Cervical Pregnancy Research Articles

Conservative treatment of ectopic cervical pregnancy with uterine artery embolization and cervical curettage: a case report

Cervical pregnancy is a rare form of non-tubal ectopic pregnancy. Although uncommon, this condition can determine serious complications with massive hemorrhages and a high rate of fatality. The choice of the appropriate management depends on several factors, such as severity of vaginal bleeding, gestational age, serum β-hCG level, and on embryonic cardiac activity. However, no specific guidelines have been developed, and the “gold standard” treatment has yet to be defined. The authors report a case of cervical pregnancy successfully managed through a combined approach of percutaneous bilateral uterine artery embolization immediately followed by cervical curettage.

Hysteroscopic management of cervical pregnancy: Case series and review of the literature

PurposeTo evaluate the hysteroscopic management on cervical pregnancy. Materials and methodsA case series report and literature review on patients with early first trimester cervical pregnancy (CP) treated by hysteroscopy. The symptoms upon admission, β-hCG levels, hysteroscopy technique, blood loss and operation outcomes were presented. ResultsFour patients with early CP between 5 and 7 weeks were successfully managed with operative hysteroscopy. Three out of four patients had at least one risk factor for cervical ectopic pregnancy. Two patients were diagnosed on routine examinations and the other two presented with vaginal spotting and pelvic pain. Mechanical hysteroscopy was used in three patients while one case was managed by a 10mm resectoscope. Three women discharged home on the same day and one patient 24h after the operation. Literature review revealed 16 publications of cervical pregnancy managed with operative hysteroscopy. 14 articles demonstrated single case reports and two papers were CP case series. Hysteroscopic surgery was successfully reported in 12 cases as a sole treatment, in seven cases after failure of methotrexate treatment and in eight cases as a combined treatment with uterine artery embolization. ConclusionsOur case series demonstrated that operative hysteroscopy can be used as a sole treatment in early, less than 8-week CPs with safety. Literature review demonstrated that most of the early first trimester CP cases were treated by hysteroscopy and the rest after failure of methotrexate treatment or in combination with uterine artery embolization.

Management of Cervical Ectopic Pregnancies: A Systematic Review [9Q

INTRODUCTION: Cervical pregnancies are 0.01% of ectopic pregnancies and pose a considerable risk of hemorrhage. There is currently no consensus on management. This is a systematic review of published cases in the last decade. METHODS: PubMed and other databases were searched on July 2, 2017 using variations of the terms “cervical ectopic pregnancy” and “cervical pregnancy” for peer-reviewed citations published in English, Spanish, or French between 2007 and 2017. RESULTS: One-hundred-and-eleven articles representing 209 patients were included. Initial interventions included expectant management (3); vaginal removal of lesion (2); uterine artery embolization (UAE) (1); UAE and curettage (34); curettage (42); UAE and methotrexate (22); methotrexate alone (79); hysteroscopic resection (12), UAE and laparoscopy (5), and hysterectomy (6). Sixty patients failed initial intervention, including 38 who received methotrexate alone (58%), 5 who underwent methotrexate with UAE (26%), and 10 who underwent curettage (23%). Thirty-seven patients experienced hemorrhage, including 21% who initially received methotrexate; 40% who initially underwent curettage; and 12% of those initially managed with curettage and UAE. These patients were managed with hysterectomy (6); cerclage (4); curettage (7); UAE (7), and UAE and curettage (3). Overall patients did well with conservative management. CONCLUSION: For stable cervical ectopic patients, conservative management with methotrexate (including intraamniotic feticide if fetal cardiac activity is present) may be considered. Importantly, uterine artery embolization is worth considering prior to either surgical or medical management, and is recommended in any unstable patient.

