Hysteroscopy pp 171-179 | Cite as

Cervical Ectopic Pregnancy: The Role of Hysteroscopy

  • Salvatore Giovanni Vitale
  • Agnese Maria Chiara Rapisarda
  • Antonio Simone Laganà


Cervical pregnancy (CP) is a rare form of ectopic pregnancy. It is defined as the implantation of the blastocyst in the endocervix. The cervix is a highly vascularized area, which is potentially suitable for the implantation of a fertilized ovum. However, it is also extremely vulnerable to heavy bleeding due to its suboptimal hemostatic mechanical capacity and its insusceptibility to respond to uterotonic agents.

Despite its rarity, CP is a rare but potentially life-threatening condition because, when undiagnosed, it carries the potential risk of large-scale blood loss. In previous decades, a diagnosis was made when dilation and curettage, performed as a result of a presumably incomplete abortion, resulted in sudden and uncontrollable hemorrhage. To save the patient’s life, the treatment often required was an hysterectomy. Today, cervical pregnancy can be diagnosed through an ultrasound during the first trimester of pregnancy. This recognition at an early stage has led to a development of more conservative treatments, with the objective of preserving fertility. Different approaches have been implemented, but due to the rarity of this condition standard recommendations have not yet been elucidated. Recently, hysteroscopic resection of ectopic CP was described as an effective and fertility-preserving surgical therapy, having been used alone or in combination with another complementary therapy. Although some authors dispute its complementary function with methotrexate (MTX), others believe that it could be used as a rescue method in the case of MTX failure. However, to date, there has been no consensus on the exact role of hysteroscopy in CP.


Ectopic pregnancy Cervical pregnancy Hysteroscopy Conservative treatment 


  1. 1.
    Kamwendo F, Forslin L, Bodin L, Danielsson D. Epidemiology of ectopic pregnancy during a 28 year period and the role of pelvic inflammatory disease. Sex Transm Infect. 2000;76:28–32.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Lagana AS, Vitale SG, De Dominici R, Padula F, Rapisarda AM, Biondi A, et al. Fertility outcome after laparoscopic salpingostomy or salpingectomy for tubal ectopic pregnancy a 12-years retrospective cohort study. Ann Ital Chir. 2016;87:461–5.PubMedGoogle Scholar
  3. 3.
    Oron G, Tulandi T. A pragmatic and evidence-based management of ectopic pregnancy. J Minim Invasive Gynecol. 2013;20:446–54. doi: 10.1016/j.jmig.2013.02.004.CrossRefPubMedGoogle Scholar
  4. 4.
    Rubin IC. Cervical pregnancy. Am J Obstet Gynecol. 1911;13:625–33.Google Scholar
  5. 5.
    Jankowitz J, Leake J, Huggins G, Gazaway P, Gates E. Cervical ectopic pregnancy. Review of the literature and report of a case treated by single-dose methotrexate therapy. Obstet Gynecol Surv. 1990;45:405–14.CrossRefGoogle Scholar
  6. 6.
    Singh S. Diagnosis and management of cervical ectopic pregnancy. J Hum Reprod Sci. 2013;6:273–6. doi: 10.4103/0974-1208.126312. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod. 2002;17:3224–30.CrossRefPubMedGoogle Scholar
  8. 8.
    Hofmann HM, Urdl W, Höfler H, Hönigl W, Tamussino K. Cervical pregnancy: case reports and current concepts in diagnosis and treatment. Arch Gynecol Obstet. 1987;241:63–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Paalman RJ, McElin TW. Cervical pregnancy; review of the literature and presentation of cases. Am J Obstet Gynecol. 1959;77:1261–70.CrossRefPubMedGoogle Scholar
  10. 10.
    Scutiero G, Nappi L, Matteo M, Balzano S, Macarini L, Greco P. Cervical pregnancy treated by uterine artery embolisation combined with office hysteroscopy. Eur J Obstet Gynecol Reprod Biol. 2013;166:104–6. doi: 10.1016/j.ejogrb.2012.10.013.CrossRefPubMedGoogle Scholar
  11. 11.
