Case Report

Three-Dimensional Sonographic Findings of a Cervical Pregnancy

David M. Sherer, MD, Constantine Gorelick, MD, Mudar Dalloul, MD, Margarita Sokolovski, RDMS, Mila Kheyman, RDMS, Sangeetha Kakamanu, MD, Ovadia Abulafia, MD

A
Abbreviations -hCG, -human chorionic gonadotropin

cervical pregnancy is an uncommon ectopic pregnancy that accounts for less than 1% of such gestations.1 This condition is associated with an extremely high risk of massive hemorrhage and previously often required hysterectomy.1 The current diagnostic modality of this potentially lifethreatening condition is transvaginal sonography, supported at times by magnetic resonance imaging.24 The definitive diagnostic imaging feature of a cervical pregnancy is the location of a gestational sac in the cervix in the presence of a closed internal uterine cervical os.27 We report the 3-dimensional transvaginal sonographic findings of a cervical pregnancy at 6 weeks gestation.

Case Report
A 34-year-old woman, gravida 3, para 0, came to the emergency department at State University of New York Downstate Medical Center with mild uterine hemorrhage. Her medical history was unremarkable. The patient had 2 previous spontaneous first-trimester miscarriages. Physical examination revealed a healthy individual. She was afebrile with a blood pressure of 120/78 mm Hg, a pulse of 84 beats per minute, and a respiratory rate of 20 breaths per minute. Her abdomen was soft and nontender, with no peritoneal signs elicited. Bimanual pelvic examination disclosed a soft, mildly enlarged uterus. Both adnexa were normal. The cervix was long and closed and appeared boggy on inspection. Laboratory test results revealed a hemoglobin level of 13.6 g/dL, a hematocrit value of 42%, a white blood cell count of 7.29 109/L, and a platelet count of 255 109/L.

Received August 8, 2007, from the Divisions of Maternal-Fetal Medicine (D.M.S., M.D., M.S., M.K.) and Gynecologic Oncology (C.G., S.K., O.A.), Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York USA. Revision requested August 15, 2007. Revised manuscript accepted for publication August 16, 2007. Address correspondence to David M. Sherer, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, 445 Lenox Rd, Box 24, Brooklyn, NY 11203-2098 USA. E-mail: dmsherer@aol.com

2008 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2008; 27:155158 0278-4297/08/$3.50

Three-Dimensional Sonographic Findings of a Cervical Pregnancy

Figure 1. Sagittal 2-dimensional sonogram depicting the gestational sac distal to the closed internal os of the uterine cervix and eccentric to the endocervical canal. The endocervical canal distal to the eccentrically located cervical pregnancy, is shown to the right of the gestational sac and is depicted with asterisks. The arrow points to the internal cervical os, abutting the endometrium (e). The proximal endocervical canal can be seen immediately to the right of (and inferior to) the internal os.

Figure 2. Multiplanar (coronal) 3-dimensional sonogram depicting the gestational sac (note the embryonic pole) located within the uterine cervix distal to the intact endometrium. The arrow (corresponding to the arrow depicted in Figure 1) points to the internal cervical os, abutting the endometrium. Note the proximal endocervical canal represented by the thin line extending distal (inferior) to the internal os and above the gestational sac.

Serum creatinine, blood urea nitrogen, electrolyte, prothrombin time, and partial thromboplastin time values were normal, and her serum -human chorionic gonadotropin (-hCG) level was 5859 mIU/mL. Transvaginal sonography (iU22; Philips Medical Systems, Bothell, WA) depicted a uterus with a normal endometrial echo. No evidence of an intrauterine gestation was seen. Both adnexa were normal. No free fluid was noted in the cul-de-sac. Within the cervix, eccentric to the endocervical canal, a gestational sac containing a yolk sac and an embryonic pole measuring 11 mm was noted. Embryonic cardiac activity was also observed. Difficulty visualizing the internal os was encountered (Figure 1). Multiplanar transvaginal 3-dimensional sonography of the endometrial cavity (Philips iU22 3D 9-3v) clearly depicted the gestational sac (containing the embryonic pole) distal to the endometrium (Figure 2). Considering the patients hemodynamic stability and desire to maintain fertility, conservative expectant management with high-dose methotrexate (1 mg/kg, days 1, 3, 5, and 7) and leucovorin (0.1 mg/kg, days 2, 4, 6, and 8) rescue therapy was performed. Six days later on transvaginal sonography, the previously depicted embryonic pole was not noted. The serum -hCG level remained at 2700 mIU/mL 2 days after the above therapeutic course, and a second similar course of high-dose methotrexate and leucovorin rescue therapy was administered, followed by a continued gradual decrease in serum -hCG levels. The patient was discharged in good health.

Discussion
The differential diagnosis of a cervical pregnancy includes a miscarriage in process of an intrauterine gestation, with the gestational sac in the process of being expelled from the uterus, traversing the endocervical canal and meeting resistance at the level of the external os. The resulting ballooning of the endocervical canal has been defined as a cervical abortion.8 Vas et al8 described the associated sonographic findings of 4 such cases. Accordingly, a cervical abortion is suggested sonographically by uterine enlargement beyond the nongravid state in contrast with the minimal uterine enlargement seen in a cervical pregnan156 J Ultrasound Med 2008; 27:155158

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cy. Categorically, the internal os is dilated in a cervical abortion and closed in a cervical pregnancy. In cases of a cervical abortion, the gestational sac is located within the endocervical canal and not eccentric to this structure (as depicted in Figure 1). In addition, a miscarriage in the process of an intrauterine gestation would be less likely in the presence of embryonic/fetal cardiac activity. Three-dimensional sonography of the endometrial cavity and endometrium has been advocated for detection of congenital uterine anomalies, insertion and location of intrauterine contraceptive devices, and depiction of endometrial growth and vascularity throughout the normal menstrual cycle.917 Other applications of 3-dimensional sonography of the endometrium include endometrial volume measurements in patients with postmenopausal bleeding, assessment of intracavitary lesions, evaluation of endometrial receptivity during in vitro fertilization, localization of the maximal implantation point during sonographically guided embryo transfer, and use in association with extrauterine gestations.1823 Recently, 3-dimensional transvaginal sonography of the endometrium has assisted the diagnosis of interstitial and intramural pregnancies.2426 In these cases, as in our case of a cervical pregnancy, 3-dimensional transvaginal sonography of the endometrium enabled precise depiction of the intact endometrium and the presence of an adjacent gestational sac located within the myometrium or uterine cervix, respectively. A systematic English language literature search (PubMed and MEDLINE) between 1966 and 2007 using the search terms cervical pregnancy, endometrium, endometrial cavity, threedimensional ultrasound, and ultrasound indicated that the 3-dimensional sonographic findings associated with a cervical pregnancy have not been reported previously. This case suggests that when difficulty is encountered assessing the internal os in patients with a suspected cervical pregnancy, 3-dimensional sonography of the endometrium may assist in confirming the presence of a cervical pregnancy.

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