Material and Methods
This is a retrospective review, with institutional review board approval, of 13 consecutive first trimester cervical pregnancies, 1995-2014, all treated with the same surgical technique by the author ( Table 1 ). All cases were identified through university patient visits and from outside referrals to the author. All of the cases had ultrasound confirmation of a cervical implantation pregnancy, meeting the Timor-Tritsch criteria, and only number 9 lacked an identifiable embryo with cardiac activity. The second case is a recurrent cervical ectopic from case number 1. All cases had pathologic confirmation of chorionic villi, and had post-evacuation serial measurement of serum hCG levels until reaching a nonpregnant level, and all resolved without additional treatment. Follow up postevacuation serial measurement of hCG levels is recommended to exclude persistent ectopic. Historical information for each case is included within the table. Case number 2 is the only woman in this series with 2 consecutive cervical pregnancies; 5 women had prior curettage, and 3 women had had other cervical procedures. Case number 11 was a heterotopic twin cervical pregnancy after egg donation IVF and was treated with ultrasound-guided suction evacuation of the cervical pregnancy, leaving the intrauterine twin undisturbed. For this particular woman, because of the living intrauterine twin, a postevacuation balloon tamponade was not placed, and because of the cervical canal disruption, a shirodkar cerclage was placed treating potential cervical insufficiency. No other therapy for ectopic pregnancy was offered during this treatment period.
| Age | G | P | A | Gestational age by US CRL | HCG, pretreatment | Presenting symptom | Risk factors |
|---|---|---|---|---|---|---|---|
| 29 | 4 | 1 | 2 | 12 1/7 | Vaginal spotting | Prior curettage, cx insufficency and prior cerclage, prior cesarean | |
| 30 | 5 | 1 | 3 | 12 0/7 | Vaginal spotting | Prior cervical ectopic, prior curettage, cx insufficiency and prior cerclage, prior cesarean | |
| 40 | 1 | 0 | 0 | 8 0/7 | 58,155 | None, found with US | None |
| 21 | 1 | 0 | 0 | 6 0/7 | 4400 | None, found with US | None |
| 38 | 1 | 0 | 0 | 6 0/7 | 50,906 | Vaginal spotting | None |
| 21 | 1 | 0 | 0 | 8 0/7 | 3672 | Vaginal spotting | None |
| 42 | 3 | 0 | 2 | 7 0/7 | 6188 | None, found with US | Prior curettage |
| 41 | 3 | 0 | 2 | 7 2/7 | 16,137 | None, found with US | Smoker, 2 elective terminations with curettage, smoker, substance abuse, cervical cryo |
| 32 | 3 | 2 | 0 | 7 0/7 | 1587 | None, found with US | Smoker and substance abuse, cervical cryotherapy for CIN |
| 35 | 2 | 1 | 0 | 11 5/7 | Vaginal spotting | Smoker, prior classical cesarean at 24 weeks | |
| 44 | 5 | 0 | 4 | 7 0/7 | None, found with US | Prior curettage; donor egg IVF twin pregnancy, heterotopic cervical pregnancy | |
| 28 | 4 | 1 | 2 | 11 0/7 | 78,487 | Vaginal spotting | Prior curettage |
| 28 | 2 | 1 | 0 | 6 5/7 | 43,252 | Vaginal spotting | None |
Results
This series demonstrates that a specialized suction curettage technique was 100% successful in terminating 1st trimester cervical pregnancy. Unless already identified by transvaginal ultrasound, the usual first complaint is painless vaginal bleeding, and speculum examination may reveal an open external cervical os with a fleshly type endocervical mass presenting ( Figure 3 ). The technique begins with circumferential infiltration of the cervical stroma around the cervical pregnancy with a hemostatic vasoconstricting agent, such as 20 mL of dilute vasopressin (20 units diluted within 50 mL of injectable normal saline) to a depth reachable with a 1 ½ inch, 21 gauge needle ( Figure 4 ). This is followed by the placement of an untied cervical suture high around the cervical portio, using a McDonald cerclage technique ( Figure 5 ). This stitch is left in place ready to tie, if necessary, to temporarily occlude the descending cervical branches of the uterine arteries should bleeding occur during the procedure. Then, without cervical canal dilation (the canal is already open containing the pregnancy) an appropriately sized suction curettage (diameter in millimeters equal to the gestational age in weeks), attached to suction, is rotated and slowly passed through the cervical canal and into the endometrial cavity ( Figure 6 ). Immediately postcurettage a cervical canal balloon, such as a 30 mL balloon foley catheter, is placed against the cervical canal placental bed and inflated to permit a tamponade effect within the cervical canal ( Figure 7 ). The balloon must be inflated within the cervical canal and not within the endometrial cavity.The balloon tamponade is left in place for approximately 24 hours, then slowly deflated, in anticipation of no cervical bleeding. Should such bleeding occur the balloon is reinflated for later removal. Pain control may be needed because of balloon catheter postprocedure cervical canal distention, but in my experience this has been unnecessary.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