    Masuda H, Endo T, Yoshimasa Y, Uchida H, Nakabayashi A, Maruyama T, et al. A case of hysteroscopic resection of cervical pregnancy after successful treatment with systematic methotrexate. J Obstet Gynaecol. 2016;36:865–6. doi: 10.1080/01443615.2016.1174837.CrossRefPubMedGoogle Scholar
  12. 12.
    Kofinas JD, Purisch SE, Brandt JS, Montes M. Hysteroscopic removal of cervical ectopic pregnancy following failed intramuscular/intra-sac methotrexate: a case report. J Gynecol Surg. 2012;28:369–71. doi: 10.1089/gyn.2012.0006.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Mangino FP, Ceccarello M, Di Lorenzo G, D’Ottavio G, Bogatti P, Ricci G. Successful rescue hysteroscopic resection of a cervical ectopic pregnancy previously treated with methotrexate with no combined safety precautions. Clin Exp Obstet Gynecol. 2014;41:214–6.PubMedGoogle Scholar
  14. 14.
    Coste J, Bouyer J, Job-Spira N. Epidemiology of ectopic pregnancy: incidence and risk factors. Contracept Fertil Sex. 1996;24:135–9.PubMedGoogle Scholar
  15. 15.
    CDC Centers for Control of Disease. Pregnancy-related mortality surveillance-United States, 1991–1999. 2003. Accessed 1 Feb 2017.
  16. 16.
    Kouliev T, Cervenka K. Emergency ultrasound in cervical ectopic pregnancy. J Emerg Med. 2010;38:55–6. doi: 10.1016/j.jemermed.2007.09.059.CrossRefPubMedGoogle Scholar
  17. 17.
    Karande VC, Flood JT, Heard N, Veeck L, Muasher SJ. Analysis of ectopic pregnancies resulting from in-vitro fertilization and embryo transfer. Hum Reprod. 1991;6:446–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Kraemer B, Abele H, Hahn M, Wallwiener D, Rajab TK, Hornung R. Cervical ectopic pregnancy on the portio: conservative case management and clinical review. Fertil Steril. 2008;90:2011.e1–4. doi: 10.1016/j.fertnstert.2008.06.018.CrossRefGoogle Scholar
  19. 19.
    Burg E. Cervical pregnancy. Zentralbl Gynakol. 1958;80:852–4.PubMedGoogle Scholar
  20. 20.
    Ginsburg ES, Frates MC, Rein MS, Fox JH, Hornstein MD, Friedman AJ. Early diagnosis and treatment of cervical pregnancy in an in vitro fertilization program. Fertil Steril. 1994;61:966–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Hoellen F, Diedrich K, Dittmer C. Cervical ectopic pregnancy: therapeutic management. Exp Rev Obstet Gynecol. 2011;6:91–8.Google Scholar
  22. 22.
    Murji A, Garbedian K, Thomas J, Cruickshank B. Conservative management of cervical ectopic pregnancy. J Obstet Gynaecol Can. 2015;37:1016–20.CrossRefPubMedGoogle Scholar
  23. 23.
    Boyko TR, O’Brien JF. Cervical pregnancy: a case report. Ann Emerg Med. 2001;38:177–80. doi: 10.1067/mem.2001.115442.CrossRefPubMedGoogle Scholar
  24. 24.
    Vela G, Tulandi T. Cervical pregnancy: the importance of early diagnosis and treatment. J Minim Invasive Gynecol. 2007;14:1–4. doi: 10.1016/j.jmig.2006.11.012. CrossRefGoogle Scholar
  25. 25.
    Verma U, Goharkhay N. Conservative management of cervical ectopic pregnancy. Fertil Steril. 2009;91:671–4. doi: 10.1016/j.fertnstert.2007.12.054.CrossRefPubMedGoogle Scholar
  26. 26.
