Chronic ectopic pregnancy is a condition in which the pregnancy does not completely resorb during expectant management. The condition arises when there is persistence of the chorionic villi with bleeding into the tubal wall, which is distended slowly and does not rupture. It may arise from chronic bleeding from the fimbriated end of the fallopian tube with subsequent tamponade. In a series of 50 patients with a chronic ectopic pregnancy, pain was present in 86%, vaginal bleeding was present in 68%, and both symptoms were present in 58% (234). Ninety percent of the patients had amenorrhea ranging from 5 to 16 weeks (mean, 9.6 weeks). Most patients develop a pelvic mass that usually is symptomatic. The β-hCG level usually is low but may be absent; ultrasonography may be helpful in the diagnosis; rarely, bowel involvement or ureteral compression or obstruction exists (234,235).
This condition is treated surgically with removal of the affected tube. Often, the ovary must be removed because there is inﬂammation with subsequent adhesion development. A hematoma may be present secondary to chronic bleeding.
Cervical Pregnancy The incidence of cervical pregnancy in the United States ranges from
Pregnancy 1 in 2,400 to 1 in 50,000 pregnancies and accounts for less than 1% of ectopic pregnancies (236,237). The cause of cervical ectopic pregnancies is unknown and the rare occurrence prevents identification of known risk factors. The incidence does appear to be higher with in vitro fertilization procedures, accounting for 3.7% of IVF-related ectopic pregnancies (238).
The clinical criteria for diagnosing a cervical pregnancy include the following findings (239): 1.
Uterus is smaller than the surrounding distended cervix; 2.
3.
4.
Profuse bleeding on manipulation of cervix.
Patients classically present with painless vaginal bleeding, but reports of associated cramping and pain are published (240).
Table 20.5 Ultrasound Criteria for Cervical Pregnancy 1.
Gestational sac or placental tissue visualized within the cervix 2.
Cardiac motion noted below the level of the internal os 3.
4.
Hourglass uterine shape with ballooned cervical canal 5.
No movement of the sac with pressure from transvaginal probe (i.e., no “sliding sign” that is typically seen with incomplete abortions) 6.
Adapted from Kung FT, Lin H, Hsu TY, et al. Differential diagnosis of cervical ectopic pregnancy and conservative treatment with the combination of laparoscopy-assisted uterine artery ligation and hysteroscopic endocervical resection. Fertil Steril 2004;81:1642–1649.
When a cervical pregnancy is suspected, imaging studies are useful in confirming the diagnosis. Ultrasonographic diagnostic criteria are described that are helpful in differentiating a true cervical pregnancy from an ongoing spontaneous abortion (Table 20.5). MRI of the pelvis is used in this situation (241). Other potential diagnoses that must be differentiated from cervical pregnancy include cervical carcinoma, cervical or prolapsed submucousal leiomyomas, trophoblastic tumor, placenta previa, and low-lying placenta.