A Case of Cervical Pregnancy

Frank O’KeeffeAGTS Meeting, Tasmania 2011

Cervical Pregnancy27 year old

Para 1 Delivered by Emerg Caesarian Section at term Obstructed labour 2008

1 miscarriage at 9 weeks…D&C 2009

Fit and well

Trying for pregnancy

Positive preg test, unsure dates ….Dating scan

Dating scan

Cervical ectopic pregnancy

Cervical Ectopic Pregnancy

Rare, < 1% of all ectopics

?more common ART IVF ?3%

Assoc with prev surgery/ curettes

SIGN Hour glass uterus, GS below UADiscrete sac doesn’t move ? FH

Dx U/Soundimpression 88% correct

Differential DxCaesar scar Ectopic

Above UA Anterior wall

Incomplete Miscarriage

Moves, Less discrete sac

Other products /Clot in uterus

Ext os open

?MRI

Manage conservatively with MTX

Wants more children

? Avoid disaster

Local experience and tertiary advice indicate high chance of morbidity & possible hysterectomy

Pt aware of risks and consents to Rx

What to Do???Manage as tubal ectopic / no literature for Cx

preg

Surgical

Past Caesar ? Wound ectopic

? Incomplete M/carriage

? Risk profile

Local experience

Tertiary Opinion

Follow upNeed compliant patient

Serial bhCG

Pt to present if significant bleeding /Cramping pain

MTX ProtocolsSingle Dose

hCG 50mg/m2

Day 4 hCG

Day 7 hCG

If <15% drop Repeat dose

Multidose

1mg /kg IM bhCG +folinic acid 0.1mg/kg oral

Day 3,5,7 bhCG if < 15% drop rpt dose

Up to 5 doses

Cervical ectopicBUT bhCG rises and continues to rise

Fetal heart activity

Enlarging sac Min Loss

Cx expanding……………….WHAT TO DO!!!!!

Ultrasound

CD serial scan

Cervical PregnancyGyn Onc Consult

GOG Protocol Trophoblastic Disease

MTX 50mg /m2 weekly / folinic acid

Twice weekly bhCG

Cervical pregnancyPt not happy wants curette

Bh CG begins to fall

Fetal heart stops

Gradual resolution over 10 weeks

bhCG 0 at 16 weeks post Dx

Sac resorption

Serial Scan

Serial Scan

Cervical PregnancyWants more children How to counsel

? Risks Possible complications of cx pregnancyC/SectionCuretteCx ectopic

? Cx incompetence? Recurrence

Pregnant Again 6Mo LaterEarly Scan (s)

Cervical length

Cx 46mm at 20w

Normal pregnancy

Planned Rpt Elective C/Section 38-39 weeks

ResultDelivers baby boy

5720 g !!!!!!

Uncomplicated post op

Planning another!!!!!!!

Thank You

Enjoy North West Tassie