    Padula F, Laganà AS, Vitale SG, Mangiafico L, D'Emidio L, Cignini P, et al. Ultrasonographic evaluation of placental cord insertion at different gestational ages in low-risk singleton pregnancies: a predictive algorithm. Facts Views Vis Obgyn. 2016;8:3–7.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Kirk E, Condous G, Haider Z, Syed A, Ojha K, Bourne T. The conservative management of cervical ectopic pregnancies. Ultrasound Obstet Gynecol. 2006;27:430–7. doi: 10.1002/uog.2693.CrossRefPubMedGoogle Scholar
  28. 28.
    Ushakov FB, Elchalal U, Aceman PJ, Schenker JG. Cervical pregnancy: past and future. Obstet Gynecol Surv. 1997;52:45–59.CrossRefPubMedGoogle Scholar
  29. 29.
    Gun M, Mavrogiorgis M. Cervical ectopic pregnancy: a case report and literature review. Ultrasound Obstet Gynecol. 2002;19:297–301. doi: 10.1046/j.1469-0705.2002.00559.x.CrossRefPubMedGoogle Scholar
  30. 30.
    Matson LM, Dotters DJ, Katz VL. Methotrexate and angiographic embolization for conservative treatment of cervical pregnancy. South Med J. 1996;89:246–8.CrossRefGoogle Scholar
  31. 31.
    Sönmez AS, Kafkasli A, Balat O, Saraç K, Uryan I, Turhan O, et al. Cervical pregnancy: can age and parity be predisposing factors? Acta Obstet Gynecol Scand. 1994;73:734–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Vas W, Suresh PL, Tang-Barton PL, Salimi Z, Carlin B. Ultrasonographic differentiation of cervical abortion from cervical pregnancy. J Clin Ultrasound. 1984;12:553–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol. 1996;8:373–80. doi: 10.1046/j.1469-0705.1997.08060373.x.CrossRefPubMedGoogle Scholar
  34. 34.
    AT E, Lam SL. Clinics in diagnostic imaging (92). Singap Med J. 2003;44:656–60.Google Scholar
  35. 35.
    Timor-Tritsch IE, Monteagudo A, Mandeville EO, Peisner DB, Anaya GP, Pirrone EC. Successful management of viable cervical pregnancy by local injection of methotrexate guided by transvaginal ultrasonography. Am J Obstet Gynecol. 1994;170:737–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Van de Meerssche M, Verdonk P, Jacquemyn Y, Serreyn R, Gerris J. Cervical pregnancy: three case reports and a review of the literature. Hum Reprod. 1995;10:1850–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Pellerito JS, Taylor KJ, Quedens-Case C, Hammers LW, Scoutt LM, Ramos IM, et al. Ectopic pregnancy: evaluation with endovaginal color flow imaging. Radiology. 1992;183:407–11. doi: 10.1148/radiology.183.2.1561341.CrossRefPubMedGoogle Scholar
  38. 38.
    Jung SE, Byun JY, Lee JM, Choi BG, Hahn ST. Characteristic MR findings of cervical pregnancy. J Magn Reson Imaging. 2001;13:918–22.CrossRefPubMedGoogle Scholar
  39. 39.
    Itakura A, Okamura M, Ohta T, Mizutani S. Conservative treatment of a second trimester cervicoisthmic pregnancy diagnosed by magnetic resonance imaging. Obstet Gynecol. 2003;101:1149–51.PubMedGoogle Scholar
  40. 40.
    Yazici G, Aban M, Arslan M, Pata O, Oz U. Treatment of cervical viable pregnancy with a single intraamniotic methotrexate injection: a case report. Arch Gynecol Obstet. 2004;270:61–3. doi: 10.1007/s00404-002-0450-0.CrossRefPubMedGoogle Scholar
  41. 41.
    Weibel HS, Alserri A, Reinhold C, Tulandi T. Multidose methotrexate treatment of cervical pregnancy. J Obstet Gynaecol Can. 2012;34:359–62.CrossRefPubMedGoogle Scholar
  42. 42.
    Fylstra DL. Cervical pregnancy: 13 cases treated with suction curettage and balloon tamponade. Am J Obstet Gynecol. 2014;210:581.e1–5. doi: 10.1016/j.ajog.2014.03.057.CrossRefGoogle Scholar
  43. 43.
