Combined Minimally Invasive Approach to Preserving Fertility in Patients with Cervical Pregnancy

Abstract

Study Objective Assess the feasibility of the minimally invasive methods in preserving the fertility in patients with cervical pregnancy. Design Canadian Task Force: Level II-2 Prospective and retrospective analysis. Setting Department of Operative Gynecology, V.I Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation; Moscow, Russian Federation. Patients or Participants 66 women with cervical pregnancies desiring preservation of fertility (ages 25-44 years), treated at the Department of Operative Gynecology during the past 13 years. Interventions Standard diagnostic clinical protocol was carried out in all patients. Patients with cervical pregnancy received intravenous methotrexate at an average of 50 mg/every 48 hours and 6 mg of intramuscular leucovorin rescue injection at 28 hours after methotrexate administration followed by resectoscopy or combined selective uterine embolization and resectoscopic approach. 2 women with massive bleeding on admission required hysterectomy. Measurements and Main Results The gestational age on admission ranged from 5 to 11 weeks with mean gestational age being 6.8 ± 0.8 weeks. 64 women underwent combined therapy with preoperative systemic methotrexate and resectoscopic excision. 28 of these patients had chorionic invasion into the cervix and required selective uterine artery embolization (SUAE), followed by resectoscopy. 2 patients with massive bleeding underwent emergent hysterectomy. Uterus preserving surgical procedures were started when a decreasing levels of β-hCG of 4000-7000I U/l were demonstrated. Bilateral SUAE was utilized in 28 cases, through the right femoral approach (12 cases) and through the right radial artery (16). The blood loss in all cases was less than 25 cc, including the ones with chorionic invasion. Conclusion The results of our study suggest that resectoscopic removal of embryos with previous cytostatic therapy with methotrexate allows for the preservation of fertility in young women with early cervical pregnancy. SUAE provides minimal operative blood loss and shorter hospital stay, and preserves reproductive potential in women with chorionic cervical invasion.