A Novel Treatment for Cervical and Cesarean Section Scar Pregnancies by Transvaginal Injection of Absolute Ethanol to Trophoblasts: Efficacy in 19 Cases

Study ObjectiveTo evaluate the efficacy of a nonsurgical treatment for cervical pregnancy (CP) and cesarean section scar pregnancy (CSP). DesignRetrospective clinical study (Canadian Task Force classification III). SettingPrivate assisted reproductive technology practice. PatientsNineteen women with CP (n = 16) or CSP (n = 3), including 6 patients with positive fetal heartbeat. InterventionTransvaginal local injection of absolute ethanol (AE) into the hyperechoic ring (lacunar space) around the gestational sac under ultrasound guidance. Measurements and Main ResultsSerum beta-human chorionic gonadotropin (β-hCG) was measured at frequent intervals, and ultrasound and/or magnetic resonance imaging was used to observe the gestational sac. In 9 patients, the serum β-hCG level was effectively reduced with a single AE injection at 2 hours. In the remaining 10 patients, the level decreased but then increased in 4 and slowly decreased in the other 6; all of these 10 patients required 2 to 5 repeat AE injections. In all patients, serum β-hCG level was reduced by 50% within 3 days and decreased to <10% of the initial level within 14 days. In 18 patients (95%), the level was decreased to 1.0 mIU/mL within 40 days. Seven patients were treated on an outpatient basis. Twelve patients received no anesthesia. Five patients subsequently became pregnant, and each had a live birth. There was no recurrent CP or CSP. The procedure was successful in all 19 patients. ConclusionThis procedure is an effective treatment for CP or CSP that could be used in place of conventional surgical interventions and medical treatment using MTX.

Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy

To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy. Transvaginal ultrasound is the primary imaging modality in ectopic pregnancy and MRI is used as a problem-solving tool in selected indications as detailed in the article. MRI features of tubal, interstitial, cervical, cesarean scar, cornual, ovarian, abdominal, and heterotopic pregnancies are provided to familiarize the radiologists with their appearances thereby assisting them in making early and accurate diagnosis.

Management of uterine ectopic pregnancy - local vs. systemic methotrexate.

The aim of this study was to compare ultrasound-guided local methotrexate (MTX) vs. systemic methotrexate in uterine ectopic pregnancy regarding the beta human chorionic gonadotropin (hCG) clearance duration. Patients with interstitial pregnancy, cervical pregnancy or cesarean scar pregnancy were included. Methotrexate was administered locally ultrasound-guided (25mg methotrexate fixed dose) or systemically (intramuscular; 50mg/m2 body weight). Beta hCG clearance duration in days formed the main outcome measure. Forty-six patients with uterine ectopic pregnancy were included. The mean estimated beta hCG clearance duration was 29.2days longer in patients with local methotrexate compared with systemic methotrexate (64.7 vs. 31.5days, respectively; p=0.026). There was no significant difference between local vs. systemic methotrexate regarding adverse events such as bleeding (p=0.376), pain (p=0.146) or secondary surgery (p=0.631). There was no association of initial beta hCG levels (p=0.746), initial progesterone levels (p=0.870) or patients' age (p=0.604) and the beta hCG clearance duration. No significant difference in beta hCG clearance duration comparing local methotrexate injection with aspiration vs. local methotrexate injection without aspiration could be found (mean 49.4 and 71.6days, respectively, p=0.225). In patients with uterine ectopic pregnancies, the mean estimated beta hCG clearance duration was 29.2days longer when applying local methotrexate compared with systemic methotrexate.

