American Journal of Emergency Medicine 32 (2014) 397.e1–397.e3
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Case Report
Pitfalls in cervical ectopic pregnancy diagnosis by emergency physicians using bedside ultrasonography Abstract Pelvic pain and vaginal bleeding are common complaints in pregnant women presenting to emergency department. Cervical ectopic pregnancy (EP) is a rare type of EP, with a higher likelihood of complications if missed. Its sonographic findings can be difficult to distinguish from normal pregnancy or an abortion in progress. In this report, we present a rare case of a cervical EP, diagnosed using bedside ultrasonography, and characterize the pitfalls associated with its diagnosis. First trimester vaginal bleeding and pelvic pain are common chief complaints in the emergency department. Ruptured ectopic pregnancy (EP) is the leading cause of maternal death in the first trimester and is responsible for up to 15% of all maternal deaths [1]. Cervical EP (CEP) can be mistaken for an intrauterine pregnancy (IUP) or a threatened abortion. Because of the hypervascularity of the cervix in pregnancy, CEP tends to bleed profusely when surgical intervention is necessary and, as a result, is associated with a high rate of emergent hysterectomy [2]. The incidence of CEP varies between 1:2500 and 1:16000 pregnancies [3]. Despite increased utilization of bedside ultrasonography, there have been few reports of emergency medicine physicians primarily diagnosing CEP. This report describes a CEP diagnosed at bedside by
Fig. 1. A sagittal transvaginal ultrasound shows the retroflexed uterus. The fundus is outlined by white arrowheads. The elongated gestational sac containing a yolk sac can be seen extending from the lower extent of the endometrium into the endocervical canal (black arrowheads), which also contains a small amount of fluid. A small amount of free fluid can be seen between the posterior wall of the cervix and some loops of bowel. Abbreviations: GS, gestational sac; YS, yolk sac; EM, endometrium; F, fluid; B, bowel. 0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
emergency medicine physicians using ultrasonography. The distinguishing characteristics are reviewed. A 29-year-old woman, G4P1021, presented with a 7-day history of increased vaginal bleeding and cramping abdominal pain. Her last menstrual period was 5 weeks prior. She denied any use of contraceptive agents. Her medical and surgical histories were significant for elective abortion. The patient was hemodynamically stable, with mild suprapubic tenderness without peritoneal signs. Pelvic examination was notable for large blood clots in the vaginal vault, with a closed internal cervical os. Her laboratory values were unremarkable. Transabdominal and transvaginal ultrasound examinations revealed a retroflexed uterus with an intact gestational sac in the cervical canal, a yolk sac, and fetal heart tones (Figs. 1-3). No free fluid was detected in the cul-de-sac. Repeat pelvic ultrasonography by radiologist confirmed the diagnosis of CEP. Methotrexate 107.5 mg on day 0, 2, and 4 was administered with passage of the product of conception. Follow-up β-human Chorionic Gonadotropin level trended down appropriately over the course of 4 days (12 083-1894 mIU/mL). A follow-up transvaginal ultrasonography examination revealed an involuting EP. She was discharged home without complications. Cervical EP is defined as an embryo implantation in the endocervical canal. Risk factors include prior dilatation, curettage, intrauterine devices use, history of cesarean section, congenital structural anomalies, large uterine fibroids, infection or inflammation, in vitro fertilization, and advanced maternal age [4,5]. The most common chief complaint is profuse vaginal bleeding. The speculum and bimanual examinations will typically reveal vaginal bleeding but be otherwise unremarkable. A disproportionately soft and large cervix
Fig. 2. Ultrasonography of CEP transvaginal longitudinal view. Abbreviations: YS, yolk sac; FP, fetal pole; GS, gestational sac; CX, cervix; IO, internal os; EO, external os; U, uterus.
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Fig. 3. Fetal heart rate in transvaginal ultrasonography of CEP. Abbreviation: FHR, fetal heart rate.
in relation to the uterus may be palpated. Rarely, visible fetal tissue through an open cervical os, which typically appears blue or purple, may be present on speculum examination [6]. An intrauterine double decidual sign is recognized as the earliest sign of IUP; however, most emergency medicine physicians will not diagnose an IUP until a yolk sac or fetal pole is identified [7]. Distinguishing CEP from an IUP or abortion in progress is therefore the province of ultrasonography. The most sensitive findings for CEP include the presence of a gestational sac implanted within the endocervical canal with a normal endometrial stripe [8]. An hourglass-shaped uterus with a ballooned cervical canal may be observed reflecting a growing gestation within the canal. When gentle pressure is applied using an endocavitary probe, a CEP will resist being displaced from the surrounding structures. In contrast, the contents of an abortion
in progress will slide separately with gentle pressure [9]. In equivocal cases, repeat ultrasound scanning in 24 hours may reveal a stable gestational sac in contrast to the appearance of an abortion in progress. Color Doppler can identify signs suggestive of endocervical implantation (high-velocity and low-impedance blood flow in the endocervical canal), in the presence of a nonspecific endometrial sac [9]. Treatment options for CEP are based on clinical stability of the patient, gestational age, and fetal cardiac activity (Fig. 4) [6]. Successful conservative management of CEP using methotrexate (systemic or local) with or without potassium chloride injection has been reported. Only few women required an additional procedure (Shirodkar suture insertion, uterine artery embolization, Foley catheter balloon tamponade, or emergent hysterectomy) to control bleeding [2,4-6,8,10,11]. Surgical treatment (ligation of bilateral
Fig. 4. Algorithm of CEP treatment [7].
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internal iliac arteries to complete hysterectomy) is necessary in the case of failed medical management or massive hemorrhage. The diagnosis of CEP can be made based on bedside ultrasonography; however, there are numerous pitfalls in distinguishing CEP from IUP or abortion in progress. Familiarity with the ultrasonographic differences between the 2 can avoid misdiagnosis of CEP and its resultant catastrophic complications. Dewi Chrestiana MD Alfred B. Cheng MD Nova L. Panebianco MD, MPH Anthony J. Dean MD Department of Emergency Medicine University of Pennsylvania Medical Center Philadelphia, PA, USA E-mail address:
[email protected] http://dx.doi.org/10.1016/j.ajem.2013.10.055
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