Abstract
Cervical pregnancy is a rare ectopic pregnancy, but because of assisted reproduction the incidence appears to be increasing. To make Readers aware of this rare entity this case is reported.

Introduction

Cervical pregnancy is a rare life- threatening form of ectopic pregnancy in which the implantation site is within the cervical mucosa that lines the endocervical canal with reported incidences ranging from 1:1000 to 1:18000. The incidence appears to be increasing, in part due to newer forms of assisted reproduction, but especially after in-vitro fertilization and embryo transfer. In the past,the diagnosis was made late in the first trimester and patient often presented with life-threatening haemorrhage from the eroded blood vessels within the cervical tissue.1 However, a more practical, rapid and therapeutically meaningful diagnosis and treatment can be provided today with the availability of quantitative serum beta-hCG assays and the latest developments in ultrasound technology,thus permitting conservative management for potential fertility.

Case Report

Thirty two year old married gravida three, para one, living one, MTP one was referred from private hospital Jalgaon in view of probable diagnosis of a live 7.5 weeks gestation cervical ectopic pregnancy. Patient had history of two and half months amenorrhoea and bleeding per-vaginum since six days with history of passage of blood clots and history of pain in lower abdomen since two days. No significant past medical or surgical illness.
Her obstetric history revealed first-LSCS 12 year old female child. Second was first trimester termination at eight weeks of gestation 11 years back.
On examination general condition was fair, afebrile, pulse of 96 per minute, BP of 120/80 mm Hg. Respiratory and Cardiovascular examination revealed no abnormality.

On per abdominal examination abdomen was soft, there was no guarding or rigidity. Tenderness was present in right infraumbilical region. On per speculam examination there was blood stained foul smelling discharge, there was a small clot seen at external os.

On per-vaginal examination uterus was midposed, bulky, soft, 6 weeks in size, fornices were clear. There was no cervical movement tenderness. No tenderness in either fornix. No localised swelling in the cervical region.Ultra-sonography and Doppler studies done at KEM hospital revealed a live cervical ectopic pregnancy of 7.5 weeks of gestation situated in isthmus below the insertion of uterine arteries.

Bleeding time and clotting time were within normal limits. A diagnosis of cervical ectopic pregnancy was made.

Patient was started on injectable antibiotics and one pint of blood transfusion was given in view of severe anaemia. bhCG was 37,735 MIU/ml SGOT 55 IU/ml, SGPT 40 IU/ml.

Patient was given option of medical and surgical line of management, but patient opted for medical line of management. Patient was started on injection methotrexate 1 mg/kg on day 1, 3, 5, 7 and injection folinic acid 0.1 mg/kg on day 2, 4, 6, 8. On third day of injection methotrexate SGOT and SGPT were repeated and they were raised i.e. SGOT of 92 IU/ml, SGPT of 40 IU/ml Gastroenterology reference was done in view of raised SGOT, SGPT and advised to continue methotrexate injection. After completion of total dose of methotrexate SGOT, SGPT were repeated which were within normal limits.

Serial bhCG titre studies done every third day of treatment which were (41,835 mIUl, 25,236 mIU/ml, 10,070 mIU/ml).Repeat ultrasonography was done after completion of methotrexate treatment i.e. on ninth day of methotrexate treatment showed absent foetal cardiac activity. Patient was stable throughout hospital stay.
Patient was discharged at persistent request and was asked to followup with regular bhCG report. Serial bhCG titre on 23.1.02 was 1047 mIU/ml, on 30.1.02 was 20.8 mIU/ml and on 10.2.02 it was 8.28 mIU/ml which showed decreasing trend.

Ultrasonography done on 15.3.03 showed uterus retroverted, normal size uterus. Endometrial thickness was 4 mm and no evidence of any gestational sac in the uterus and cervix. Patient got her menses on 14.3.03.

Discussion

Historically, 70% of reported cervical pregnancies have required hysterectomy for treatment.² More recent methods of treatment have included methotrexate, uterine artery embolization and intracervical catheter balloon tamponade.⁴ Ultrasound facilitates early diagnosis.

The possible aetiological factors responsible for this cervical ectopic pregnancy could be cervical implantation of the fertilized ovum because of previous caesarean section,^4,5 Previous dilation and curettage.

Today, nonsurgical treatments are the first line of therapy.5

The following conditions are necessary for chemotherapeutic management:

1. A reliable diagnosis of cervical pregnancy.
2. An haemodynamically stable patient, without bleeding or with mild bleeding.
3. Menstrual age of less than 10 weeks for viable cervical pregnancy.
4. No active renal or hepatic disease.
5. No evidence of leucopenia or thrombocytopenia.

The anticancer drug methotrexate has been used successfully to treat cervical pregnancy. In summary, the agent has been injected directly into the gestational sac with or without KCl to induce foetal death; it has been given systematically in single high-dose therapy with folinic acid rescue; it has been given in lower-dose prolonged courses; and finally it has been given in various combinations, usually intraamnionically after failure of systemic therapy. More advanced pregnancies, that is, those greater than 6 weeks gestation generally require induction of foetal death or high-dose and prolonged therapy with methotrexate.

References

1. Douglas Stromme. Operative obstetrics. Quilligan EJ, Zuspan F. Appleton-Century-Crofts. 4th Edition. New York. Ectopic Pregnancy 1982; 219-52.
2. Hung TH. Jeng CJ. Yang YC. Wang KG. Lan CC. Treatment of cervical pregnancy with methotrexate. International Journal of Gynecology and Obstetrics 1996; 53 (3) : 243-7.
3. Marcovivi I. Rosenzweig BA. Brill Al. Khan M. Scommegna A. Cervical pregnancy: case reports and a current literature review. Obstetrical and Gynecological Survey 1994; 49 (1) : 49-55.
4. Iffy L, Charles D. Operative perinatology. Macmillan publishing Co, First Edition, New York. Pelosi MA : Cervical pregnancy. 1984; 344-52.
5. Mantalenakis S, Tsalikis T, Grimbizis G, Aktsalis A, Mamopoulos M, Farmakides G. Related Articles, Links Successful pregnancy after treatment of cervical pregnancy with methotrexate and curettage. A case report. J Reprod Med 1995; 40 (5) : 409-14. Review.
6. Ushakov FB, Elchalal U, Aceman PJ, Schenker JG. Cervical pregnancy: pastand future. Obstetrical and Gynecological Survey 1997; 52(1) : 45-59.

*Lecturer; **Third Year Resident: ***Professor; Department of Obstetrics and Gynaecology, Seth GSMC, KEM Hospital, Parel, Mumbai 400 012.