J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.290 on 1 July 1997. Downloaded from MEDICAL PRACTICE Cervical - A Forgotten Entity in Family Practice

David A. Acosta, MD

Background: Cervical pregnancy is a rare form of that is associated with considerable maternal morbidity and a high mortality rate if early diagnosis and treatment are not carried out in a timely fashion. Alethods: The current medical literature was reviewed by searching MEDLINE files from 1985 to 1996, using the key words "ectopic pregnancy" and "cervical pregnancy." Older articles were accessed from cross-reference of the more recent publications. Results: The incidence of cervical pregnancy is 1 in 2400 deliveries and represents less than 1.0 percent of all ectopic . No clear cause of cervical pregnancy has been described, and criteria for the clinical, pathologic, and sonographic diagnosis have been well established. The most common clinical complaint is painless . Routine transvaginal sonography early on allows for conservative management and avoids adverse outcomes. administered systemically and by intra-amniotic instillation are the therapeutic options of choice. Gestational age and the presence or absence of fetal cardiac activity are major prognostic factors for its success. Conclusion: Earlier diagnosis of cervical pregnancy using sonography and conservative management of this condition have reduced considerably the morbidity and mortality associated with this rare form of ectopic pregnancy and have helped preserve a woman's future fertility. (J Am Board Fam Pract 1997;10:290-95.)

Cervical pregnancy is a rare form of ectopic preg­ was reviewed by searching MEDLINE files from nancy, yet it is a devastating condition when en­ 1985 to 1996, using key words "ectopic preg­

countered, and all physicians practicing nancy" and "cervical pregnancy" to investigate http://www.jabfm.org/ should have some awareness regarding this prob­ the possible causes and management of this rare lem. It is interesting that in a review of the litera­ form of ectopic pregnancy. Older articles were ture on this subject, cervical pregnancy has never accessed from cross-reference of the more recent been reported in any of the family practice litera­ publications. Interestingly, the search did not ture. As a family physician who has been practic­ yield any findings on this subject from any of the ing obstetrics for the past 14 years, I have deliv­ published family practice literature. ered more than 1000 babies. The following is a on 26 September 2021 by guest. Protected copyright. report of the single case of cervical pregnancy Case Report that I encountered; it is one case that I will never A 39-year-old woman, gravida 4, para 1, aborta 2, forget. came to the emergency department with painless vaginal bleeding 20 days before admission. The Methods patient's serum f3-human chorionic gonadotropin A case of a young woman who had a cervical (f3-hCG) was 6622 mIU/mL, but a transabdo­ pregnancy and survived using conservative treat­ minal sonogram did not reveal any products of ment is described. The current medical literature conception within the uterine cavity. The emer­ gency department physician made a presumed di­ agnosis of a completed , and the patient Submitted, revised, 27 February 1997. was sent home with instructions for outpatient From the Tacoma Family Medicine Family Practice Residency, follow-up in 2 to 3 days. Her discharge hemat­ Tacoma, and the Department of Family Medicine, Universiry of Washington, Seattle. Address reprint requests to David A. Acosta, ocrit was 38.5 percent. \\'hen she was seen 3 days MD, 521 Martin Luther KingJr. Way, Tacoma, WA 98405-4238. later, her only complaint was mild weakness and a

290 ]ABFP July-August 1997 Vol. 10 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.290 on 1 July 1997. Downloaded from small amount of vaginal spotting with a browni h discharge. She denied any active vaginal bleed­ ing. At that time her ~ -hCG was 14,580 mIU/mL. A second transabdominal sonogram showed a 4-mm yolk sac embedded in the proxi­ mal portion of the endocervical canal. Cardiac ac­ tivity was seen. The patient adamantly refused any medical or surgical intervention because of her strong desire to continue with this pregnancy (dle patient had been infertile since her last preg­ nancy 11 years earlier). On the day of admission, she again complained of painless vaginal bleeding. She claimed to have soaked six pads in 1 hour and had passed some clots 1 day earlier, but did not notice any tissue Figure 1. Transabdominal sonogram showing an that might have passed. She denied fever, chills, intracervical pregnancy at 8.1 weeks gestation. sweats, or any history of dizziness. Her medical b - bladder, c - , u - , white arrow - fetal history was notable for two spontaneous mis­ pole within . carriages, each followed with dilatation and curettage, and one primary cesarean section de­ neous bleeding, the large amount of fluid (pre­ livery 11 years earlier for failure to progress. Oth­ sumably blood) accumulating in her uterine cav­ erwise, she had no other important illnesses. The ity, and the drop in her hematocrit, the decision patient was very interested in bringing this preg­ was made to take the patient to the operating nancy to term, if possible, and in preserving her room. A dilatation and suction curettage was per­ future fertility. formed and, as expected, there was profuse bleed­ On examination, she was not in any acute dis- ing. Initial measures to control the bleeding in­ tress. Findings of the abdominal examination cluded intravenous methergine, followed by were normal. On a sterile speculum examination, vaginouterine massage and compression. Subse­ the cervix appeared ballooned out and boggy, ap­ quently, tlle descending branches of the uterine

