A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriage

1. A case report of cervical ectopic pregnancy
misdiagnosed as cervical miscarriage

2. Case Report
A case report of cervical ectopic pregnancy
misdiagnosed as cervical miscarriage
Ahmed S. Elagwany*, Tamer M. Abdeldayem
Department of Obstetrics and Gynecology, Alexandria University, Egypt
a r t i c l e i n f o
Article history:
Received 19 September 2013
Accepted 7 October 2013
Available online xxx
Keywords:
Cervical ectopic pregnancy
Ultrasound
Balloon tamponade
Cervical abortion
a b s t r a c t
Cervical pregnancy is a rare variety of ectopic gestation. The aetiology is obscure. Diagnosis
may be difficult unless the clinician/the radiologist is conscious of the entity. The evalu-
ation of first trimester vaginal bleeding or pelvic pain is an important task for the emer-
gency physician. The early identification of an ectopic pregnancy can help prevent
significant morbidity and mortality for patients seeking emergency care. We present the
case of a patient found to have a cervical ectopic pregnancy.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Cervical ectopic pregnancy is extremely rare, accounting for
less than 1% of all ectopic pregnancies. Its aetiology is still
unclear. However, there are reports of association with chro-
mosomal abnormalities as well as a prior history of pro-
cedures that damage the endometrial lining such as caesarean
section, intrauterine device, and in vitro fertilization.1
The important causes of first trimester bleeding are spon-
taneous abortion, ectopic pregnancy, and gestational tropho-
blastic disease. The clinical assessment of pregnancy outcome
is often unreliable, and ultrasound evaluation combined with
quantitative beta human chorionic gonadotropin (B-HCG) is
an established diagnostic tool in these patients. In the setting
of first trimester bleeding, it is important for physicians to
consider the diagnosis of ectopic pregnancy because signifi-
cant morbidity and mortality may result from a missed or
delayed diagnosis.2
We present the case of a cervical ectopic
pregnancy.
2. Case report
A 35-year-old female gravida three with a history of two
caesarean sections at full term and one spontaneous abortion
presented to our clinic with vaginal bleeding. The patient
underwent dilatation and curettage one week before for cer-
vical abortion in a district hospital. Ultrasound was done in
that hospital early in pregnancy with no suspicion of cervical
pregnancy. The patient was HCV positive. The patient was
complaining of vaginal bleeding since then.
On admission, vital signs were stable. HB was 7 g/dl.
Coagulation profile and liver function tests were in the normal
range. Transvaginal ultrasound (Fig. 1) showed a well-defined
uterus with echogenic tissues and fluid at the very lower
segment of the uterus essentially below the prior caesarean
section scars and in the cervix, colour Doppler showed active
blood flow around and in the tissues with high suspicion of
remnants of conception. Quantitative beta hCG was
4000 mLU/mL at this point. Speculum examination showed a
* Corresponding author. El-Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt. Tel.: þ20 1228254247.
E-mail address: Ahmedsamyagwany@gmail.com (A.S. Elagwany).
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3
Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed as
cervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004
0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.10.004

3. copious amount of bleeding and clots and an enlarged tender
opened cervix with tissues protruding.
The patient was transferred to the operating theater for
evacuation under anaesthesia. Curettage of the remnants was
performed under ultrasound guidance, that revealed highly
adherent conceptus tissues (Fig. 2) with severe bleeding. So, a
diagnoses of cervical ectopic pregnancy was highly suspected.
Intracervical balloon tamponade with Foley’s catheter and
vaginal bilateral uterine artery ligation were done. The balloon
was removed after 48 h without any recurrence in bleeding.
The tissues were sent to pathology, which confirmed
remnants of cervical ectopic pregnancy. Beta hCG was
500 mLU/mL on the day after the procedure and 30 mLU/mL
and 2 mLU/mL 2 weeks after. Follow up was done till B-hCG
reached zero after three weeks. Bleeding stopped completely
and the patient resumed her normal periods. Written
informed consent was obtained from the patient to publish
this case.
3. Discussion
The aetiology of cervical pregnancy is unknown, although it is
likely to result from a combination of factors, including local
cervical pathology mainly of iatrogenic origin such as previous
dilatation and curettage, Asherman’s syndrome, previous
Caesarean section, previous cervical or uterine surgery and
in vitro fertilization e embryo transfer.3
Presenting symptoms generally include vaginal bleeding
which is usually painless but may be coupled with abdominal
pain and urinary problems, particularly in more advanced
pregnancies. Findings at admission vary, but include an
enlarged, globular or distended cervix, which is often associ-
ated with external os dilatation.4
Diagnosis of cervical pregnancy requires visualization of
an intracervical ectopic gestational sac or trophoblastic mass.
Transvaginal ultrasound improves visualization in cases of
early cervical pregnancy. However, it is limited by a restricted
field of view inherent in the scanning technique. Trans-
abdominal imaging, although inferior in imaging detail, al-
lows visualization of the uterus, canal and vagina in a single
plane. It may be preferable in advanced cases of cervical
pregnancy. It has been suggested by Ushakov et al4
that
visualization of an intact part of the cervical canal between
the endometrium and gestational sac reflects an intracervical
placentation.
Differentiation of a true cervical pregnancy from an isth-
micocervical pregnancy is important and requires demon-
stration of a closed internal os. The internal os (on a coronal
view) is said to be at the level of the insertion of the uterine
arteries. Thus, if the internal os cannot itself be visualized, the
sac should be below the uterine artery insertion, which should
be identifiable.4
Early cervical pregnancy may be mistaken for the cervical
stage of miscarriage where the abortus is retained by a resis-
tant external os, thereby ballooning out the cervical canal. The
larger or globular uterus compared to the hourglass configu-
ration in cervical pregnancy is particularly helpful. The
‘sliding sign’ which occurs when the gestational sac of an
abortus slides against the endocervical canal following gentle
pressure by the sonographer and which will not be seen in an
implanted cervical pregnancy may also assist in the differ-
entiation.5
Local endocervical tissue invasion by the tropho-
blast is also important in cervical pregnancy and it may be
possible to identify the site with ultrasound. The hyperechoic
trophoblastic ring will be thicker in the area of invasion. It
may be more difficult to visualize the remaining thinned
cervical wall. Low resistance placental blood flow due to the
trophoblastic villi, termed peritrophoblastic arterial flow, has
been useful in the diagnosis of tubal ectopic pregnancy using
Fig. 1 e Ultrasound picture showing remnants of
conception intra cervical.
Fig. 2 e Remnants of conception after curettage.
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e32
Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed as
cervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004

