Direct injection into GS, alone or with systemic

doses (Jeng, 2007; Kirk, 2006).

Multidose MTX therapy with intraamniotic and/or

intrafetal injection of local KCL (intracardiac

injection of 5 mEq) when fetal cardiac activity is

present (Verma, 2009).

If β-hCG levels do not decline more than 15%

after 1 w, a 2nd dose of MTX can be given. Song and associates (2009) described management of 50 cases and observed that sonographic resolution lagged far behind serum β-hCG regression.

ABOUBAKR ELNASHAR

More advanced gestations where fetal cardiac

activity is present:

1. combined treatment with both M multidose MTX

and intraamniotic and/or intrafetal injection of KCL:

prompt fetal death: facilitate pregnancy resorption,

which can take a few months

Intrasac injection in the operating room

{there is a risk of hge when the sac collapses}.

A 2022 gauge needle is advanced transvaginally

into the GS and fetal thorax under US using a

needle guide attachment. When the tip of the needle

is in the embryo, KCL (1 to 5 mL of 20% KCL

solution) is injected until there is cessation of

cardiac activity.

ABOUBAKR ELNASHAR

Heavy vaginal bleeding when the pregnancy is

involuting may require

1. intraarterial embolization to control hge.

2. If this is not successful:

A. dilation and evacuation is the next step:

B. hysterectomy is a last resort.

ABOUBAKR ELNASHAR

Results

1. Ablation of the ectopic gestation

2. Preservation of the uterus in 80%

3. Resolution and uterine preservation are

achieved for gestations < 12 ws in 91% of

cases (Kung, 1997).

ABOUBAKR ELNASHAR

2. Foley catheter

In the event of hemorrhage

26F Foley catheter with a 30-mL balloon placed

intracervically and inflated: hemostasis by vessel

tamponade and to monitor uterine drainage.

Remains inflated for 24 to 48 h

gradually decompressed over a few days (Ushakov, 1997).

ABOUBAKR ELNASHAR

3. Uterine artery embolization

Indication:

1. As an adjunct to medical or surgical therapy

2. As a response to bleeding or

3. As a preprocedural preventive tool (Hirakawa, 2009; Nakao, 2008; Zakaria, 2011).

methotrexate infusion combined with UAE (Xiaolin, 2010).

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

II. Systemic

1. Single-dose IM MTX

Dose

between 50 and 75 mg/m2 BSA

Higher failure (Hung et al, 1996)

G age > 9 w,

β-hCG levels > 10,000 mIU/mL

CRL10 mm

Fetal cardiac activity.

For this reason, many induce fetal death with

intracardiac or intrathoracic injection of KCl

ABOUBAKR ELNASHAR

Contraindications of systemic MTX for the tt of

any ectopic pregnancy (ACOG, 2009)

1. hCG ≥5000 mIU/ mL

2. Embryonic cardiac activity

very commonly found with cervical pregnancies,

are relative

ABOUBAKR ELNASHAR

No visible cardiac activity:

Single dose of MTX

no advantage in the use of a multipledose regimen (Kirk et al, 2006)

local MTX or KCl injection with or without interval

curettage.

If such techniques are not available: multiple-dose

systemic MTX is an alternative.

ABOUBAKR ELNASHAR

2. IM multidose MTX alone

Often adequate for tt of very early cervical

pregnancies without fetal cardiac activity [24]. MTX IM rather than IV {IM is more convenient and there are no data indicating that one route is superior to the other}.

The multidose MTX drug protocol is the same as

that used in patients with tubal ectopic pregnancy

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

Evolution of serum β-hCG during multidose MTX

Both patients were followed with serial serum β-hCG

measurements. Arrows indicate injections of methotrexate

(MTX) 50 mg/m2. ABOUBAKR ELNASHAR

Success rate

overall: 55-83%

With cardiac pulsation: 40%

Without cardiac pulsation: 91% {37, 42}. Conservative treatment with methotrexate chemotherapy of patients with either viable, or nonviable cervical pregnancies at <12 weeks’ gestation, carries a 91% success rate for preservation of the uterus. The structure of the cervix was restored and menstruation returned for all patients in whom the uterus was preserved after treatment (Fu-Tsai Kung, 1999). Resolution of the cervical mass on sonography lagged far behind resolution of the serum HCG level. The cervical mass evolved from a gestational sac into a mixed echoic lesion on serial TVS (Song et al, 2009).