proximately 0.5-cm dilated, with a clot extruding arteries were ligated with 2-0 chromic sutures, http://www.jabfm.org/ out of the os. There was a small amount of dark but without much success in controlling the blood in the vaginal vault. No products of con­ bleeding. A 36-French Foley catl1eter was then ception were seen. On a bimanual examination inserted into the endocervical canal, and 30 cc of her uterus was nontender to palpation and of nor­ saline were instilled into the catheter balloon. mal contour, and its size was consistent with a 14- 'Tamponade was successfuJly achieved.

to 16-week gestation. No masses were felt in the The interoperative blood loss was e timated to on 26 September 2021 by guest. Protected copyright. adnexa or in the cul-de-sac. She was admitted for be 500 cc. Her immediate postoperative hemat­ furd1er care. ocrit was 25.5 percent. She continued to have The patient's hematocrit was 29.4 percent on mild oozing intermittently during the next 6 admission, a drop of 8.6 percent from her hemat­ hours, with a subsequent drop in her hematocrit ocrit measurement 3 weeks earlier. The ~-hCG to 21.2 percent. She received 2 units of packed measurement was not repeated. A transabdominal red blood cell. The Foley cath ter was deflated sonogram confirmed an 8-week gestational sac lo­ and removed completely approximately 13 hours cated in the proximal posterior portion of the after the initial procedure. There were no signs of cervix (Figure 1). Cardiac activity was evident. bleeding. The rest of her postoperative course There was a large amount of fluid within the uter­ was uneventful, and she was discharged on the ine cavity, but fetal parts were not seen within the second po toperative day wid, a hematocrit of 26 uterine cavity, and no free fluid was seen in the percent. cul-de-sac. A diagnosis of a cervical pregnancy was When ilie patient was seen in clinic 1 day and 1 made, and an obstetrician was consulted. week after discharge, she had n clinical eviden Because of her history of recurrent sponta- of bleeding on examination. At 2 we ks she till

291 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.290 on 1 July 1997. Downloaded from