Clinical analysis of 50 patients with heterotopic pregnancy after ovulation induction or embryo transfer

ObjectivesThe purpose of this study was to evaluate the clinical characteristics, prenatal diagnosis, and management of patients with heterotopic pregnancy after ovulation induction or embryo transfer.MethodsThis was a retrospective study of fifty cases with heterotopic pregnancy, in which the fertilization way, type and number of embryo transferred, gestational age, clinical presentation and outcome of intrauterine, ultrasound presentation and site of ectopic pregnancy, bilateral fallopian tube and treatment were evaluated.ResultsSix patients had spontaneous pregnancy and two had artificial insemination after ovulation induction. Sixteen had fresh and nineteen had frozen embryo transfer with seven patients unrecorded its embryo type and number. The average days from transplantation (or intercourse/insemination) to diagnosing heterotopic pregnancy was thirty-seven with the earliest eighteen and the latest more than 70 days. Although the most common presentation was vaginal bleeding or abdominal pain, more than 21% was found by ultrasound and rare individuals even presented with gastrointestinal symptom which may imply ruptured EP and hemorrhagic shock. Giving proper treatment (surgery or local drug injection), the majority of them had a successful intrauterine pregnancy with only seven miscarried.ConclusionsOvulation induction or embryo transfer increased the risk of HP greatly and clinician should raise high suspicious during the whole first trimester. Although the most ectopic site was ampullary, other sites such as cornual, cervical, abdominal especially interstitial or tubal stumps should also be assessed by ultrasound even in patients with bilateral salpingectomy or tubal obstructed. Repeated ultrasound tests 2 weeks after the diagnosis of intrauterine pregnancy with heart beating was very necessary to find the missed ones in suspicious patients. Compared with surgery, embryo suction with or without proper local drug injection would be more advisable for patients with cervical, cornual, or interstitial pregnancy in order to reserve the intrauterine pregnancy.

Conservative management of interstitial pregnancies: experience of a single centre

The aim of this study was to compare the effect of local intracavitary methotrexate (MTX) injection and laparoscopic (L/S) cornuostomy in the treatment of interstitial pregnancy (IP) in terms of clinical and reproductive outcome. The data of patients with IP (n:10) who were treated between September 2011 and December 2016 with either an intra-amniotic MTX injection (n:7) or L/S cornuostomy (n:3) were retrospectively evaluated. All cases (7/7) in the local injection group and two (2/3) in the L/S group were successfully treated with the initial treatment. One case (1/3, 33%) in L/S group needed systemic MTX due to an elevated β-hCG. No serious complication or secondary surgical intervention was observed in the study group. Five (71.4%) women in MTX group and two (66%) women in the L/S group had pregnancy after index case (p > .05). Post-treatment (hysterosalpingography) HSG results revealed that tubal patency was significantly higher in the MTX group (7/7 (100%) vs. 0/3 (0%) p < .05). Conservative treatment of IP with both methods was generally successful with regard to maternal morbidity and reproductive function. However, local MTX was superior for tubal patency compared to L/S cornuostomy. Since this is a retrospective study including a small study population, our results should be confirmed with larger prospective studies.Impact StatementWhat is already known on this subject? Earlier diagnosis of an interstitial pregnancy (IP) enables clinicians to pursue more conservative treatment modalities that can prevent morbidity (severe bleeding, rupture and massive transfusion, etc.) and loss of fertility. MTX treatment and conservative laparoscopic surgical procedures are gaining importance. High serum β-hCG levels and positive foetal cardiac activity are known as unfavourable pre-treatment prognostic predictors for systemic MTX treatment in patients with an ectopic pregnancy. Local MTX treatment is widely used for caeserean scar pregnancies or cervical pregnancies. L/S cornuostomy is an attractive alternative to L/S cornual resection, because it preserves the normal uterine myometrium.What the results of this study add? In the present study, we showed that the local MTX and laparoscopic cornuostomy were successful methods in IP patients and did not impair the fertility potential of the patients. We also demonstrated that local MTX application is superior to L/S cornuostomy in terms of the post-treatment tubal patency and this fact should be kept in mind when tailoring the treatment in patients desiring pregnancy.What the implications are of these findings for clinical practice and/or further research? The value of local MTX injection in cases with IP and high β-hCG levels should be further clarified.