ABOUBAKR ELNASHAR

On day 2 after systemic methotrexate administration (7 MHz

probe).

A) Color doppler flow showing remnant trophoblastic perfusion;

B) endometrial cavity filled with a central anechogenic area

suggestive of blood and a thinner surrounding endometrium

ABOUBAKR ELNASHAR

On day 45 (7 MHz probe). Normal cervix.

ABOUBAKR ELNASHAR

III. Surgical therapy

1. Dilation and evacuation

Suction curettage

favored in rare cases of a heterotopic pregnancy

composed of a cervical and a desired uterine

pregnancy (Moragianni, 2012).

A key point:

not attempt cervical dilation before initiation of the

passage of an appropriately sized suction canula.

Dilation can disrupt implantation and immediately

lead to heavy vaginal bleeding.

Complication

high incidence of severe hge

ABOUBAKR ELNASHAR

Cervical pregnancy at the time of dilatation and

curettage ABOUBAKR ELNASHAR

Before curretage

intraoperative bleeding may be lessened by

1. Preoperative UAE 2. Transvaginal ligation of the cervicovaginal

branches of the uterine artery

done by deviating the cervix to one side and placing a suture at 3 and 9 o'clock on the lateral side of the cervix. The suture is placed high just below the lateral vaginal fornix, similar to sutures placed for hemostasis during cold knife conization. use 20 polyglactin (Vicryl)

ABOUBAKR ELNASHAR

3. Vasopressin injection

20 to 30 mL of vasopressin (0.5 U/mL) solution with a 1.5inch 21 gauge needle circumferentially deep into the dense cervical stroma. 4. Shirodkar cerclage

placed at the internal cervical os to compress

feeding vessels (Davis, 2008; De La Vega, 2007; Trojano, 2009; Wang, 2011).

ABOUBAKR ELNASHAR

Infiltration of the cervical

stroma with dilute

vasopressin around

the cervical pregnancy

Initiation of suction

curettage

without cervical dilation

Foley catheter balloon

tamponade of the

cervical implantation site

after curettage ABOUBAKR ELNASHAR

Placement of a cerclage-type suture high

on the cervical portio ABOUBAKR ELNASHAR

Following curettage

1. Foley balloon is placed to tamponade bleeding

size 26 Foley catheter with a 30 mL balloon into the

dilated cervix, with the tip extending into the uterine

cavity.

Sterile water (as much as 95 mL) is used to inflate

the balloon for 24 to 48 h.

2. A purse string suture can be placed around the

external cervical os and tied after inflation of the

balloon to prevent expulsion.

3. After 24 to 48 h, the balloon is gradually deflated

over a period of hours to days and removed, but

may be reinflated at any time if bleeding picks up or

recurs.

The catheter also allows constant uterine drainage. ABOUBAKR ELNASHAR

4. injection of prostaglandin F2α.

{ increase uterine contractions, promote

vasoconstriction, and therefore, reduce

hemorrhage.

ABOUBAKR ELNASHAR

Additional measures that can be employed in

women who continue to bleed:

Hemostatic sutures locally in the cervix

Angiographic embolization, Bilateral internal iliac artery ligation

Bilateral uterine artery ligation.