4. colour flow Doppler and may be useful in both diagnosis and
monitoring of treatment in cervical.4,6
The low resistance flow
may be detected in an intracervical position confirming the
site of implantation. A non-viable sac passing through the
cervix will have no peritrophoblastic flow.7
Following diagnosis, conservative medical and/or surgi-
cal management is generally undertaken in an attempt to
avoid hysterectomy and preserve fertility. Over the last
decade, therapeutic regimes including chemotherapy, Foley
catheter tamponade, curettage and local prostaglandin in-
jection and arterial embolization have been pursued with a
consequent reduction in the number of hysterectomies
performed.4,8
Methotrexate is the most commonly used systemic
agent, although the drug has also been administered intra-
muscularly, intravenously, intracervically and intra-
amniotically. The presence of a viable foetus or advanced
gestational age have been associated with higher rates of
treatment failure.9
If there is an increase in bleeding or
reappearance of vaginal bleeding during methotrexate
treatment, further intervention with intra-arterial emboli-
zation is warranted. Arterial embolization has been used to
control bleeding to enable the maintenance of a concurrent
intrauterine heterotopic pregnancy in the presence of a
cervical pregnancy.7,10
In the case of cervical pregnancy, it may also be preferable
to wait for at least 6 months before conceiving to minimize
any effect. Furthermore, it may be important to watch for
possible increased risk of preterm labour or incompetent
cervix, which are not due to the cervical pregnancy itself but
rather its predisposing factors.10
In conclusion, early diagnosis of cervical pregnancy with
the use of ultrasound and utilization of conservative treat-
ment regimens has decreased associated morbidity and
improved the possibility of on-going fertility in affected
patients.
Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
1. Gun M, Mavrogiogis M. Cervical ectopic pregnancy: a case
report and literature review. Ultrasound Obstet Gynecol.
2002;19:297e301.
2. Tayal VS, Cohen H, Norton HJ. Outcome of patients with an
indeterminate emergency department first-trimester pelvic
ultrasound to rule out ectopic pregnancy. Acad Emerg Med.
2004;11:912e917.
3. Honey L, Leader A, Claman P. Uterine artery embolizationda
successful treatment to control bleeding cervical pregnancy
with a simultaneous intrauterine gestation. Hum Reprod.
1999;14:553e555.
4. Ushakov FB, Elchalal V, Aceman PJ. Cervical pregnancy: past
and future. Obstet Gynecol Sur. 1996;52:45e59.
5. Benson CB, Doubilet PM. Strategies for conservative
treatment of cervical ectopic pregnancy. Ultrasound Obstet
Gynecol. 1996;8:371e372.
6. Spitzer D, Steiner M, Graf A. Conservative treatment of
cervical pregnancy by curettage and local prostaglandin
injection. Hum Reprod. 1997;12:860e866.
7. Cosin JA, Bean M, Grow D. The use of methotrexate and
arterial embolisation in a case of cervical pregnancy. Fertil
Steril. 1997;67:1169e1171.
8. Kung FT, Chang JC, Tsai YC. Subsequent reproduction and
obstetric outcome after methotrexate treatment of cervical
pregnancy: a review of original literature and international
collaborative follow-up. Hum Reprod. 1997;12:591e595.
9. Yitzhak M, Orvieto R, Nitke S. Cervical pregnancyda
conservative stepwise approach. Hum Reprod.
1999;14:847e849.
10. Kung FT, Chang SY. Efficacy of methotrexate treatment in
viable and nonviable cervical pregnancies. Am J Obstet
Gynecol. 1999;181:1438e1444.
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3 3
Please cite this article in press as: Elagwany AS, Abdeldayem TM, A case report of cervical ectopic pregnancy misdiagnosed as
cervical miscarriage, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.004

5. Apollohospitals:http://www.apollohospitals.com/
Twitter:https://twitter.com/HospitalsApollo
Youtube:http://www.youtube.com/apollohospitalsindia
Facebook:http://www.facebook.com/TheApolloHospitals
Slideshare:http://www.slideshare.net/Apollo_Hospitals
Linkedin:http://www.linkedin.com/company/apollo-hospitals
Blog:Blog:http://www.letstalkhealth.in/