Risk factors, management, and fertility in cervical, cesarean scar, and interstitial ectopic pregnancies over 11 years

Risk factors, management, and fertility in cervical, cesarean scar, and interstitial ectopic pregnancies over 11 years

A case report of cervical ectopic pregnancy

Cervical Ectopic pregnancy is an extremely rare condition with potential grave consequences if not diagnosed and treated early enough. We present a case with clinical detail and sequential ultrasound images of early cervical ectopic pregnancy with a history of two previous cesarean sections. The cervical ectopic pregnancy was successfully diagnosed on ultrasound, treated with dilation and curettage followed by methotrexate without any complications. We discuss the differential diagnosis, imaging findings, complications and treatment options of the case. Morbidity and fertility of patient can be preserved by timely accurate diagnosis

Cervical pregnancy treated with hysteroresectoscopic resection after systemic methotrexate administration: Two case reports

Objective: To assess safe, accurate, and fertility-preserving treatment of cervical pregnancy (CP).

Total laparoscopic hysterectomy for successful treatment of uterine cervical pregnancy: a report of 2 cases

Total laparoscopic hysterectomy for successful treatment of uterine cervical pregnancy: a report of 2 cases

Cervical ectopic pregnancy with colic abdominal pain

Background: Very few case reports of ectopic cervical pregnancy with clear photos are available in the scientific world literature. Is a leading cause of maternal morbidity and mortality with a pregnancy-related mortality. Cervical pregnancy is more common in pregnancies achieved after assisted reproductive technologies; it occurs in 0.1% of in vitro fertilization pregnancies. The potential morbidity demonstrates the importance of early diagnosis of a cervical ectopicso as early intervention and treatment may be employed. The most common symptom of cervical pregnancy is vaginal bleeding, which is often painless.Case report: A 39 year old woman, G4 P2 C1 A0 L3, two spontaneous vaginal deliveries and last child birth by caesarean section + Pomeroy 15 years back, who underwent three embryo transfer 6.1 weeks ago; referred to the obstetric emergency department with 8 days increasing colic abdominal pain with some vaginal bleeding.Discussion: This is an interesting case report with few bleeding and increasing colic abdominal pain that did not answer to methrotexate and required a hysterectomy as the most viable solution.

Hysteroscopic removal of cesarean scar pregnancy after primary therapy with methotrexate: a case series

Purpose of Investigation: To present the clinical outcome of cesarean scar pregnancies (CSP) managed by methotrexate (MTX) administration followed by hysteroscopy removal. Materials and Methods: A retrospective study was undertaken in eight consecutive patients admitted to the present Hospital with a diagnosis of CSP, based on ultrasound assessment. The patients underwent systemic (five patients) or local (three patients) MTX administration for pregnancy termination, followed by hysteroscopy removal. A 27Fr resectoscope was used for hysteroscopy surgery. Results: Mean gestational age was of 7.8 weeks and five patients showed a viable embryo. All pregnancies were terminated after MTX; since drug administration, hysteroscopy removal was carried-out after a mean time of 36.1 days. Hysteroscopy view found type 1 and type 2 CSP in one and six patients, respectively. In one patient hysteroscopy assessment demonstrated a cervical pregnancy instead of a type 1 CSP suspected by ultrasound. Mean operating time was of 20.8 minutes, no further intervention was needed, and neither complications were reported. The mean time of menses resumption was of 35.5 days. After the first menstrual period all patients showed &#x03B2;-hCG level in the non-pregnant range and empty uterine cavities. Conclusions: Termination of CSP by MTX, combined with its hysteroscopic removal, resulted to be safe and effective.