Table 1. Clinical Diagnostic Criteria for Cervical Diagnosis Pregnancy. Cervical pregnancy is defined as the implantation of a fertilized ovum in the endocervix. The fol­ Closed internal cervical os lowing are accepted pathologic criteria for mak­ History of painless uterine bleeding after amenorrhea (presumptive pregnancy) ing a diagnosis of cervical pregnancy: (1) the cer­ Partially open external cervical os vical glands must be opposite the placental Products of conception are entirely confined within attachment, (2) the attachment of the to the endocervix the cervix must be intimate, (3) the .placenta must Softened and disproportionately enlarged cervix palpably be below the peritoneal reflection of the anterior equal to or larger than the uterus and posterior surfaces of the uterus, and (4) fetal Derived from Yankowitz et aJ.2 elements must not be found within the uterine cavity.2 Because these criteria are based on patho­ logic specimens, however, other more clinically had no further bleeding, and her uterus had re­ useful criteria have been established for the diag­ verted back to its normal size. At her I-month nosis of cervical pregnancy (Table 1). follow-up visit, results of her examination were The most common clinical manifestation is normal, and her ~-hCG had decreased to 50 painless vaginal bleeding, which most studies mIU/mL. She was counseled to avoid pregnancy show almost always occurs in the first trimester, for at least 3 to 6 months. although there have been reports of vaginal bleeding occurring even as late as 19 weeks' ges­ Discussion tation.lO The differential diagnosis includes an in­ Incidence evitable, incomplete, or complete abortion; cervi­ Cervical pregnancy is a rare form of ectopic preg­ cal neoplasia; advanced fundal malignancy; nancy that can be associated with serious mater­ degenerative cervical leiomyoma; trophoblastic nal morbidity and a high mortality rate. In earlier tumor; or a low-lying placenta and placenta pre­ studies mortality rates were reported to be be­ via.II The clinical criteria for the diagnosis of cer­ tween 40 to 45 percent, 1 but recent reports sug­ vical pregnancy that have been established in­ gest that the mortality rate has decreased consid­ clude (1) a history of uterine bleeding after erably. That no maternal deaths have been amenorrhea without cramping pain (presumptive reported since 1953 1 is believed to be the result of pregnancy), (2) a softened and disproportionately http://www.jabfm.org/ earlier diagnosis by sonography and the earlier enlarged cervix that appears to be equal to or utilization of conservative management. The re­ larger than the palpable position of the uterus, (3) ported incidence of cervical pregnancy has been the products of conception being entirely con­ variable but has been estimated to range from 1 in fined within and firmly attached to the endo­ 1000 to 1 in 18,000 deliveries.2 Generally, it is cervix, (4) a snug internal os, (5) a partially open considered to occur at a rate of at least 1 in 2400 external os.2 deliveries and represents less than 1.0 percent of The initial examination of the patient should on 26 September 2021 by guest. Protected copyright. all ectopic pregnancies. 1 include a complete blood count, a quantitative ~­ hCG titer, and blood typing and screening. The Etiology quantitative ~-hCG along with findings from a There is no clear explanation for cervical preg­ transvaginal or transabdominal sonogram will nancy, although several contributing factors have help estimate the gestational age, which in turn been proposed: (1) induced abortion with sharp will help in the decision making for the most ap­ curettage,3 (2) intrauterine devices,4 (3) Asher­ propriate treatment. The routine use of sonogra­ man syndrome (severe intrauterine adhesions phy has made it possible to diagnose cervical secondary to uterine curettage),4 (4) cesarean sec­ pregnancy much earlier, which gives the physi­ tion,4 (5) structural uterine and cervical anom­ cian the option of conservative management. alies,S (6) uterine fibroids and malformations,6 (7) The accepted sonographic (transabdominal) endometrial atrophy and chronic endometritis,' criteria for the diagnosis of cervical pregnancy are and (8) abnormal transport and secondary attach­ well established (Table 2).12 Timor-Tritsch et alB ment of the fertilized ovum.8,9 recently proposed a new set of criteria specific for

292 ]ABFP July-August 1997 Vol. 10 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.290 on 1 July 1997. Downloaded from transvaginal "sonographic examinations: (1) the Table 2. Diagnostic Criteria by Sonography placenta and the entire chorionic sac containing a (Transabdominal) for Cervical Pregnancy. live should be below the internal os (they lo­ Ahsence of intnlUterine pregnancy cate the internal os at the level of the insertion of Diffuse mnorpholls intrauterine echoes the uterine arteries), (2) the uterine cavity should Enlarged cervix be empty, and (3) the cervical canal should be bar­ Uterine enlargcmcnt rel-shaped and noticeably dilated. Rosenberg and 12 Williamson 14 further suggest that duplex Dop­ Derived from Kohayashi et 011. pler scanning of the lower uterine segment be considered if no gestational sac is seen within the cervical canal on a sonogram during the initial agents in the treatment of cervical pregnancy. evaluation. Finding trophoblastic-type blood Methotrexate has been used systemically in the flow and marked vascularity would suggest cervi- same dosing regimen as for tubal ectopic preg­ cal pregnancy. nancies with some success (1 mg/kg intramuscu­ larly on day 1,3, 5, and 7, followed with folinic Management acid rescue, O.lmg/kg, on day 2,4,6, and 8), but Treatment of cervical pregnancy has changed dra­ there have been serious side effects associated matically since it was first reported. Historically, with its use: stomatitis, pharyngitis, gastritis, tran­ most diagnoses of cervical pregnancy were made sient elevation of liver function tests, and tran­ at the time of surgical instrumentation of the sient bone marrow suppression. Two case studies cervix, unfortunately resulting in profuse hem­ have even reported good results with etoposide3o orrhage, shock, and an emergency . and actinomycin-D31 administered systemically. The diagnosis is now generally made before the Unfortunately, there were major side effects asso­ onset of complications, and with the experience of ciated with these agents: severe global alopecia nonsurgical treatment of tubal e'ctopic pregnan­ and bone marrow suppression with etoposide; cies, conservative management has become the nausea, vomiting, and skin and subcutaneous tis­ therapeutic choice. This approach becomes espe­ sue necrosis with actinomycin-D. cially important for those patients who wish to Recently several authors have reported success preserve their childbearing capacity. with methotrexate instilled directly into the am­

