Cervical ectopic gestation is rare and may potentially be associated with high morbidity. We report acase of cervical ectopic pregnancy that was managedusing cervical cerclage with Mersilene tape as an intervention to reduce intraoperative haemorrhageduring evacuation.
A 36-year-old woman, gravida 3 para 2, with two previous caesarean sections in 2004 and 2012 (reasons not known), was referred by a general practitioner (GP) with a history of vaginal bleeding. A provisional diagnosis of threatened miscarriage requiring further assessment and treatment had been made by the GP. Further history from the patient at presentation revealed that she had been admitted to a district hospital by the GP 2 weeks earlier for anaemia, and had been transfused with two units of blood. The cause of the anaemia had not been investigated. She was on highly active antiretroviral therapy, which was assumed to be the cause of the anaemia. She had been discharged to see a gynaecologist for further evaluation of the cause of the anaemia. Pregnancy was not diagnosed at that time. The patient’s last menstrual period had been during the previous
month (exact date not known), and she was not on any contraceptive as pregnancy was anticipated. There was no further history of note. She was not pale, and was haemodynamically stable. Abdominal examination was unremarkable. Vaginal examination showed a closed but bulky and hyperaemic cervix with a pinkish stain on the examining glove. It was slightly tender to pressure. Transvaginal ultrasound examination showed an empty uterus with no adnexal mass. A gestational sac was found in the endocervix with a fetal pole consistent with a 4-week pregnancy (compatible
with the last menstrual period). Cervical ectopic pregnancy was diagnosed.
Admission, treatment modalities and potential risks were
discussed and consent was obtained. The beta-human chorionic
gonadotrophin (hCG) level was 1 838 mIU/ml, urea and electrolyte
levels were normal, and the haemoglobin and haematocrit levels
were 9.8 g/dl and 31%, respectively. Two units of blood were made
available for evacuation and other possible surgical intervention.
The patient was placed in the lithotomy position. Vasopressin,
20 U/ml, was diluted 1 in 20 and injected paracervically while
suction evacuation was done with an 8 mm flexible plastic curette.
Copious cervical bleeding ensued immediately post evacuation
and was arrested by placing a Mersilene tape circumferentially on
the uterine cervix. Bleeding was controlled and two units of blood
were given. The patient was sent to the recovery ward. She was
closely monitored for post-evacuation haemorrhage and discharged
to the gynaecological high-care ward for further monitoring. The
first postoperative day was uneventful, and the Mersilene tape was
removed 36 hours after the procedure. The patient was discharged
in a satisfactory condition 2 days after evacuation. Follow-up was
arranged weekly for 3 weeks. Repeat haemoglobin was 9.1 g/dl a
week after discharge. Weekly monitoring of the beta-hCG level
showed decreasing levels until <5 mIU/ml 3 weeks after procedure.
The patient made an uneventful recovery. Written consent was
obtained from her for publication of this case report.
Cervical ectopic pregnancy is a rare occurrence; the incidence is
less than 1% of ectopic pregnancies. There may be cases where
the diagnosis could have been missed and the patient managed as
an inevitable miscarriage. With the use of transvaginal ultrasound,
many more cases are being diagnosed. Patients may present with
mild abdominal cramps and vaginal bleeding. The notable risk
factors are use of an intrauterine contraceptive device, previous
abortion, a history of smoking, a history of dilatation and
evacuation, caesarean section and in vitro fertilisation with embryo
transfer.[2,3] Ultrasound imaging was first used in the diagnosis
of cervical pregnancy in 1978 and has been the ‘gold standard’.
Diagnosis by ultrasound examination, as suggested by Raskin,
should include four factors: enlargement of the cervix, uterine
enlargement, diffuse amorphous intrauterine echoes, and absence
of intrauterine pregnancy. In 1993, Timor-Tritsch et al. proposed
more stringent criteria: the placenta and entire chorionic sac
containing the live pregnancy must be below the internal os, and
the cervical canal must be dilated and barrel shaped. The point of
insertion of the uterine artery was used as the level of the internal
os. Later reports with transvaginal and colour Doppler imaging
modified the diagnostic criteria.[6[
The pathogenesis of cervical ectopic pregnancy is still debated,
but it has been postulated to be due to abnormal embryonic
implantation to the mostly fibrous tissue of the uterine cervix.
The 80% fibrous tissue and 20% smooth-muscle component of
the cervix has poor contractility, and it is therefore predisposed to
haemorrhage with poor response to uterotonic agents.
Management is preferably medical with the use of methotrexate
and potassium chloride, with a varying degree of success. Massive
bleeding can occur after methotrexate treatment as a result of
decidua shedding from the atonic cervix. Feticide with the use of
potassium chloride has been advised in cases of embryonic cardiac
activity prior to methotrexate administration to minimise failure.
Conservative surgical treatment under general anaesthesia includes
suction curettage, Foley balloon tamponade and intracervical
infiltration of Carboprost. In a study undertaken by Kirk et al.,
the success of conservative surgical treatment could be predicted
by the diagnostic accuracy of initial ultrasound. The accuracy
of early diagnosis will minimise the chance that hysterectomy
or blood transfusion will be necessary. However, failure of medical
intervention warrants surgical manoeuvres that can vary
from dilatation and curettage and cervical artery angiographic
embolisation to hysterectomy.
Our report combines the use of a vascular constrictive agent and
mechanical pressure on the cervical arteries using Mersilene tape
during the evacuation procedure, without the use of intracervical
tamponade. The emphasis in this clinical report is the use of
Mersilene tape to arrest haemostasis. Mersilene tape (Ethicon Endo-
Surgery Inc.) is a polyethylene terephthalate suture, which is nonabsorbable
and braided. It is used in cases of cervical incompetence
in early pregnancy to prevent miscarriage or premature delivery. The
tape, which is 5 mm in width, is circumferentially placed close to the
internal os and the ‘purse string’ tightened to occlude the cervico/
uterine arteries. As in our case, this may arrest haemorrhage to an
acceptable level and prevent massive bleeding. The use of a cervical
cerclage and Foley’s balloon tamponade in preventing haemorrhage in
cervical ectopic pregnancies has been reported in three cases. The
tamponade was removed on postoperative day 2 and the cervical
cerclage was removed on day 7. We removed the cerclage on our
patient’s second postoperative day. We assumed that the normal
haemostatic mechanism would have been optimised during this
period, thereby reducing the cost of hospitalisation.
Adjuvant cervical cerclage in this case report and a few other
previously reported cases will bring into focus the gradual introduction
of cervical cerclage as a conservative surgical procedure
in the armamentarium of surgical intervention in cervical ectopic