Journal of Postgraduate Medicine
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CASE REPORTS
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Year : 1994  |  Volume : 40  |  Issue : 1  |  Page : 33-5  

Isthmico-cervical ectopic pregnancy following caesarean section.

SR Hingorani, SV Parulekar, KL Ratnam 
 Depts of Obstet and Gynaecol and Radiology, KEM Hospital, Parel, Bombay, Maharashtra.

Correspondence Address:
S R Hingorani
Depts of Obstet and Gynaecol and Radiology, KEM Hospital, Parel, Bombay, Maharashtra.

Abstract

A 30 year old woman (gravida 4, para 2) presented with 2 1/2 mth amenorrhoea and vaginal spotting. On bimanual pelvic examination, an old tear was felt on posterior cervical lip with enlarged cervix and normal sized uterus. Ultrasonography revealed ectopic pregnancy with placenta implanted on isthmus and upper cervix. Dilatation and curettage was done with cervical packing.



How to cite this article:
Hingorani S R, Parulekar S V, Ratnam K L. Isthmico-cervical ectopic pregnancy following caesarean section. J Postgrad Med 1994;40:33-5


How to cite this URL:
Hingorani S R, Parulekar S V, Ratnam K L. Isthmico-cervical ectopic pregnancy following caesarean section. J Postgrad Med [serial online] 1994 [cited 2019 Dec 7 ];40:33-5
Available from: http://www.jpgmonline.com/text.asp?1994/40/1/33/574


Full Text




  ::   IntroductionTop


Isthmico-cervical ectopic pregnancy is a rare and life threatening condition. It is characterised by implantation of the fertilized ovum in the isthmus, and its subsequent development in the isthmus and cervical canal. Usually it presents with severe haemorrhage vaginally and is often mistaken for an inevitable abortion[1].


  ::   Case reportTop


Mrs. SM, a 30 years of old woman, married for 8 years, fourth gravida second para with 1 abortion and 2 living issues (one full term normal delivery and other caesarean section) presented with 2 months amenorrhoea and vaginal spotting. She had another episode of vaginal spotting one month ago.

Her general condition was fair, and vital parameters were within normal limits. Systemic examination revealed no abnormality. Bimanual pelvic examination revealed an external of which admitted a tip of a finger, an old longitudinal tear on the posterior cervical lip, ballooned out cervix measuring 5 to 6 cm in diameter and a normal - sized uterus on top of the cervix.

Real time ultrasonography[2] [Figure:1] showed a 5.4 x 5.6 cm. gestational sac with decidual reaction around it, in the isthmus and upper cervix. The placenta was implanted on the anterior wall of the isthmus and upper cervix. Foetal cardiac activity was present. The uterus was of normal size and empty. No part of the fetus or placenta was present in the uterine cavity.



A decision was made to evacuate the products of conception under general anaesthesia. The cervix was dilated rapidly to No. 12 Hegar's, and the products were removed by suction through a No. 12 cannula. Check curettage was done. There was profuse bleeding through the cervix following the curettage. The ballooned out cervix and isthmus were explored with a finger and were found to be empty. The scar of the caesarean section was intact. The isthmus and cervix were tightly packed with a roller-pack, the terminal portion of which was soaked in povidone-iodine solution. The vagina was packed to maintain the uterine pack in position. A Foley's catheter was passed into the bladder. Uterine contraction was maintained with 15 methyl PGF2-alpha. The patient was given injectable cloxacillin and gentamicin. The pack controlled the bleeding. It was removed after 24 hours under light general anaesthesia, following which there was no bleeding. The patient made an uneventful recovery and was discharged after 5 days.


  ::   DiscussionTop


Isthmico-cervical pregnancy is extremely rare. Its etiology is not known. A number of factors have been proposed to be responsible e.g. multiparity, high maternal age, previous abortions, uterine leiomyomas and abnormal timing of fertilization in relation to the menstrual Cycle[3].

Isthmico-cervical ectopic pregnancies cannot grow and reach term. Usually the patient presents with profuse vaginal bleeding either due to erosion of a blood vessel by the trophoblast, or trauma during sexual intercourse. Owing to the open external os and products in the cervical canal, a wrong diagnosis of inevitable abortion is often made. However, the internal os is closed. Ultrasonography is very useful in diagnosis before bleeding starts, as in the case presented[2].

Haemorrhage from the placental bed after removal of the ectopic pregnancy by curettage is the rule, since the cervix does not contract and retract, and shut off the vessels feeding the placemental site. Packing is the most conventional and extremely effective method of stopping such bleeding. Other methods of stopping such bleeding include anterior cervicotorny and underrunning the bleeding vessels with sutures of 1 - 0 chromic catgut, electrocoagulation, cervical cerclage by MacDonald's technique to constrict the blood Vessels[4], and cryocauterization of the bleeding area. Conservative treatment of cervical ectopic pregnancy is possible with methotrexate[5],[6] or mifepristone[6], provided the patient is not bleeding from that site. However, such treatment has no place in the management of bleeding patients, as most of them are uncontrollable. Uncontrollable haemorrhage usually requires total abdominal hysterectomy, though ligation of the anterior division of the internal iliac arteries should be attempted if possible to conserve the reproductive function[3].

In the case presented, implantation may have been in the isthmico-cervical region due to the scar of caesarean section. This is a rare complication of a caesarean section.

References

1 Badar-Armstrong B, Shah Y, Rubens D. Use of ultrasound and magnetic resonance imaging in the diagnosis of cervical pregnancy. J Clin Ultrasound 1989; 17:283-285.
2Thomas RL, Gingold BR, Gallagher MW. Cervical pregnancy. A report of two cases. J Reprod Med 1991; 36:459-460.
3Rubin GL, Peterson HB, Dorfman SL. Ectopic pregnancy in the United States: 1970 through 1978. JAMA 1983; 249:1725-1730.
4Bachus KE, Stone D, Suh B. Conservative management of cervical pregnancy with subsequent fertility. Am J Obstet Gynecol 1990; 162:450-452.
5Yankowitz J, Leake J, Huggins G. Cervical ectopic pregnancy: review of literature and report of a case treated by single-dose methotrexate therapy. Obstet Gynedol Surg 1990; 45:405-412.
6Keningsberg D, Porte J, Hull M. Medical treatment of residual ectopic pregnancy: RU 486 and methotrexate. Fertil Steril 1987; 47:402-404.

 
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