    Timor-Tritsch IE, Cali G, Monteagudo A, Khatib N, Berg RE, Forlani F, et al. Foley balloon catheter to prevent or manage bleeding during treatment for cervical and cesarean scar pregnancy. Ultrasound Obstet Gynecol. 2015;46:118–23. doi: 10.1002/uog.14708.CrossRefPubMedGoogle Scholar
  44. 44.
    Habek D, Cerkez Habek J, Curzik D. Unrecognized cervical pregnancy treated by suction curettage and cervicovaginal tamponade. Zentralbl Gynakol. 2002;124:184–5. doi: 10.1055/s-2002-32264.CrossRefPubMedGoogle Scholar
  45. 45.
    Spitzer D, Steiner H, Graf A, Zajc M, Staudach A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection. Hum Reprod. 1997;12:860–6.CrossRefPubMedGoogle Scholar
  46. 46.
    De La Vega GA, Avery C, Nemiroff R, Marchiano D. Treatment of early cervical pregnancy with cerclage, carboprost, curettage, and balloon tamponade. Obstet Gynecol. 2007;109:505–7. doi: 10.1097/01.AOG.0000220599.74326.94.CrossRefGoogle Scholar
  47. 47.
    Matteo M, Nappi L, Rosenberg P, Greco P. Combined medical-hysteroscopic conservative treatment of a viable cervical pregnancy: a case report. J Minim Invasive Gynecol. 2006;13:345–7. doi: 10.1016/j.jmig.2006.03.009.CrossRefPubMedGoogle Scholar
  48. 48.
    Kung FT, Lin H, Hsu TY, Chang CY, Huang HW, Huang LY, et al. Differential diagnosis of suspected cervical pregnancy and conservative treatment with the combination of laparoscopy-assisted uterine artery ligation and hysteroscopic endocervical resection. Fertil Steril. 2004;81:1642–9. doi: 10.1016/j.fertnstert.2003.11.034.CrossRefPubMedGoogle Scholar
  49. 49.
    Trambert JJ, Einstein MH, Banks E, Frost A, Goldberg GL. Uterine artery embolization in the management of vaginal bleeding from cervical pregnancy: a case series. J Reprod Med. 2005;50:844–50.PubMedGoogle Scholar
  50. 50.
    Goldberg JM, Widrich T. Successful management of a viable cervical pregnancy by single-dose methotrexate. J Womens Health Gend Based Med. 2000;9:43–5. doi: 10.1089/152460900318948.CrossRefPubMedGoogle Scholar
  51. 51.
    Hung TH, Shau WY, Hsieh TT, Hsu JJ, Soong YK, Jeng CJ. Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: a quantitative review. Hum Reprod. 1998;13:2636–42.CrossRefPubMedGoogle Scholar
  52. 52.
    Bai SW, Lee JS, Park JH, Kim JY, Jung KA, Kim SK, et al. Failed methotrexate treatment of cervical pregnancy. Predictive factors. J Reprod Med. 2002;47:483–8.PubMedGoogle Scholar
  53. 53.
    Samal SK, Rathod S. Cervical ectopic pregnancy. J Nat Sci Biol Med. 2015;6:257–60. doi: 10.4103/0976-9668.149221.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Polak G, Stachowicz N, Morawska D, Kotarski J. Treatment of cervical pregnancy with systemic methotrexate and KCI solution injection into the gestational sac—case report and review of literature. Ginekol Pol. 2011;82:386–9.PubMedGoogle Scholar
  55. 55.
    Yamaguchi M, Honda R, Erdenebaatar C, Monsur M, Honda T, Sakaguchi I, et al. The treatment of cervical pregnancy with ultrasound-guided local methotrexate injection. Ultrasound Obstet Gynecol. 2016; doi: 10.1002/uog.17384.
  56. 56.
    Alammari R, Thibodeau R, Harmanli O. Vaginal hysterectomy for treatment of cervical ectopic pregnancy. Obstet Gynecol. 2017;129:63–5. doi: 10.1097/AOG.0000000000001782.CrossRefPubMedGoogle Scholar
  57. 57.