Conservative Management of Synchronous Intrauterine Molar Pregnancy and Cervical Ectopic Pregnancy : A case Report

Background: Systemic arterial hypertension is a common disease in patients undergoing surgery. Bisoprolol and Enalapril are anti-hypertensive drugs that affect the perioperative hemodynamics (blood pressure and pulse rate) in different manners. Objectives: The aim of the present study was to compare the effect of general anesthesia on the hemodynamics of hypertensive patients undergoing elective surgery and controlled on Enalapril versus Bisoprolol as a primary outcome, and criteria of discharge from recovery room, postoperative pain assessment, and adverse effects as a secondary outcome. Patients and Methods: In this comparative clinical randomized study, thirty hypertensive patients of both sexes, aged from 40 to 60 years, according to the American Society of Anesthiologists (ASA) physical status class II, undergoing elective surgery under general anesthesia of less than two hours duration (Abdominal and upper limb surgery), and controlled on antihypertensive medication regularly administered for at least six months duration (Enalapril versus Bisoprolol) were enrolled in the study. The study started from January, 2016 to February, 2018. Patients were randomly allocated into equal two groups, group (A) hypertensive patients controlled on Enalapril 10 mg and group (B) hypertensive patients controlled on Bisoprolol 5 mg. To evaluate intraoperative arterial blood pressure:( systolic arterial blood pressure, diastolic arterial blood pressure and mean arterial blood pressure) and Heart rate as follow: preoperative basal arterial blood pressure and pulse rate reading (0), immediately after induction, (1), every 5 minutes for 20 minutes and every 15 minutes till the end of the operation. Results: Hypertensive patients controlled on Enalapril (group E) had more statistically significant decrease in blood pressure (systolic-diastolic-mean) after induction of general anesthesia and more hypotensive episodes in the first 30 minutes after induction than patients treated with Bisoprolol 5 mg (group B) while, group A had more increase in blood pressure post-intubation, post-extubation and on exposure to noxious stimuli. When comparing heart rate changes between both studied groups the results showed that hypertensive patients controlled on Bisoprolol (group B) had more statistically significant heart rate control (decrease) all over the operation especially at periods of intraoperative stress as post-intubation, 1st 30 minutes of operation and post extubation than hypertensive patients controlled on Enalapril (group A). The remaining intraoperative periods of the operation are nearly comparable between both studied groups (A and B) as regard blood pressure and heart rate. Patients of both groups (A and B) had no statistically significant difference as regard criteria of discharge from recovery room, postoperative pain assessment and adverse effects. Conclusion: Bisoprolol as a beta blocking antihypertensive drug was associated with effective control of pulse rate and blood pressure and attenuation of pressor response to all stressful events all over the operation especially after laryngoscopy, intubation, extubation and the first 30 minutes of operation ensuring more hemodynamic stability under general anesthesia when compared to hypertensive patients controlled on Enalapril. Recommendation: Beta blockers (Bisoprolol) are recommended before surgery even for those who do not use them when exposed to anesthesia unless there are contraindications.

Ektopinis nėštumas gimdos kaklelyje: klinikinis atvejis ir literatūros apžvalga

Įvadas Nėštumas gimdos kaklelyje yra reta patologija, kurios tiksli etiologija nežinoma. Ši būklė gali būti gyvybiškai pavojinga ir gydoma totalia laparotomine histerektomija, tačiau tobulėjanti diagnostika leidžia ektopinį nėštumą gimdos kaklelyje gydyti išsaugant vaisingumą. Klinikinis atvejis 38 metų pacientė buvo paguldyta į Klaipėdos Jūrininkų ligoninę dėl kraujavimo iš makšties ir skausmo apatinėje pilvo dalyje. Nuodugniai ištyrus pacientę, buvo diagnozuotas nėštumas gimdos kaklelyje. Apsvarsčius skirtingas gydymo taktikas, totali laparotominė histerektomija buvo pasirinka kaip tinkamiausias gydymo būdas. Operacija buvo sėkminga, pooperacinis lai­kotarpis sklandus. Diskusija Ultragarso tyrimas yra pagrindinis nėštumo gimdos kaklelyje diagnostikos metodas. Skėtikliais ir bimanualinio tyrimo metu dažniausiai randami svarbūs pakitimai, kurie padeda pagrįsti diagnozę. Totali laparotominė histerektomija buvo pagrindinis gydymo metodas, tačiau tobulėjant diagnostikos metodams metotreksatas tapo pirmos eilės pasirinkimu kaklelinio nėštumo atveju. Kiti konservatyvūs gydymo metodai, pavyzdžiui, gimdos ir gimdos kaklelio abrazija, lydima tamponavimo Foley kate­teriu, ar gimdos arterijos embolizacija, tampa vis populiaresni. Išvados Duomenys apie kaklelinį nėštumą yra riboti dėl šios patologijos retumo ir kiekvienas atvejis turi būti vertinamas individualiai. Noras išsaugoti vaisingumą ir pacientės būklė yra pagrindiniai rodikliai, į kuriuos būtina atsižvelgti nusprendžiant, kokią gy­dymo taktiką pasirinkti esant nėštumui gimdos kaklelyje.

