Cervical Ectopic Pregnancy Easy to Miss

ACEP News
February 2010

By Michele G. Sullivan
Elsevier Global Medical News


KISSIMMEE, FLA. -- Women who present with vaginal bleeding--with or without abdominal pain--in the first trimester of pregnancy should undergo an ultrasound scan to rule out an ectopic pregnancy in the cervix, according to Dr. Valerie Shavell.

Because cervical pregnancy is so rare--about 1 in 9,000 pregnancies--it may not be on the diagnostic radar when a woman arrives in the emergency department with such common symptoms. Thus, a cervical pregnancy can easily be misdiagnosed as a threatened spontaneous abortion, she said at the annual meeting of the AAGL.

If the patient is then discharged under watchful waiting, rupture may occur with a potentially fatal bleed. Hemorrhage is also possible if she undergoes a dilation and curettage for a suspected threatened abortion. Either way, the outcome may be a hysterectomy, said Dr. Shavell of Wayne State University, Detroit.

Ultrasound can identify more than 80% of cervical pregnancies in time for medical or minimally invasive therapy, which can prevent hysterectomy and preserve fertility, said Dr. Shavell and her colleague, Dr. Mark Zakaria.

Dr. Shavell discussed symptoms and ultrasound findings in a case series of 14 women (mean age 32 years) who were treated for cervical pregnancy at the Detroit Medical Center over a 10-year period. Most of the patients (eight) presented directly to the hospital's emergency department. Four were transferred from other hospitals, and two were admitted from the resident clinic. Their mean gravidity was 5, and their mean parity was 2.

Consistent with the area's demographics, 71% were black. Eleven of the women had a risk factor for cervical pregnancy: prior termination of pregnancy (nine), cesarean section (four), or cervical cone biopsy (two). The gestational age at presentation ranged from 5 to 11 weeks.

All patients presented with vaginal bleeding, which was mild in seven, moderate in four, and heavy with clots in three. Six patients also reported some abdominal pain or cramping.

"In all cases, ultrasound identified a gestational sac and yolk sac consistent with the gestational age as measured by the last menstrual period," Dr. Shavell said. "We also saw prominent vascularity surrounding the gestational sac in every case."

Fetal heart activity was present in 64%. The distance between the external cervical os and the leading edge of the gestational sac ranged from 7 to 25 mm.

Dr. Zakaria reported treatment outcomes for all 14 of the patients, plus 1 additional patient. All received the first-line therapy of methotrexate and leucovorin (used to protect healthy cells from methotrexate); this was sufficient to terminate the pregnancy in five.

Six women received additional therapy and also underwent a uterine artery embolization. In four patients, the methotrexate combination was delivered in conjunction with a fetal intraembryonic potassium chloride injection, followed by uterine artery embolization.

It's important to carefully assess both the patient and the services available to her while making treatment decisions, Dr. Zakaria said.

"Methotrexate is a reasonable first-line therapy. It's easy to administer and can be given in any hospital. The other treatments require an interventional radiologist, who might not always be available at a community hospital. If the patient comes to the emergency department and the physician suspects a cervical pregnancy, that physician should consider whether the hospital is equipped to do these interventions, or whether a transfer might be necessary."

Dr. Zakaria examined the correlation between certain patient characteristics and the level of intervention the patient required. Although he found no significant associations, there were some trends to discuss.

"Generally, those who had lower human chorionic gonadotropin levels required less intervention, although it's hard to say what that means," he said in an interview. "It could have been that these women were in an earlier stage of pregnancy, or we could have also caught them at a later stage, when the pregnancy was already failing and the hormones were already on the way down."

The mean hemoglobin level was also lower--although not significantly so--upon presentation in those who required a uterine artery embolization. More of these patients also ended up needing a transfusion.

"This brings up the idea that patients with lower hemoglobin and more bleeding at presentation are more critical, and may need more interventions," Dr. Zakaria said. "That may be something to look at in the emergency department--you may consider an embolization for a patient who has heavy bleeding instead of painless spotting."

None of the patients required a hysterectomy, and the colleagues were able to confirm that three of them had subsequent pregnancies.

Two women had intrauterine pregnancies that led to delivery (one term vaginal delivery and one cesarean section after preterm rupture of membranes). One pregnancy resulted in an early miscarriage.

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