Conservative management can be both surgical niotic sac using transvaginal sonographic guid­ http://www.jabfm.org/ and nonsurgical. Reported options include (1) lo­ ance.1.27.28 The procedure entails using sonog­ 15 cal excision and curettage j (2) curettage, vagi­ raphy to guide a needle through the anterior noabdominal compression of the cervix or uterus, cervical wall into the . Both the and tamponade with packinglO j (3) cervical cer­ transvaginal and transabdominal approaches have clagel6; (4) curettage and tamponade with Foley been described as successful. Entering the amni­ catheter placed into the cervical cana1'7.18 j (5) lig­ otic sac by means of the cervical canal has been ation of the descending branches of the uterine reported to have led to the rupture of the amni­ on 26 September 2021 by guest. Protected copyright. artery and curettage19j (6) preoperative angio­ otic sac with subsequent failure. Consequently, graphic uterine artery embolization prior to this technique has not been recommended. Two curettage20 j (7) methotrexate administered sys­ milliliters of 10 percent potassium chloride32 are temically21-25; (8) potassium chloride adminis­ usually injected first into the amniotic sac to stop tered by intra-amniotic injection26; and (9) cardiac activity, aspiration follows, and then methotrexate administered by intra-amniotic in­ methotrexate (1 mg/kg body weight) is instilled stillation.1.27.28 Even with conservative manage­ directly into the amniotic sac. No side effects ment, the potential remains for hemorrhage, have been reported with methotrexate used in shock, and the possibility of an emergency ab­ this manner, although considerable technical skill dominal hysterectomy.29 is required to perform this procedure. None of Because of the reported successes with metho­ the patients who received this therapeutic option trexate when treating tubal ectopic pregnancies required curettage or a hysterectomy. and other trophoblastic diseases, more attention Not all cervical pregnancies have been success­ has been drawn to the use of chemotherapeutic fully treated with methotrexate, however. There

