Home > Academic OB/GYN Cases, Gynecology, Imaging > Academic OB/GYN Cases – Cervical Ectopic Pregnancy

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.

About these ads
  1. February 11, 2010 at 3:08 pm

    I have a question. I had thought for many years that all ectopic pregnancies would rupture, then I came across several cases profiled in either literature or t.v. where the pregnancy went to term (or viability) and baby was deliveried via c-section. I understand that the vast amount of ectopic pregnancies will rupture if left to themselves and that a rupture can cause the death of the mother, but I do not know if there have been any studies on the actual likelihood of death of the mother due to rupture or on the potential viability of an ectopic pregnancy. Is it known what the likelihood is of reaching viability or is it so remote as to be statistically meaningless? Do different type of out of uterine pregnancies have different statistics? (cases I have heard about have ranged from in the falopian tube to attached to the liver) And, assuming prompt medical attention, what is the death rate from a ruptured ectopic pregnancy? Any insight would be appreciated.

    • February 21, 2010 at 6:03 am

      Jespren –

      There is a small fraction of ectopic pregnancies called abdominal pregnancies, where the fetus and placenta implant on some abdominal structure rather than inside of the tube. The implantation on the liver that you mention would be considered an abdominal pregnancy. Abdominal pregnancies are approximately 1% of ectopics. In rare situations these pregnancies have continued on and are delivered at laparotomy. Abdominal pregnancy exceedingly dangerous for the mother, as without a uterus between the placenta and the mother the vascular anatomy can be very bizarre. In some cases there can be near aorta sized new blood vessels going into the abdominal pregnancy, which at the time of delivery can lead to massive hemmorhage. Usually the baby is delivered and the placenta is left in place, as its vascular attachment to the mother can be difficult if not impossible to separate without huge life threatening bleeding. In many cases the placenta will eventually dissolve, sometimes with the help of methotrexate injections, though this process can be fraught with complications.

      Though there have occasionally be cases of abdominal pregnancies going to term, these are the exception rather than the rule, and usually are the result of failing to diagnose the abdominal pregnancy early. In some cases the abdominal pregnancy can eventually look so much like an intrauterine pregnancy that it is indistinguishable on ultrasound. If an abdominal pregnancy is identified early, typically it will be removed via laparoscopy or laparotomy, or if very early treated with methotrexate. These are very rare cases, and each will be treated in an individualized way.

      In general ectopic pregnancies are not considered viable. They are clearly life threatening to the mother. An ectopic pregnancy that is not treated will frequently lead to severe bleeding and death of the mother. I say this based on history, however, as in this day and age ectopics are diagnosed nearly 100% of the time before that happens. Usually they are diagnosed before they rupture, but in some cases a patient will present to the ED with a ruptured ectopic, at which time they will get surgery to deal with it. Death from ectopic pregnancy would be a pretty unheard of event, assuming that the woman presents to medical care when she has symptoms. Ectopics usually hurt for days to weeks before they rupture, giving women time to come. Most women who present with ruptured ectopics tell stories of having pain for weeks that they ignored, or in some cases they presented but did not get a timely diagnosis of what was going on.

      Thanks for the question!

  2. drwhoo
    February 21, 2010 at 4:00 am

    Cool video…and scary diagnosis. We had one in residency who bled half her blood volume out before getting to the hospital. We didn’t use UAE, but did the balloon tamponade post-op and she did wonderfully well. Hope not to see one again…

  3. September 16, 2010 at 10:46 am

    Just a quick question. Was this done in Trans-V or external? I’m just wondering because at 6 weeks and depending on the mother, I could see how this might be missed if they didn’t go to tv?
    Regards,
    Rose

  4. September 16, 2010 at 2:06 pm

    These are transvaginal images. As you mention, early pregnancies are difficult to image transabdominally, making transvaginal imaging far superior in these cases.

  5. Tiffany
    November 14, 2010 at 5:20 pm

    I was diagnosed with a Cervical Pregnancy last week and was treated with two shots (2.3) of MTX and am still waiting for my hCG to return to 0. This has been the worst week of my life and I only pray it’s over soon. :-(

  6. November 24, 2013 at 11:46 pm

    In addition, it has a definitely dominant fishy character.
    When the fish are in the Hampton Roads area
    and you haven’t fished from this ocean side pier you should
    definitely put it on your own. By Larry LarsenThe Sarasota area is a great
    idea to bring a fishing dating salmon identification book and remember to practice conservation and return fish
    to the” Players”. You want to fishing dating get
    yourself some studded rubber soled foot gear. Why not stay at one fishing dating of the best available in the Maldives.

  7. December 1, 2013 at 1:45 am

    Since that first post I’ve learned that steelhead generate a
    lot of fish present and they do like to show this fish meal angler
    360 groundbait and pellet bait. The beautiful and bountiful
    Gulf waters off Southwest Florida offer excellent fishing!
    So in the end when the time comes, go out on much awaited angler 360 journeys and
    enjoy their quality time.

  8. December 5, 2013 at 9:08 pm

    Some of angler number bc the Cygnets did really well.
    People trying to use the same rig – that iss the type of fishing boat to use.
    Money has to be really careful before placing an order for a fishing
    trip with pals. Which is where we all want to bbe able to hit the 100lbs mark.
    Drop shotting; in that you’ll want some spinning, very good Denver
    guy who might also warrant a look.

  9. December 13, 2013 at 9:35 pm

    If you want to be a professional singer, the most critical ingredient you need
    is to be able to hold a note and stay in tune.
    Again, this type of scholastic improvement has great potential to impact the teen’s overall sense of
    self. Eileen has an extensive background and family history in music which helps her to understand music at a deep level and understanding having grown up with music.

  10. April 11, 2014 at 1:27 am

    I was suggested this wweb site by my cousin.
    I’m nott sure whether this post is written bby him as nobnody else know sich detailed abojt my problem.
    You’re amazing! Thanks!

  11. May 6, 2014 at 1:23 pm

    Excellent way of describing, and fastiudious arrticle to take information concerning
    my presentation subject matter, which i amm going
    to deliver in university.

  12. May 25, 2014 at 11:05 am

    Spot on with this write-up, I absolutely think this web site needs much more attention. I’ll probably be back again to see more, thanks for the info!

  1. June 7, 2011 at 1:59 am

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 91 other followers

%d bloggers like this: