Cervical pregnancy is a variant of distal ectopic pregnancy, in which the implantation and development of the fetal egg occurs in the cervical canal of the uterus. Disease is manifested by bleeding of varying severity – from moderate discharge to copious blood loss. It is a dangerous condition, fraught with the development of lethal hemorrhagic and septic complications. Diagnosis is carried out with the help of vaginal and ultrasound examination, diagnostic curettage. If it is impossible to perform organ-preserving measures during cervical pregnancy, uterine extirpation is indicated.
ICD 10
O00.8 Other forms of ectopic pregnancy
General information
In clinical gynecology, it is customary to distinguish distal forms of ectopic pregnancy (cervical and isthmic-cervical) and proximal forms (tubal, abdominal, ovarian). Cervical and cervical-isthmian pregnancy among various variants of ectopic (ectopic) pregnancy is quite rare – in 0.3-0.4% of cases. With a true disease, the cervical canal serves as a placemat, with an isthmus-cervical localization – the isthmus area. Pathology poses a threat to a woman’s life: the main danger and cause of death in 75-85% of cases is profuse internal bleeding, less often septic complications.
Causes
The occurrence is associated with difficulty or impossibility of implantation of a fertilized egg in the body of the uterus due to the inferiority of the endometrium or insufficient maturity of the trophoblast. Conditions for cervical localization of pregnancy arise due to changes in the myometrium caused by:
- complicated course of previous labor;
- multiple abortions, diagnostic curettage, operations on the uterus;
- endometritis;
- cervical insufficiency.
It is believed that the risk of this pathology increases with Asherman syndrome, uterine fibroids, in vitro fertilization.
Pathogenesis
The immaturity of the trophoblast, combined with factors that prevent implantation of the fetal egg in the body of the uterus, can also contribute to the slipping of the blastocyst into the cervical canal. The trophoblast, and subsequently the chorionic villi of the fetal egg, germinate into the wall of the cervical canal, destroying muscle elements and vessels, which is accompanied by bleeding and impaired pregnancy development. Sometimes, with complete penetration of the cervical wall, chorionic villi penetrate into the vagina or into the parametrium.
The absence of a decidual shell and its inherent protective mechanisms leads to the fact that a true cervical pregnancy rarely develops longer than 8-12 weeks; cervical-isthmian pregnancy can last longer – up to 16-24 weeks. In extremely rare cases, distal ectopic pregnancy is carried to term.
Symptoms
The severity of the cervical pregnancy clinic depends on the gestational age and the level of implantation of the embryo. In typical situations, after a delay in menstruation, a woman has bloody discharge from the genital tract. Bleeding is moderate, profuse or profuse; sometimes its onset is preceded by scanty anointing. Disease is characterized by the absence of pain.
The presence of a well-developed network of blood vessels or varicose nodes in the cervical region contributes to the development of sudden bleeding, hemorrhagic shock and life-threatening DIC syndrome. Isthmic-cervical pregnancy, especially in the second trimester, is not accompanied by such pronounced pathognomonic symptoms and often makes you think about placenta previa.
Diagnostics
Recognition of pregnancy of cervical-isthmian localization is difficult due to the absence of an explicit clinic. This variant of distal ectopic pregnancy can be suspected by periodically recurring bleeding, which becomes more abundant as the gestation period increases; the absence of pain and signs of expulsion of the fetal egg. Additional methods:
- Gynecological examination. In cervical pregnancy, it allows to determine the presence of barrel-shaped deformity and cyanosis of the cervix, eccentric displacement of the external pharynx, fetal egg associated with the walls of the cervical canal. The size of the cervix exceeds the size of her body. When trying to separate the fetal egg with a tool or finger, there is an increase in bleeding.
- Ultrasound of the uterus. Ultrasound criteria for this disease are hyperechogenicity of the endometrium, intact uterine body, expansion of the cervical canal containing the fetal egg, the presence of placental tissue in the cervical canal.
- SDС. Often, cervical pregnancy is established only when diagnostic curettage is performed for an alleged spontaneous abortion. In this case, there are difficulties in removing the fetal egg, continued or increased bleeding after the procedure, a crater-like depression in the wall of the cervix.
In the process of diagnosis, cervical pregnancy is extremely important to differentiate from uterine fibroids (fibroids), as well as miscarriage (abortion in progress). With uterine fibromyoma, there are no indications of pregnancy (menstruation delay, positive pregnancy test). With a miscarriage, the peeling and lowering of the fetal egg into the cervical canal is preceded by cramping pains.
Treatment
Detection of cervical pregnancy is the basis for immediate hospitalization of a woman. The primary task is to stop bleeding, for which they resort to tight tamponade of the vagina, stitching its lateral arches, applying a circular seam to the cervix, inserting a Foley catheter into the cervical canal with an inflated cuff.
Promising methods for cervical pregnancy are embolization of branches of the uterine arteries or ligation of the internal iliac arteries, which then allows bloodless removal of the fetal egg. In case of ineffectiveness or impossibility of performing the listed organ-preserving measures, or intensive bleeding during cervical pregnancy, emergency supravaginal amputation of the uterus is indicated.
Prevention
Prevention consists in the rational treatment of gynecological diseases, refusal of abortions, carrying out full-fledged rehabilitation after intrauterine interventions. Careful management of pregnancy by an obstetrician-gynecologist allows you to identify the ectopic location of the fetal egg in the early stages of gestation and prevent the occurrence of life-threatening complications.
