Implantation of the fertilized ovum with subsequent development within the cervical structure without involvement of the corpus uteri (below the level of internal os) results in cervical pregnancy. In a typical case, the endocervix is invaded by the trophoblast, and the pregnancy proceeds to develop in the fibrous cervical wall. The duration of pregnancy is dependent upon the site of embryo implantation. The higher it is implanted in the cervical canal, the greater is its capacity to grow and cause haemorrhage which can be potentially life threatening.1

Seven cases are reviewed here of cervical ectopic gestation handled at the tertiary care centre-KEM Hospital Mumbai. These cases were confirmed on clinical findings, satisfying the Paalman and McElins’ criteria2 and on ultrasonography findings at the institute.

Paalman and McElin2 offered several objective clinical signs to establish diagnosis:

1. Amenorrhoea followed by uterine bleeding without cramping pain.
2. A softened and disproportionately enlarged cervix equal to or larger than, the corporeal portion of the uterus (an hour glass shaped uterus)
3. Products of conception entirely confined within and firmly attached to the endocervix.
4. A snug internal os.
5. A partially open external os.

The mode of presentation, general condition on presentation, period of amenorrhoea, predisposing factors and different treatment meted out was studied. Fig. 1 shows Cervical ectopic pregnancy (ultrasound picture).

The aetiology of cervical pregnancy is considered unknown. Several contributory factors have been noted. Most of these factors were present in our study. The predisposing factors to be studied are:in view of the transvaginal sonography showing residual trophoblastic tissue (Table 3).

1. Previous surgical trauma
2. Multiparity (in 5 cases)
3. High maternal age (in 2 cases)
4. Previous abortions (in 1 case)
5. Uterine leiomyomas
6. Atrophy and malformation
7. Rapid tubal transport of fertilized ovum
8. Abnormal timing of fertilization in relation to menstrual cycle
9. Previous caesarean section (in 2 cases)
10. Recent use of oral contraceptives

Out of the 7 cases reviewed, 2 cases had come to the general out door patients department for evaluation following their diagnosis of this condition as cervical ectopic gestation by ultrasonography by private practitioner. Rest 5 cases presented in emergency situation with history of bleeding per vaginum either minimal spotting as in 2 cases or profuse haemorrhage as in 3 cases (Table 1).

All the patients gave a history of amenorrhoea ranging from 1½ months to 3½ months. The 2 cases where there was profuse bleeding per vaginum had a history of 3½ months amenorrhoea. Two of the patients were primigravida while rest where

multigravidae. Two of the multigravidae were having no living issues, the previous issue in each case being early neonatal deaths (anomalous baby) following caesarean section in each patient. One of the multigravidae had a previous history of single abortion and no living issue (Tables 1, 2).

Treatment modalities differed in each case. In all the cases, patients and their relatives were counselled regarding the condition and their present situation (Table 3).

Two patients who were over 3½ months amenorrhoea and came with profuse bleeding per vaginum with haemorrhagic shock were clinically evaluated. Both the patients had to undergo exploratory laparotomy with obstetric hysterectomy. In both cases, incidentally, there was history of caesarean section done in the past for foetal indication. In both cases during surgery urinary bladder being stretched, congested, adhesions of previous surgery, bladder wall was injured. After bladder wall suturing both patients recovered uneventfully (Table 3).

In two cases, methotrexate was given as multiple dosage regime on 4 days at the dose of 1 mg/Kg/day alternating with Leucoverin factor at the dose of 0.1 mg/kg/day to overcome the adverse effects of methotrexate. Complete haemogram, weekly b-hCG and transvaginal sonography were done. Following the fall of b-hCG to zero, cervical curettage was done in view of the transvaginal sonography showing residual trophoblastic tissue (Table 3).

In third case, where similar methotrexate and leucoverin dosages were given, transvaginal sonography revealed no evidence of residual trophoblastic tissue. The weekly b-hCG levels showed zero range. Follow up b-hCG levels were zero even 2 months later.

