---

CERVICAL ECTOPIC PREGNANCYWITH PLACENTA PERCRETA

JIGNESH J KANSARIA*, AMIT PILANKAR**,ALKA GUPTA***, SV PARULEKAR****
*Lecturer; **Third Year Resident; ***Associate Professor; ****Professor; Department of Obstetrics and Gynaecology, Seth GS Medical College, KEM Hospital, Parel, Mumbai.

---

An unusual case of cervical ectopic pregnancy with placenta percreta is discussed.

INTRODUCTION

Cervical ectopic pregnancy is a rare variant of ectopic pregnancy. The incidence of cervical ectopic pregnancy is rising especially in IVF-ET (In Vitro Fertilization-Embryo Transfer) programmes than recognised previously. [1] The case reported here is the first report of placenta percreta in cervical ectopic pregnancy in English world literature.

CASE REPORT

Gravida 2, para 1, living 0, previous 1 caesarean section delivery presented with the chief complaint of sudden onset painless profuse bleeding per vaginum with three months amenorrhoea.

She had a first full term caesarean section delivery with early neonatal death. The caesarean section was done for obstructed labour with high floating breech presentation with lumbar meningomyelocoele. Post operatively perurethral Foley’s catheter was removed on day 5. Further details for need for prolonged catheterization not available.

On examination, patient had tachycardia, blood pressure of 90/50 mmHg, pallor and a bed side haemoglobin of 6 gm%. She had approximately lost one liter of blood by the time of examination as judged by examination of her clothes and pads.

On per abdominal examination, uterus was just palpable. No evidence of tenderness, guarding and rigidity. Scar of previous caesarean section seen.

Abdomino-pelvic examination revealed uterus corpus of normal size, the cervix and isthmus ballooned upto 10-12 weeks size, with profuse bleeding through the os. Internal os was closed. External os admitted more than one finger easily. No fornicial tenderness. POC’s felt in cervical canal.

Bed side coagulation tests were within normal limits. A provisional clinical diagnosis of cervical ectopic pregnancy was made.

Vaginal examination under anaesthesia confirmed the clinical findings. Curettage revealed products of conception from the ballooned cervical canal. The amount of product curetted out corresponded to 8 weeks pregnancy. Internal os was closed. Profuse haemorrhage continued despite of curettage and pressure and the cervix appeared like a elongated flabby loose fold of tissue. Since a large part of the placenta was implanted in the supravaginal portion of the cervix, it was considered unlikely that ligation of descending cervical arteries would be successful. Hence exploratory laparotomy with total abdominal hysterectomy was performed. Accidental injury of urinary bladder supratrigonally of 2 cm length occurred which was repaired. Continuous bladder drainage for 7 days post-operatively maintained. Patient was given adequate replacement of blood components. Postoperative period was uneventful. Gross examination revealed placenta percreta on the left antero-lateral aspect of uterus away from uterine scar (Fig. 1). Histopathology confirmed the diagnosis of cervical ectopic pregnancy fulfilling the Rubin’s criteria. It also revealed placenta percreta.

Fig 1 : Cervical ectopic prgnancy. The corpus (C) is normal sized. The expanded cervix is cut open vertcially to show the ectopic pregnancy. The site of placenta percreta is pointed out by an arrow

DISCUSSION

Cervical implantation is a serious complication of pregnancy. In the past, hysterectomy was often the only choice available because of profuse haemorrhage that accompanied attempts at removal of the cervical pregnancy. Even with hysterectomy, haemorrhage was excessive and urinary tract injury frequent due to the enlarged barrel shaped cervix. [2] In our case, patient continued to bleed inspite of curettage and pressure and the vital parameters being unstable prompted us to do total abdominal hysterectomy. The past history of previous casearean section for obstructed labour with need for continuous bladder drainage for 5 days post operative and placenta percreta in this pregnancy as per gross examination of the uterus probably increased the risk of injury to urinary bladder.

The possible aetiological factors responsible for this cervical ectopic pregnancy could be.

1.Cervical implantation of the fertilized ovum because of previous caesarean section. [3,4]

2.Delayed ovulation occurring prior to menstruation. [5]

Historically, 70% of reported cervical pregnancies have required hysterectomy for treatment. More recent methods of treatment have included methotrexate, uterine artery embolization and intracervical catheter balloon tamponade.[6] Ultrasound facilitates early diagnosis.

REFERENCES

1.Ginsburg ES, Frates MC, Rein MS, Fox JH, Hornstein MD, Friedman AJ. Early diagnosis and treatment of cervical pregnancy in an In - vitro fertilization program. Fertil Steril 1994; 61 : 966.

2.Williams : Obstetrics. Appleton and Lange, 20th Edition. Connecticut. Ectopic pregnancy 1997; 607-34.

3.Douglas Stromme. Operative obstetrics. Quilligan EJ, Zuspan F. Appleton-Century-Crofts. 4th Edition. New York. Ectopic Pregnancy 1982; 219-52.

4.Iffy L, Charles D. Operative perinatology. Macmillan publishing Co, First Edition, New York. Pelosi MA : Cervical pregnancy. 1984; 344-52.

5.Iffyl L. Contribution to the pathological mechanism of ovarian, abdominal and cervical pregnancies. Gynaecologia (Basel) 1962; 153 : 188.

6.Frates MC, Benson CB, Doubilet PM, Di Salvo DN, Brown DL, Laing FC, et al. Cervical Ectopic pregnancy : Results of conservative treatment. Radiology 1994; 191 : 773.

---

To section TOC