Cervical Pregnancy 293 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.290 on 1 July 1997. Downloaded from appear to be two important factors that influence ity, and they should be considered in every case. the success of treatment with methotrexate: ges­ Our case met both the clinical and the sono­ tational age at the time of treatment, and fetal graphic criteria for the diagnosis of cervical preg­ cardiac activity. Mantalenakis et aI28 suggest that nancy. Possible causative factors that might have methotrexate therapy is most successful for cervi­ predisposed this patient to cervical pregnancy in­ cal pregnancies of less than 9 weeks' gestation. clude two surgical curettages and one cesarean He also suggests that cardiac activity is an impor­ section delivery-both consistent with findings tant prognostic factor. If cardiac activity is absent from previous studies. Several of .the reported before treatment, intramuscular or intravenous modes of conservative management were at­ administration of methotrexate can be effective. tempted in this case: curettage, ligation of the de­ WIth fetal cardiac activity, however, this approach scending branches of the uterine arteries, vagi­ has been ineffective. Intramuscular administra­ noabdominal compression of the uterus, and tion of methotrexate, combined with intracervical finally, tamponade with the placement of a Foley or intra-amniotic injection, is considered to be catheter into the en do cervix. Methotrexate ther­ more effective. apy was not considered in this case because we Serial serum ~-hCG levels and sonographic had limited experience treating tubal ectopic findings can be used as markers for treatment ef­ pregnancies with this chemotherapeutic agent at fectiveness. The average time interval between our facility. Our patient would have been a likely treatment and the resolution of serum ~-hCG candidate for methotrexate administered by in­ levels ranges from 8 to 59 days.32 If these markers tra-amniotic injection. We were still fortunate in have not indicated regression of the cervical preg­ this case to have avoided hysterectomy and to nancy, conservative surgical treatment (eg, curet­ have preserved the patient's fertility. She has been tage) is recommended. cared for in the clinic for the last 5 years and un­ There are reports of subsequent pregnancies fortunately has not yet conceived. occurring after treatment of cervical pregnancy, some successfully going to term !6,26 and others Conclusion resulting in spontaneous .2 Recently, Cervical pregnancy is a rare but serious form of Kaplan et aI27 and Mantalenakis et aJ28 have each ectopic pregnancy that most family physicians reported successful term pregnancies in women who practice obstetrics have not witnessed or who have had a cervical pregnancy treated with even considered. The key to successful manage­ http://www.jabfm.org/ intra-amniotic injection of methotrexate. ment is early diagnosis using transvaginal sonog­ It is also unclear how long the patient should raphy. Early diagnosis allows the physician to wait to conceive after having methotrexate ther­ manage the pregnancy conservatively and to apy. Methotrexate has been reported to remain in possibly avoid an emergency hysterectomy. human tissue for at least 8 months after being ad­ Methotrexate, administered (with folinic acid) ei­ ministered systemically.33 There is no evidence in ther systemically or by instillation into the amni­ the literature suggesting that methotrexate used otic sac, has been shown to be an excellent alter­ on 26 September 2021 by guest. Protected copyright. to treat trophoblastic disease is associated with an native to surgery. Preserving the patient's capacity increased rate of congenital anomalies or sponta­ to bear children is a goal that can be achieved by neous abortions in subsequent pregnancies. No conservative management. study makes any recommendations regarding the timing of conception following the treatment References with methotrexate. 1. Marcovici I, Rosenzweig BA, Brill AI, Khan M, The technique of administering methotrexate Scommegna A. Cervical pregnancy: case reports and directly into the amniotic sac has several obvious a <:;urrent literature review. Obstet Gynecol Surv 1994;49:49-55. advantages compared with administering metho­ 2. YankowitzJ, LeakeJ, Huggins G, Gazaway P, Gates trexate systemically. The technique has greater E. Cervical ectopic pregnancy: review of the litera­ efficacy rates, shorter treatment intervals, and no ture and report of a case ~reated by single-dose serious side effects.! In any case, the overall bene­ methotrexate therapy. Obstet Gynecol Surv 1990; fit of conservative management strategies is 45:405-14. preservation of the uterus and the woman's fertil- 3. Shinagawa S, Nagayama M. Cervical pregnancy as a

