About the Authors

Babita Ramani, Rajat Mohanty, Sudipta Patnaik

Senior Resident

Dept. of Obstetrics and Gynecology

VSS Medical College, Burla, Sambalpur, Odisha

Senior Specialist and Consultant

Dept. of Obstetrics and Gynecology

Assistant Professor

Dept. of Physiology

SCB Medical College, Cuttack, Odisha

Keywords

Cervical molar pregnancy, vaginal bleeding, injection methotrexate, serum -hCG

Cervical pregnancy is a rare variety of ectopic pregnancy. Incidence of cervical pregnancy is <1% of all ectopic pregnancies.1 Molar changes in the cervical pregnancy are very rare occurrence. To preserve uterus and cervix in such a situation is really a challenge to the obstetrician.

Case Report

A 37-year-old lady G2P1L1 came to the labor room, VSS Medical College, Burla, at 9 pm on 22.04.2012 in emergency with complaint of bleeding per vaginum for 2 days at 6 weeks of pregnancy for which suction and evacuation was tried at a local hospital, but she landed up with brisk hemorrhage and was referred to higher center, where sonography revealed an enlarged uterus and distended cervix with multiple tiny anechoic structures filling the dilated cervical canal (Fig. 1). Internal os was closed and there was a cervical pregnancy, so she was referred to a tertiary center.

On examination, her pulse rate was 90/min and blood pressure (BP) 110/70 mmHg with moderate degree of pallor. Abdomen was soft with normal findings. No bleeding was present on inspection of vulva.

On per speculum examination, external os was open, no bleeding through os was seen. On bimanual examination cervix was distended, os was 2 cm dilated and soft structure felt through os. Uterus was bulky, anteverted, soft, mobile, fornices were free and nontender.

Her hemoglobin was 9.8 g/dL and serum -hCG (human chorionic gonadotropin) was 19,714.74 mIU/mL. Her liver function tests, renal function tests and thyroid-stimulating hormone were within normal limits. USG, revealed an enlarged uterus (115 ×65 × 49 mm) with complex lesion adherent to the anterior cervical wall of size 43 × 40 × 32 mm, volume 21.6 cc, mostly cystic with peripheral hypervascularity, a right ovarian cyst of size 43 × 29 × 30 mm; no identifiable gestational sac was seen (Figs. 2 and 3). Left ovary was normal. Endometrial thickness was 12 mm, with signs of invasive cervical mole. Histopathology report revealed hydropic villi with irregular scalloped outline (Fig. 4).

As she was not bleeding was managed her conservatively with 1 unit of blood transfusion and injection methotrexate 1 mg/kg on D 1, 3, 5, 7 alternating with folinic acid 0.1 mg/kg. Injectable broad-spectrum antibiotic was also given, which was continued till 29.04.12 and was discharged on 01.05.12 with advice for barrier contraception.

Serial serum -hCG gradually decreased to undetectable levels within a span of 6 weeks. She used calender method, instead of barrier contraception and conceived after 14 months in June 2013 and this time it was an intrauterine pregnancy. During this pregnancy at 6 weeks, she terminated the same by medical method.

Discussion

Four cases of cervical molar pregnancy have reported in literature till now, two of them were partial cervical moles and two were complete cervical mole. Beless et al2 have given cervical cerclage like stay sutures to control the bleeding after surgical procedure. Schorge and associates3 evaluated that fertility was not impaired and pregnancy outcomes were usually normal following successful treatment of cervical molar pregnancy.

Schwentner et al4 revealed the cause of cervical molar pregnancy, which was traumatic holding of the cervix during evacuation of a missed abortion. It has also been suggested that a previous cesarean section may play a role in the etiology of cervical pregnancy and molar changes are related to the older age group i.e., >35 years.5

These two factors may be the main cause of the present case. Aytan et al6 terminated the partial cervical molar pregnancy by suction and evacuation followed by serial serum -hCG evaluation. The present case was managed successfully by injection methotrexate in multiple doses alternating with folinic acid. She was also counseled about the future risk of choriocarcinoma.

Conclusion

Surgical intervention in such a situation is very fatal. We propose to go for a fertility sparing medical management.

References

1. Ushakov FB, Elchalal U, Aceman PJ, Schenker JG. Cervical pregnancy: past and future. Obstet Gynecol Surv 1997;52(1):45-59.
2. Beless DJ. Cervical hydatidiform mole causing severe vaginal hemorrhage: a case report. J Reprod Med 1995;40(12):855-8.
3. Schorge JO, Goldstein DP, Bernstein MR, Berkowitz RS. Recent advances in gestational trophoblastic disease. J Reprod Med 2000;45(9):692-700.
4. Schwentner L, Schmitt W, Bartusek G, Kreienberg R, Herr D. Cervical hydatidiform mole pregnancy after missed abortion presenting with severe vaginal bleeding: case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2011;156(1):9-11.
5. Parazzini F, La Vecchia C, Pampallona S. Parental age and risk of complete and partial hydatidiform mole. Br J Obstet Gynaecol 1986;93(6):582-5.
6. Aytan H, Caliskan AC, Demirturk F, Koseoglu RD, Acu B. Cervical partial hydatidiform molar pregnancy. Gynecol Obstet Invest 2008;66(2):142-4.