Introduction

Ectopic pregnancy is a major complication of pregnancy in the first trimester. Cervical ectopic pregnancy (i.e., the implantation of gestational sac in the cervical canal) is a serious threat to a pregnant woman and her fetus that is associated with high mortality and morbidity rates (1). This type of ectopic pregnancy is an extremely infrequent condition accounting for less than 1% of all ectopic pregnancies (2). In the UK, 11,000 ectopic pregnancies are diagnosed each year. Most of them occur in the fallopian tubes; however, three to five cases per 100 ectopic pregnancies happen in other sites, including the cervix or abdomen.

Currently, the majority of women with cervical ectopic pregnancy die from the condition. Six maternal mortalities were reported between 2006 and 2008 (3). In a study carried out by Andrés (2012), the incidence of cervical ectopic pregnancy was reported as 1 in 18,000 pregnancies (4). Risk factors of cervical pregnancy include previous endometrial curettage, use of intrauterine devices, any manipulations and procedures performed on the cervix, such as dilatation of the cervix with a device. In addition, previous cesarean section is considered to be as a potential risk factor. However, the prevalence of cervical ectopic pregnancy has increased with assisted reproductive technologies (5).

It should be remembered that cervical pregnancy is very dangerous. If the risk of massive hemorrhage is not considered and the patient is not properly treated, it remains to be catastrophic and life-threatening. However, in the majority of women with an ectopic pregnancy, the risk factor is not clear (6). The diagnosis of cervical ectopic pregnancy depends on the patient’s symptoms, β-subunit of human chorionic gonadotropin (βhCG) titer, and ultrasound findings. In the past, cervical pregnancies were treated with hysterectomy due to associated significant hemorrhage (7). Cervical pregnancy is a rare type of ectopic pregnancy. Most of the patients suffer from massive vaginal bleeding. Detection of the gestational sac or placental tissue within the cervix and hourglass view in transvaginal ultrasound are evidences of cervical ectopic pregnancy ( 8).The most common symptom of this type of pregnancy is spotting.  One third of the patients have reported mild discomfort in their lower abdomen. In vaginal examination, endo-cervix may be open or closed. Our patient was diagnosed with transvaginal ultrasound and clinical examination.(9)

In recent years, with the improvements in ultrasound resolution and availability, the early diagnosis of these pregnancies has become possible. Therefore, conservative management, such as fertility preservation, has been considered which led to reduced mortality rates (10). According to the results of a study conducted by Ruano et al. (2006), the diagnosis of cervical ectopic pregnancy with conventional two-dimensional ultrasound was successfully performed. In addition, he was able to treat the patient with intramuscular injections of Methotrexate (MTX) without any complications (11).

In another study carried out by  Hirakawa  et al. (2007), it was reported that 5% of the cases with cervical pregnancy required blood transfusions due to massive vaginal bleeding and only 1% of the patients needed a hysterectomy (12). Proper treatment and the early detection of cervical ectopic pregnancy resulted in fewer complications. In this report, we presented the successful management of a case of cervical ectopic pregnancy.

Case report

A 31-year-old woman with a history of one cesarean section and spontaneous abortion was referred to the oncology department of an academic hospital in Mashhad University of Medical Sciences in 2017. This report was written with the patient’s informed consent. The case suffered from light spotting following 10 weeks of amenorrhea. In physical examinations, there was no abdominal tenderness. Pelvic examination showed light spotting, cervical motion tenderness, a balloon shaped cervical canal, and intact external os of the cervix. Transvaginal ultrasound reported a live fetus of about nine weeks located in the cervical area (Figure 1). At the same time, βhCG titer was 108,000 mIU/ml.

The patient had a stable hemodynamic state. She was admitted to the hospital with a diagnosis of cervical ectopic pregnancy. In an attempt to preserve fertility, conservative management
was planned. Based on multidisciplinary team decision-making, 50 mg/m2 of intramuscular MTX was injected as a single dose. Unexpectedly, on the tenth day after the treatment, one episode of massive vaginal bleeding happened resulted
in blood transfusion. Moreover, transvaginal ligation of cervical branches of the uterine arteries was performed.

In addition, evacuation suction curettage was carried out. Subsequently, Foley catheter tamponade was placed inside the cervix for 12 h. The pathology report of the specimen was decidual tissue and chorionic villi adjacent to endocervical tissue that was consistent with the diagnosis of cervical ectopic pregnancy (Figure 2).

Based on the satisfactory general condition of the patient, she was followed by repeating the serum βHCG levels. After two consequent weeks, βHCG titer returned to a normal level (4 mIU/ml). Moreover, the ultrasound report was normal. At the moment, the patient is in a good condition with no signs or symptom of the disease.