294 ]ADFP July-August 1997 Vol. 10 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.10.4.290 on 1 July 1997. Downloaded from possible sequela of induced abortion. Report of 19 20. Lobel SM, Meyerovitz MI'~ Benson CC, Goff B, cases. Am] Obstet Gynecoll969;105:282-4. Bengtson ]M. Preoperative angiographic uterine 4. Dicker D, Feldberg D, Samuel N, Goldman]A. Eti­ artery embolization in the managcmcnt of ccrvical ology of cervical pregnancy: association with abor­ prcgnancy. Ohstet Gynecol 1990;76(5 Pt 2):938-41. tion, pelvic pathology, IUDs and Asherman's syn­ 21. Skannal D, Burkman In: Ccrvic.ll prcgnancy drome.] ReprodMed 1985;30:25-7. treated with mcthotrexate. A case report.] ReprOl! 5. Mieszczerski], Smielowski B, Dabrowski Z. [Use of Med 1989;34:496-8. hysterography for confirmation of cervix preg­ 22. Stovall TG, Ling FW, Smith WC, Felker R, Rasco nancy.] Zentralbl GynakoI1971;93:483-90. " B], Buster ]E. Successful nonsurgical trcatmcnt of 6. Dees HC. Cervical pregnancy associated with uter­ cervical pregnancy with methotrexate. Ferti! Stcri! ine leiomyomas. South Med] 1966;59:900 passim. 1988;50:672-4. 7. Fahmy K, Zikry AM, Hassan S. Cervical pregnancy. 23. Oyer R, Tarakjian D, Lev-Toaff A, Friedman A, IntSurg 1971;55:127-30. Chatwani A. Treatment of cervical pregnancy with 8. Studdiford WE. Cervical pregnancy: a partial review methotrexate. Ohstet GynccoI1988;71(3 Pt 2):469- of the literature and a report of two probable cases. 71. Am] Obstet GynecoI1945;49:169. 24. Kaplan BR, Brandt T, ]avaheri G, ScolJul1egna A. 9. Iffy I. Contribution to the etiology of ectopic preg­ Successful trcatment of a live cervical pregnancy nancy. Obstet Gynaecol Br Commonwlth 1961;8: with methotrexate and folinic acid. A case report.] 441. Reprod Med 1989;34:853-6. 10. ten Kate-Booij M], Wallenburg HC. Conservative 25. Palti Z, Rosenn B, Goshen R, Ben-Chitrit A, \'agel treatment of postpartum hemorrhage in a second­ S. Successful treatment of a viable cervical preg­ trimester cervical pregnancy. Am] Obstet Gynecol nancy with methotrexate. Am] Obstet Gynecol 1984; 150: 103-4. 1989;161:1147-8. 11. Parente ]T, Ou CS, Levy], Legatt E. Cervical preg­ 26. Frates MC, Benson CB, Doubilet PM, DiSalvo DN, nancy analysis: a review and report of five cases. Ob­ Brown DL, Laing FC, et al. Cervical ectopic preg­ stet Gynecol 1983 ;62: 79-82. nancy: results of conservative treatment. Radiology 12. Kobayashi M, Hellman LM, Fillisti LP. Ultrasound. 1994;191:773-5. An aid in the diagnosis of ectopic pregnancy. Am] 27. Kaplan"BR, Brandt T,]avaheri G, Scommegna A. Obstet GynecoI1969;103:1131-40. Nonsurgical treatment of a viable cervical pregnancy 13. Timor-Tritsch IE, Monteagudo A, Mandeville EO, with intra-amniotic methotrexate. Fertil Steril Peisner DB, Anaya GP, Pirrone EC. Successful 1990;53:941-3. management of viable cervical pregnancy by local 28. Mantalenakis S, Tsalikis T, Grimbizis G, Aktsalis A, injection of methotrexate guided by transvaginal Mamopoulos M, Farmakides G. Successful preg­ ultrasonography. Am] Obstet Gynecol 1994; 170: nancy after treatment of cervical pregnancy with

737-9. methotrexate and curettage. A case report.] Reprod http://www.jabfm.org/ 14. Rosenberg RD, Williamson MR. Cervical ectopic Med 1995;40:409-14. pregnancy: avoiding pitfalls in the ultrasonographic 29. Sepulveda WH, Vinals F, Donetch G, Ciuffardi I, diagnosis.] Ultrasound Med 1992;11:365-7. Varela]. Cervical pregnancy. A case report. Arch 15. Farghaly SA, Mathie]G. Cervical pregnancy man­ Gynecol Obstet 1993;252:155-7. aged by local excision. Postgrad Med] 1980;56:789. 30. Segna RA, Mitchell DR, Misas]E. Successful treat­ 16. Bachus KE, Stone D, Suh B, Thickman D. Conserv­ ment of cervical pregnancy with oral etoposide. Ob­ stet GynecoI1990;76(5 Pt 2):945-7. ative management of cervical pregnancy with sub­ on 26 September 2021 by guest. Protected copyright. sequent fertility. Am] Obstet Gynecol 1990;162: 31. Brand E, Gibbs RS, Davidson SA. Advanced cervical 450-1. pregnancy treated with actinomycin-D. Br] Obstet 17. Patchell RD. Cf;rvical pregnancy managed by bal­ GynaecoI1993;100:491-2. loon tamponade. Am ] Obstet Gynecol 1984; 32. IIsu]], Chiu Til, Lai 1M, Soong YK. Methotrexate 149:107. treatment of cervical pregnancy with different clini­ 18. Nolan TE, Chandler PE, Hess LW, Morrison]C. cal parameters. A report of three cases. ] Reprod Cervical pregnancy managed without hysterectomy: Med 1995;40:246-50. a case report.] Reprod Med 1989;34:241-3. 33. Walden PA, Bagshawe KD. Reproductive perfor­ 19. Kuppuswami N, Vindekilde], Sethi CM, Seshadri mance of women successfully treated for gestational M, Freese UE. Diagnosis and treatment of cervical trophoblastic tumors. Am ] Obstet Gynecol pregnancy. Obstet GynecoI1983;61:651-3. 1976;125:1108-14.

Cervical Pregnancy 295