One of the patients presented with 3 months amenorrhoea and profuse bleeding per vaginum. Bilateral descending cervical artery ligation, followed by evacuation of the products of conception from cervical canal was performed.

One of the patients was treated by systemic methotrexate therapy which failed to show any response, hence injection KCl was injected into the foetal heart by transvaginal sonography needle puncture with subsequent spontaneous autolysis of the trophoblastic tissue. The b-hCG levels fell to zero. Transvaginal sonography revealed a minimal residual trophoblastic tissue for which cervical curettage was done.

There was no mortality in the series.

Two of the patients with conservative management on follow up subsequently have conceived.

Cervical pregnancy is a rare and potentially life-threatening condition. The incidence quoted varies from about 1:1000 to 18,000 pregnancies.4,5

The aetiology of cervical pregnancies is considered unknown. Several contributory factors have been noted.3

Ultrasonography has facilitated early diagnosis of cervical pregnancy. The sonographic criteria for the diagnosis of cervical pregnancy are following:]

1. Diffuse amorphous intrauterine echoes.
2. Empty uterus (absence of intrauterine pregnancy).
3. Uterine enlargement.
4. Characteristic enlargement of the cervix containing the products of conception. Occasionally, a constricted isthmic portion (internal os) is present.3

All the 7 cases were verified to be cervical ectopic gestations on the basis of either clinical or ultrasonographic evaluation.3,4

Traditionally, abdominal hysterectomy has been the standard mode of treatment to control the profuse haemorrhage either on presentation or during attempted surgical curettage. When conservative surgery or medical management fails, obstetric hysterectomy might have to be resorted to; sometimes expeditiously as it is a grave life threatening condition. During hysterectomy some difficulty may be encountered in establishing the cleavage planes between the bladder, cervix and vagina, making effective haemostasis difficult and increasing the risk of injury to urinary bladder. Proper preoperative preparation of the patient and maintenance of blood volume are of paramount importance in the successful treatment of this most serious condition.1 In our study 2 patients as previously mentioned required obstetric hysterectomy and had accidental injury to urinary bladder.

Conservative surgical management has been described extensively in literature. It involves cervical currettage, cervical packing, ligation of cervical arteries, amputation and suturing of cervix which was rarely successful. Conservative management is desirable, if possible to preserve the child bearing function, especially in nullipara patients. However, it has been found to be successful in less than 8 weeks of gestation. When pregnancy progressed beyond the eighth week, severe haemorrhage invariably occurred, and hysterectomy was required.6 Several methods have been described to control the brisk haemorrhage following evacuation.

1. The endometrial cavity, dilated cervical canal, and vagina have been packed with gauze or gelfoam for counter pressure. To effect greater pressure, sewing of the external os together with interrupted sutures has been attempted.
2. Prophylactic use of a Shirodkar's cerclage and local injection of vasopressin prior to evacuation of products of conception.7
3. Haemostatic cervical sutures at 3 and 9 O’clock. Suction curettage is then performed; followed immediately by insertion of Foleys’ catheter into the cervical canal and inflating the bulb to 30 ml. The vagina is packed with gauze to further tamponade the bleeding.8,9
4. Bilateral internal iliac artery ligation was done following which the cervix was evacuated and intracervical packing done.10
5. Vaginal cevicotomy.11
6. Uterine artery embolization has been reported as having remarkable success using Gelfoam. However, post currettage heavy secondary bleeding is known to occur.12

Other methods have also been described to control bleeding including suturing the cervix. Resection of the bleeding placental area, with reconstruction of cervix and cervical amputation, all with some success in individual cases.

In our series, one patient underwent conservative surgery. She had a history of 3 months amenorrhoea and presented with profuse bleeding per vaginum. Cervical descending artery was ligated bilaterally with subsequent curettage of the endocervix. Haemostasis was achieved by interrupted sutures on the placental bed. Patient made an uneventful recovery. On subsequent follow up after 8 months, she conceived, had an uneventful antenatal period and delivered normally.

