Academic OB/GYN Cases – Cervical Ectopic Pregnancy
A patient was transferred to our service with a diagnosis of cervical ectopic pregnancy. Her history was notable for two prior term vaginal deliveries without complications. Ultrasound confirmed that she had a 6 week size pregnancy in the cervical canal with a fetal heart rate. Consideration was given to several courses of action, including D and C versus treatment with methotrexate. Due to concern for heavy bleeding with D and C, methotrexate was chosen. Consideration was given to doing uterine artery embolization along with the D an C, based on a number of literature recommendations.
The patient was started on a multidose methotrexate regimen of 1 mg/kg every other day alternating with leukovorin rescue 0.1 mg/kg every other day. Over the course of 4 treatments with MTX the Beta HCG rose from 8,000 to around 12,000 and then plateaued at that level. The patient at that point was starting to have apthous ulcers from the MTX and preferred surgical management.
Due to the size and apparent accessibility of the pregnancy, a D and C was done without uterine artery embolization. The cervix was injected with 10/40 vasopressin and a 7 mm suction was used to evacuate the cervix. After evacuation, a 30 cc foley was inflated with 10 cc of saline within the cervical canal. The procedure was uncomplicated and there was very little bleeding. The foley catheter was removed the next day and the patient was able to be discharged. Beta HCGs would be followed to 0 in the outpatient setting.
Cervical ectopic pregnancy can be a very dangerous pregnancy, and if large enough can require greater intervention than was required in this case. Large cervical ectopics can be difficult to separate from the underlying cervix. Uterine artery embolization is recommended prior to attempted D and C of large cervical ectopics. In some cases, hysterectomy can be required to control bleeding. In this case, we felt that the chance for bleeding was very low due to the size of the pregnancy and the lack of cervical body dilatation. The use of vasopressin is helpful in decreasing bleeding, and a tamponade balloon can also be helpful, though in this case it was probably redundant as there was little postoperative bleeding.