Cervical Ectopic Pregnancy

Cervical ectopic pregnancy is implantation of the gestational sac in the cervical canal, below the level of the internal os. It accounts for less than 1 percent of ectopic pregnancies and can cause massive haemorrhage that may need hysterectomy. Early diagnosis permits conservative treatment.

• Risk factors: previous curettage, caesarean section, assisted reproduction, intrauterine contraceptive device, uterine fibroids.
• Usually presents at 5 to 9 weeks.
• Curettage without diagnosis can cause uncontrollable bleeding.

Painless vaginal bleeding is the classic presentation, with a soft, enlarged, barrel shaped cervix and a normal sized fundus.

• Bleeding may be profuse after instrumentation.
• Cramping pain is mild.
• Differential diagnosis: inevitable miscarriage, incomplete miscarriage, Caesarean scar pregnancy, cervical carcinoma, cervical fibroid.
• Complications: haemorrhage, shock, hysterectomy, infertility, death.

The approach is transvaginal ultrasound and hCG, with avoidance of blind curettage.

• Ultrasound: empty uterine cavity, hourglass uterus, gestational sac below the internal os with cardiac activity, sliding sign negative (sac does not move with gentle pressure), and peritrophoblastic flow on Doppler.
• Magnetic resonance imaging where available.
• hCG, haemoglobin, cross-match 4 units, blood group and Rhesus status.
• Avoid biopsy or curettage before the diagnosis is excluded.

The principle is conservative medical treatment with preparation for haemorrhage.

• Supportive: admission; two large-bore cannulae; blood available; avoid vaginal examination beyond need.
• Pharmacological: methotrexate 50 mg/m2 IM single dose (or 1 mg/kg IM days 1, 3, 5 and 7 with folinic acid 0.1 mg/kg IM days 2, 4, 6 and 8 for hCG above 5000 IU/L or fetal heart present); hCG days 4 and 7 then weekly until negative; tranexamic acid 1 g IV over 10 minutes for bleeding.
• Procedures: Foley catheter balloon tamponade with 30 mL sterile water for bleeding; uterine artery embolisation before or after methotrexate where available; suction curettage only after embolisation or tamponade is ready; hysterectomy for uncontrolled haemorrhage.
• Special groups: Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours.
• Red flags: heavy bleeding, hypotension, pulse above 110 per minute, falling haemoglobin.
• Follow-up: hCG weekly until negative; ultrasound at 2 weeks to confirm resolution; counsel on recurrence and early scans in later pregnancies.