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