Arch Gynecol Obstet (2013) 288:687–689 DOI 10.1007/s00404-013-2807-y
REPRODUCTIVE MEDICINE
Conservative management of cervical ectopic pregnancy: systemic methotrexate followed by curettage Khadijeh Adabi • Sepideh Nekuie • Zahra Rezaeei Fatemeh Rahimi-Sharbaf • Sakineh Banifatemi • Shohreh Salimi
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Received: 9 November 2012 / Accepted: 12 March 2013 / Published online: 23 March 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Cervical ectopic pregnancy is among the rarest clinical conditions happening in women of reproductive age. Yet its management can cause a high rate of morbidity. Therefore, conservative treatment of this condition is a matter of debate. Material and methods Hereby we present two cases of cervical ectopic pregnancies that were managed successfully with a conservative approach. Conclusion Cervical ectopic pregnancy can be managed successfully with systemic Metotroxsate followed by curettage. Keywords Cervical ectopic pregnancy Conservative management Methotrexate
Introduction Cervical pregnancy is characterized by implantation of fertilized ovum in the cervical mucosa and accounts for less than 1 % of all ectopic pregnancies, with a reported incidence of 1 in 1000–95,000 pregnancies [1–3]. Sever hemorrhage, which is the most common cause of pregnancy related deaths in the first trimester, is one of the disastrous outcome signs of cervical pregnancy [4].
K. Adabi (&) S. Nekuie Z. Rezaeei F. Rahimi-Sharbaf S. Banifatemi S. Salimi Department of Obstetrics and Gynecology, Women Hospital, Tehran University Of Medical Sciences, North Ostad Nejatolahi Avenue, Karim Khan Street, 159785-6511 Tehran, Iran e-mail:
[email protected]
Transvaginal ultrasound [5, 6] or magnetic resonance imaging (MRI) [7, 8] is used for early diagnosis. Surgical management is associated with significant morbidity and potential mortality which may lead to loss of reproductive capability [9, 10]. Successful conservative treatment, which makes preservation of fertility possible, is only applicable if the condition is diagnosed early during pregnancy [11, 12]. Local or systemic methotrexate (MTX) injection, a single dose MTX or serial injections with leucovorin rescue, mifepristone, local potassium chloride (KCl) are some medical treatments that have been used for management of cervical ectopic pregnancy. On the other hand, curettage and tamponade, amputation of cervix, cervical cerclage, Foley catheter placement in the cervical canal, stepwise devascularization of the uterus, internal iliac artery ligation, angiographic uterine artery embolization, intra cervical carboprost injection and needle aspiration of the products are some other suggested approaches [6, 13–17]. In this report, we present two cases of cervical pregnancies diagnosed in the first trimester. Both cases were managed with intra muscular injection of MTX (50 mg/m2 body surface area) followed by successful dilatation and curettage. Ultrasound-guided fetal intracardiac injection of 2 mL (2 mEq/mL) KCl solution was performed in one case with cardiac activity. The patients were followed by clinic visits and serial b-hCG levels and repeated transvaginal ultrasonography as needed. A repeated dose of MTX was applied when b-hCG levels did not decline more than 15 % over below the base line after 1 week. Elective curettage was performed to shorten the followup period and decrease b-hCG levels below 10 mIU/mL [10, 17, 18].
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Case report 1 A 34-year-old gravid1 woman was referred to our clinic with a 2-week history of vaginal bleeding and abdominal cramps. She was stable and her urinary pregnancy test was positive. According to her last menstrual period (LMP) her gestational age was 11 weeks and 2 days. She did not have any remarkable past medical history including infertility or surgical procedures on her reproductive system. Vaginal ultrasound showed a cervical pregnancy with a gestational sac and an embryo crown-rump length (CRL) of 8 weeks with cardiac activity, a 34 9 34 9 11 mm hematoma in the upper pole of the sac, and another deformed gestational sac without fetal pole (blighted ovum) in the lower segment of uterus. Her quantitative b-hCG concentration was 270,100 mIU/mL on admission. Routine laboratory examination results (CBC, ALT, AST, blood urea nitrogen, creatinine) were within normal limits except ALT (ALT = 127 approximately three-fold above normal). She did not have any past medical history of hepatic diseases and her serum viral markers were normal. 2 mL (2 mEq/mL) KCL solution was injected in the cardiac cavity of fetus under ultrasound guide. The patient was observed in the hospital and after 1 week her ALT returned to normal. Hence she was treated with IM MTX (50 mg/m2BSA) weekly. Serum b-hCG level was checked weekly until the level decreased to 1,700 mIU/mL within 7 weeks, then the patient underwent suction and curettage. No remarkable bleeding was observed in the following 24 h and she was discharged the next day. Serum b-hCG level returned to \10 mIU/mL within 1 week.