The key to successful conservative management of a cervical pregnancy is still early diagnosis and is more likely to succeed before 12 weeks of gestation because of less trophoblastic infiltration in the cervical walls.

Farabow et al3 were the first to report the use of methotrexate for cervical pregnancy.

Hung et al13 analysed some prognostic factors affecting the outcome of conservative methotrexate management. They found that methotrexate therapy was likely to fail when:

1. Serum b-hCG levels greater than 10,000 IU/L.
2. A gestational age > 9 weeks amenorrhoea
3. Positive foetal cardiac activity or,
4. A crown-rump length greater than 10 mm

In our study 3 patients were successfully treated with methotrexate in multiple dose regime. However, single dose therapy is equally effective and more preferable as the toxicity of methotrexate was directly proportional to duration of exposure and much less so to concentration.14 Two patients required cervical curettage post methotrexate therapy when b-hCG values had fallen to zero but transvaginal sonography showed residual endocervical trophoblastic tissue.

One patient who underwent methotrexate therapy on 2 successive occasions, did not show response to it; there was persistent foetal cardiac activity. This patient underwent transvaginal sonographically guided potassium chloride instillation in the foetal heart. Subsequent bhCG titres dropped to zero. Transvaginal ultrasonography revealed minimal residual trophoblastic tissue for which cervical curettage was performed. The patient made uneventful recovery after 4 weeks.

Recently prostaglandins have been used in conjunction with methotrexate for treatment of cervical ectopic gestation. Spitzer, et al15 have described 3 cases in which intracervically 10 mg of prostaglandin F2 alpha was injected under transvaginal guidance in the site of cervical implantation. Systemic prostaglandins - sulprostone 500 micrograms (3 doses) has been reported, along with single dose methotrexate for conservative management of viable cervical pregnancies.14

Possible toxicities of methotrexate include, primarily, myelo suppression, gastrointestinal mucositis and nephrotoxicity, all of which were not seen in any of our patients. Bagshawe and Walden et al also reported that methotrexate may be retained in animal tissue for 8 months after treatment. Further evaluation regarding subsequent conception following the treatment of cervical pregnancy with this agent needs to be done.

Angiographic embolisation of the uterine artery bilaterally has met with success. Nonetheless, these are all performed electively where diagnosis precedes complication and where facilities are available.

Analysing the results of these patients studied, gives us a broad idea of patients with cervical ectopic pregnancy to be divided into two groups;

1st group : Those patients who are asymptomatic or present with minimal bleeding per vaginum. These patients are suitable candidates for conservative medical management.

2nd group : Those patients who present with profuse bleeding per vaginum and varying stages of shock. These patients are ideal for emergency conservative surgical management or obstetric hysterectomy.

We suggest that, if the patient is parous and elderly, then in such patients, who may not present with life threatening situation, but minimal spotting per vaginum one would prefer a planned elective obstetric hysterectomy; instead of subjecting the patient to conservative medical or surgical treatment with the risk of potential drug toxicities or spontaneous profuse bleeding per vaginum which may require emergency obstetric hysterectomy, increasing maternal morbidity and mortality.

Despite an apparent increase in incidence, mortality from cervical ectopic gestation has plunged from 45% to 0% and has remained as such.16 This remarkable decrease may be attributed to advances in blood banking, anaesthesia, surgical technique and greater awareness leading to early diagnosis. The use of pelvic sonography in the evaluation of patients with first trimester bleeding facilitates the early recognition of this complication.

Recent advances in interventional radiology and medical management by use of methotrexate and prostaglandins in early diagnosed cervical ectopic gestation have enabled conservative management for maintaining uterus for fertility meanwhile, the place of hysterectomy, particularly in life threatening situations is firmly established.