Cervical Pregnancy

Cervical Pregnancy: Rare Surgery saves patient’s fertility

Transcatheter arterial embolization has become a major integral part in the treatment of cervical ectopic pregnancy. Around 16 such cases have been reported successfully so far worldwide and Sri Balaji Action Medical Institute is one of them which effectively helped in preserving the fertility of the patient by avoiding traditional approach of uterus removal. This will surely give a ray of hope to the woman of becoming a mother again.

A Cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix.^[1]Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity - a so-called cervico-isthmic pregnancy - it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage. The diagnosis is made in asymptomatic pregnant women either by inspection seeing a bluish discolored cervix or, more commonly, by obstetric ultrasonography. A typical non-specific symptom is vaginal bleeding during pregnancy. Ultrasound will show the location of thegestational sac in the cervix, while the uterine cavity is "empty". Cervical pregnancy can be confused with a miscarriage when pregnancy tissue is passing through the cervix.

On a very rare occasion, a cervical pregnancy results in the birth of a live baby- typically the pregnancy is in the upper part of the cervical canal and manages to extend into the lower part of the uterine cavity.

Early diagnosis and treatment is critical to avoid serious complications such as severe hemorrhage and the need for hysterectomy. This is exactly what doctors from Sri Balaji Action Medical Institute  did and took an unconventional approach for preserving the fertility of a patient reported with a rare form of ectopic pregnancy. There are only 15 more such cases of Cervical Pregnancy reported across the globe in which uterus has been saved.

In such cases the foetal sac is formed in Cervix (the lower end of the uterus) and is associated with morbidity and disastrous effects on the future aspects of the patient’s fertility. The doctors shed down the traditional approach which suggests removal of the uterus and successfully treated the patient, keeping her hopes of becoming a mother alive.

Pregnant for a little over 5 weeks, Rashmi (28) came to OPD of Sri Balaji Action Medical Institute and reported  painless bleeding clots through vagina since a day. She also had an episode of similar spotting 3-4 days back too. She had no previous history of intrauterine procedures or devices, and no pelvic inflammatory disease.

“ The number  of cervical pregnancies is rising day by day, as the number  of  IVF  procedures, cesarean sections , IUCD insertion and pelvic inflammatory diseases    are increasing. but such a procedure of uterine artery embolization is underused  and  only 15 such cases of treatment  bilateral uterine artery embolization have been reported as far as our  knowledge is concerned”, says Dr. Ruby Sehra, HOD & Sr. Consultant (OBS & Gynae), Sri Balaji Action Medical Institute.

“  Her Beta-HCG  ( biochemical marker of pregnancy ,the rising values of which are suggestive of an ongoing live pregnancy) had gone up from 2700 to 5700 and ultrasound showed normal cardiac activity of the growing baby. On investigations, the team could see the foetal sac, nodes, cardiac activity all in the cervix.”

Speaking about the case Dr. Ruby said, “Ectopic pregnancy can occur anywhere away from the uterine cavity including fallopian tube (most common – 98%), ovary, abdomen, etc.  Ectopic pregnancy in the cervix, account for less than 1 per cent of all ectopic pregnancies. Diagnosis of cervical pregnancies also remains a challenge and is often delayed as it is often confused with faiiing spontaneous threatened abortion .High resolution ultrasound machine with coloured  doppler can only diagnose such kind of a rare cervical ectopic pregnancy. Moreover only a highly skilled radiologist with good clinical acumen can diagnose such a pregnancy.The massive blood clots often necessitate emergency removal of the uterus.”

Looking at the patient profile - young age, married a year back and first pregnancy; doctors decided to avoid  uterus removal and preserve the fertility of the patient. Dr. Ruby  was assisted by an expert team including Dr. Rupinder Singh Baweja, MD (Radiodiagnosis), DM (Neuroradiology),  opting for preservative therapeutic approach to safeguard patient’s fertility. Potential risks and alternatives methods were explained to the patient. Evacuation of cervix was performed under GA ( General Anaesthesia)with the help of an Interventional cardiology team performing bilateral uterine artery embolization so as to block the cervical branches.

Why is cervical pregnancy more risky in comparison with fallopian tube (most common – 98%), ovarian and abdominal pregnancy?

Cervical pregnancy is more risky in comparison with fallopian tube pregnancy as the embryo is implanted in the cervix which is highly vasculired organ and receives its bllod supply from both the uterine arteries via descending cervical branches .Any manipulation, that is evacuation of the pregnancy,can lead to massive haemorrhage  necessitating major surgical procedres such as laprotomy followed by internal iliac ligation and in 50 per cent of the cases the patient  may have to undergo emergency hysterectomy thus losing their fertility. “ Once this rare form of cervical ectopic pregnancy is diagnosed, the patient should be immediately referred to tertiary care hospital where all kinds of facilities such as blood bank, ICU CATHLAB,24 hour-gynaecology, surgical and an aesthesia teams are available.”

 “It was a herculean task to remove the fetus without harming the uterus with minimal blood loss. The post-operative recovery period was uneventful and the patient is in stable condition and we hope that she can carry a normal pregnancy soon”, added Dr. Ruby.