Case report 2 A 31-year-old gravid4, para 2, abort 1 woman was referred to our clinic with spotting and a possible diagnosis of cervical pregnancy. Her previous history revealed two cesarean sections. Transvaginal ultrasound depicted a deformed gestational sac equal to 6 weeks within the endocervical canal without fetal pole. The uterus was empty. Vital signs were stable. The abdomen was soft and non-tender. Laboratory examination revealed normal CBC, blood urea nitrogen, creatinine, electrolytes and liver enzymes. b-hCG level was 54,977 mIU/mL. She was admitted to the hospital for close observation and intramuscular MTX (50 mg/m2) was administered weekly. The patient was discharged in stable condition after 10 weeks and was followed with weekly serum B-hCG levels until the level decreased to 1,180 mIU/mL after 6 weeks.
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Under controlled condition, after the injection of desmopressin at 3 and 9 o’ clock in cervix, gentle dilatation and curettage were done and products of conception were removed, an inflated Foley catheter balloon was placed in cervical canal to tamponade the bleeding of implantation site. She was discharged the next day. Serum b-hCG level returned below 10 mIU/mL within 1 week.
Discussion Recently, there has been an emphasis on a more conservative approach in management of cervical ectopic pregnancies [19–21]. Advanced gestational age, high serum b-hCG levels and presence of a viable fetus are associated with higher rates of treatment failure [22, 23]. Intracardiac KCl injection in presence of fetal cardiac activity might make methotrexate treatment more effective [10]. In a case report of 24 cervical ectopic pregnancies by Verma [10, 11], the mean b-hCG level at presentation was 35,447 mIU/mL (165.5–179,900) mIU/mL. In a review of the literature, reported by Kirk et al. [9], the mean serum b-hCG level was 3821 IU/L in those with no fetal cardiac activity, compared with 17,702 IU/L in the group with fetal cardiac activity. In our study, serum b-hCG level in case 1 (270,100 mIU/mL) with fetal cardiac activity was higher than case 2 (54,977 mIU/mL) with no fetal cardiac activity. We did not find any difference in response to MTX, serum b-hCG level reduction rate, and duration of follow-up in our cases. In Kirk et al. [9] report, conservative management was successful in 86 cases of 90 patients with cervical ectopic pregnancy (95.6 %), and hysterectomy was done only in four patients (4.4 %). The success rate of primary systemic methotrexate treatment was 83 %. Success rate of conservative management for cervical pregnancies without cardiac activity was higher in comparison with pregnancies with cardiac activity, 91 versus 40 % [23]. Management of cervical pregnancy with methotrexate may be accompanied by severe uterine hemorrhage [24]. This hemorrhage can be controlled by different means such as: local tamponade utilizing an inflated Foley catheter balloon in addition to other hemostatic measures including ligation of the cervical branches of the uterine artery, epinephrine injection, and a nylon purse-string suture that were successful in 21 percent of cases [15, 25–28]. Sometimes curettage is necessary to reduce massive hemorrhage from the atonic cervix caused by MTX [21, 23]. Mesogitis et al. [21] and Hassiakos et al. [29] reported successful conservative management with curettage following
Arch Gynecol Obstet (2013) 288:687–689
local methotrexate injection in 15 cases and there were no serious squeals regarding combined MTX and curettage. Conservative management seems to be superior for the majority of patients, especially, those who desire for future fertility, but overall, the cost effectiveness needs to be further studied compared with the classic surgical approach because of the lengthy follow-up period.
Conclusion
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Cervical ectopic pregnancies can be safely and successfully treated with systemic methotrexate followed by curettage. Conflict of interest
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We declare that we have no conflict of interest. 18.
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