    Rossetti D, Vitale SG, Bogani G, Rapisarda AM, Gulino FA, Frigerio L. Usefulness of vessel-sealing devices for peripartum hysterectomy: a retrospective cohort study. Updat Surg. 2015;67:301–4. doi: 10.1007/s13304-015-0289-0.CrossRefGoogle Scholar
  58. 58.
    Ash S, Farrell SA. Hysteroscopic resection of a cervical ectopic pregnancy. Fertil Steril. 1996;66:842–4.CrossRefPubMedGoogle Scholar
  59. 59.
    Hardy TJ. Hysteroscopic resection of a cervical ectopic pregnancy. J Am Assoc Gynecol Laparosc. 2002;9:370–1.CrossRefPubMedGoogle Scholar
  60. 60.
    Giacobbe V, Rossetti D, Vitale SG, Rapisarda AM, Padula F, Laganà AS, et al. Otorrhagia and nosebleed as first signs of intravascular absorption syndrome during hysteroscopy: from bench to bedside. Kathmandu Univ Med J. 2016;14:87–9.Google Scholar
  61. 61.
    Laganà AS, Vitale SG, Muscia V, Rossetti P, Buscema M, Triolo O, et al. Endometrial preparation with Dienogest before hysteroscopic surgery: a systematic review. Arch Gynecol Obstet. 2017;295:661–7. doi: 10.1007/s00404-016-4244-1.
  62. 62.
    Sudano MC, Vitale SG, Rapisarda AM, Carastro D, Tropea A, Zizza G. The REP-b (removal of endometrial pathologies-basket) in-office hysteroscopy. Updat Surg. 2016;68:407–12. doi: 10.1007/s13304-015-0294-3.CrossRefGoogle Scholar
  63. 63.
    Deans R, Abbott J. Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril. 2010;93:1735–40. doi: 10.1016/j.fertnstert.2008.12.099.CrossRefPubMedGoogle Scholar
  64. 64.
    Lin CY, Chang CY, Chang HM, Tsai EM. Cervical pregnancy treated with systemic methotrexate administration and resectoscopy. Taiwan J Obstet Gynecol. 2008;47:443–7. doi: 10.1016/S1028-4559(09)60015-2.CrossRefPubMedGoogle Scholar
  65. 65.
    Roussis P, Ball RH, Fleischer AC, Herbert CM III. Cervical pregnancy. A case report. J Reprod Med. 1992;37:479–81.PubMedGoogle Scholar
  66. 66.
    Yoshimasa Y, Uchida H, Nakabayashi A, Maruyama T, Tanaka M. A case of hysteroscopic resection of cervical pregnancy after successful treatment with systematic methotrexate. J Obstet Gynaecol. 2016;36:865–6. doi: 10.1080/01443615.2016.1174837.CrossRefPubMedGoogle Scholar
  67. 67.
    Kim JS, Nam KH, Kim TH, Lee HH, Lee KH. Hysteroscopic management of cervical pregnancy with intrauterine irrigation with H2O2. J Minim Invasive Gynecol. 2008;15:627–30. doi: 10.1016/j.jmig.2008.06.006.CrossRefPubMedGoogle Scholar
  68. 68.
    Jozwiak EA, Ulug U, Akman MA, Bahceci M. Successful resection of a heterotopic cervical pregnancy resulting from intracytoplasmic sperm injection. Fertil Steril. 2003;79:428–30.CrossRefPubMedGoogle Scholar
  69. 69.
    Vitale SG, Gasbarro N, Lagana AS, Sapia F, Rapisarda AM, Valenti G, et al. Safe introduction of ancillary trocars in gynecological surgery: the “yellow island” anatomical landmark. Ann Ital Chir. 2016;87:608–11.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Salvatore Giovanni Vitale
    • 1
  • Agnese Maria Chiara Rapisarda
    • 2
  • Antonio Simone Laganà
    • 1
  1. 1.Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”University of MessinaMessinaItaly
  2. 2.Department of General Surgery and Medical Surgical SpecialtiesUniversity of CataniaCataniaItaly

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