Hysteroscopic resection with a resectoscope has

also been reported to be successful in one case

ABOUBAKR ELNASHAR

The technique begins with circumferential infiltration of the cervical stroma around the cervical pregnancy with a hemostatic vasoconstricting agent, such as 20 mL of dilute vasopressin (20 units diluted within 50 mL of injectable normal saline) to a depth reachable with a 1 1/2 inch, 21 gauge needle This is followed by the placement of an untied cervical suture high around the cervical portio, using a McDonald cerclage technique . This stitch is left in place ready to tie, if necessary, to temporarily occlude the descending cervical branches of the uterine arteries should bleeding occur during the procedure. Then, without cervical canal dilation (the canal is already open containing the pregnancy) an appropriately sized suction curettage (diameter in millimeters equal to the gestational age in weeks), attached to suction, is rotated and slowly passed through the cervical canal and into the endometrial cavity

ABOUBAKR ELNASHAR

Immediately postcurettage a cervical canal balloon, such as a 30 mL balloon foley catheter, is placed against the cervical canal placental bed and inflated to permit a tamponade effect within the cervical canal . The balloon must be inflated within the cervical canal and not within the endometrial cavity. The balloon tamponade is left in place for approximately 24 hours, then slowly deflated, in anticipation of no cervical bleeding. Should such bleeding occur the balloon is reinflated for later removal. Pain control may be needed because of balloon catheter postprocedure cervical canal distention, but in my experience this has been unnecessary. A key point with this suction evacuation is to not attempt cervical dilation before initiation of the passage of an appropriately sized suction canula. The cervical canal is already dilated by the cervical implantation, and further dilation can lead to immediate and profuse cervical bleeding. Sharp curettage is to be avoided.

ABOUBAKR ELNASHAR

During the treatment of these 13 women, no procedure lasted more than 15 minutes, and no immediate intraoperative nor delayed postoperative bleeding occurred. The cerclage suture was never tied but remained in place until after the curettage, ready to be tied should immediate intraoperative bleeding occur. The cerclage suture was removed followed the curettage and placement of the balloon tamponade. Despite not encountering intraoperative bleeding, the balloon tamponade was used in all cases with the anticipation that as the effect of the hemostatic cervical infiltration weaned, bleeding from the cervical placental bed would occur.

ABOUBAKR ELNASHAR

2. Cervicotomy.

ABOUBAKR ELNASHAR

3. Hysterectomy

Indication

1. bleeding uncontrolled by conservative methods.

2. women who have completed their families or

have additional uterine pathology and do not want

to assume the risk of hemorrhage, which can

occur in the course of conservative surgery or

medical therapy.

{close proximity of the ureters to the ballooned

cervix} urinary tract injury rates are of concern

with hysterectomy.

ABOUBAKR ELNASHAR

Cervical pregnancy treated by hysterectomy ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

FUTURE

1. Spontaneous pregnancies after conservative

management of cervical pregnancy (2).

2. increased incidence of cervical insufficiency in

subsequent pregnancies.

3. increased incidence of preterm labor.

4. UAE may affect future fertility

decreased fertility and limited ovarian reserve.

ABOUBAKR ELNASHAR

COCLUSIONS

CEP is the rarest type of ectopic pregnancy

There is a high rate of incorrect diagnosis. The

most common misdiagnosis is cervical miscarriage.

CEP is a challenging to manage and diagnose.

Preservation of fertility is dependent on early

recognition and tt.

Severe hge is the main risk of CEP.

Due to the low incidence of CEP, there is a strong

argument for referral to specialist tertiary referral

units. These units will have more experience in managing such cases

and will be able to offer a variety of treatment options. What will be successful tt for one CEP may fail for another.

ABOUBAKR ELNASHAR

No RCT to suggest which tt modality is superior.:

TT should be individualised

Medical rather than surgical tt is recommended

(Grade 2C).

Multidose, systemic MTX IM.

If fetal cardiac activity is present: inject MTx or KCL

into the gestational sac/embryo. Nonsurgical tt should be the initial option Successful tt may be achieved by means of a combination of systemic and local MTX and local hemostasis.

ABOUBAKR ELNASHAR

Thanks

ABOUBAKR ELNASHAR