Case Report

A thirty-year-old lady Gravida four Para one presented to the early pregnancy unit at 7 to 8 weeks with amenorrhoea, pain and bleeding per vaginum. A transvaginal scan confirmed a single live foetus with a crown rump length equivalent to 7 weeks and 3 days gestation. The sac was very low in cervical canal and yolk sac was seen. There were multiple fibroids largest measuring 5 cm in the uterus. Her haemoglobin was 10.5 g/dl. Diagnosis of cervical pregnancy was suspected and the lady was advised follow up in a week for review.

One week later she presented in pain with heavy bleeding. A transvaginal scan confirmed that the pregnancy was in the cervix and viable (fig 1). Speculum examination showed presence of the sac in the os. She was admitted to gynaecology ward. Her haemoglobin was 6.3 g/dl and she was transfused 4 units of blood. She continued to bleed and after discussion with the couple, decision to proceed to termination of pregnancy was made. In view of risks of suction termination, medical management was chosen with methotrexate. Methotrexate was administered in dose of 50mg/sq m intramuscularly. Repeat scan six days later showed sac still in cervix but absent foetal heart. Patient continued to bleed and about 300 ml clot was removed on examination.

She was consented for an evacuation of retained products after full explanation including risks of haemorrhage and hysterectomy. In the operating theatre, products of conception were evacuated using sponge forceps. She continued to bleed from the cervix after evacuation, pressure was applied with a swab and as this reduced the bleeding; gauze pack was inserted and left for 12 hours, her vital signs remained stable. Pack was removed the following day and no excess bleeding noted. The lady was discharged home the following day. Follow up scan a week later revealed a normal cervix with a fibroid uterus. Histology confirmed products of conception.

Discussion

Cervical ectopic pregnancy is a rare event with a frequency between 1/10000 and 1/16000 deliveries. To identify a cervical ectopic pregnancy, cervical glands must be attached to the placenta, the placenta must be implanted below the place where the uterine vessels reach the uterus and the attachment between the placenta and the cervix should be intimate.(₁) These conditions are known as Rubin's criteria.

Cervical ectopic pregnancy can be associated with unexpected occurrence of uncontrollable haemorrhage from the cervix which may need hysterectomy. Diagnosis and treatment of cervical ectopic pregnancy has changed dramatically in last fifteen years. Conservative medical management in form of methotrexate systemically and locally has been described. It is unclear whether advanced cervical ectopics should be managed primarily by surgical evacuation or by the more conservative medical management with chemotherapeutic agents.(₂) This case is reported as it is rarely seen.

Correspondence to

Dr S Hemmadi, MRCOG 125 Heol-Y-Coed, Rhiwbina, Cardiff. CF14 6HS Email:shyla_sree@hotmail.com