Treatment of cervical pregnancy with ultrasound-guided local methotrexate injection.

Cervical pregnancy (CP) is a rare type of ectopic pregnancy. While methotrexate (MTX) is generally the first-line method of choice for clinically stable women, there is still no consensus on the most appropriate treatment for this abnormal pregnancy. The aim of this study was to investigate the efficacy of a single local MTX injection under transvaginal ultrasound guidance for the initial treatment of CP and to assess post-treatment fertility. We reviewed retrospectively 15 patients with CP treated with local MTX injection under transvaginal ultrasound guidance. In all patients, the serum human chorionic gonadotropin (hCG) levels were monitored and the gestational sac was evaluated using ultrasonography after treatment. Magnetic resonance imaging (MRI) was performed as necessary. We evaluated the patients' clinical characteristics and clinical course after treatment, the efficacy of the treatment and the post-treatment fertility in patients desiring subsequent pregnancy. The median estimated gestational age at the time of MTX injection was 6 + 2 (range, 5 + 2 to 11 + 0) weeks. All 15 patients were treated successfully, without the need for blood transfusion or surgical procedures; however, three patients required an additional local MTX injection due to a poor decline in serum hCG level following the initial injection, while one patient required uterine artery embolization due to persistent vaginal bleeding and an enlarging gestational sac with blood vessels visible on contrast-enhanced MRI. The mean time following initial MTX injection for hCG normalization was 43.8 (95% CI, 33.3-54.3) days and for resumption of menses was 68.4 (95% CI, 51.9-84.9) days. Seven of the 10 women desiring subsequent pregnancy following treatment had uneventful pregnancy, one became pregnant but miscarried spontaneously at 8 weeks of gestation, one was treated by laparoscopic surgery after diagnosis of a tubal pregnancy and one did not conceive. A single, ultrasound-guided, local MTX injection is apparently effective for the treatment of CP without the need for concomitant procedures or surgical intervention. Furthermore, this conservative technique both preserves fertility and allows for the possibility of subsequent uneventful pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

265 - Laparoscopic and Hysteroscopic Management of a Cervical Ectopic Pregnancy

Introduction: Cervical ectopic pregnancy is a rare but serious condition. Management of cervical ectopic pregnancy varies by institution depending on surgical expertise and availability of interventional radiology.

Intraoperative Hemorrhage Requiring Emergent Hysterectomy: Failed Conservative Management of a Cervical Placenta Accreta

Background: Emergent peripartum hysterectomy is warranted for a variety of indications, including uterine rupture, uterine atony, retained placenta, and abnormal placentation. Abnormal placentation is an increasingly common phenomenon that can be attributed to disruptions in the endometrial decidua following cesarean delivery, myomectomy, dilation and curettage, endometritis, endometrial ablation, and other operative procedures. Case: At 10 weeks of gestation, a patient with two previous cesarean deliveries and two terminations of pregnancy via dilation and curettage underwent a suction dilation and curettage for a missed abortion. Hemorrhage occurred; she became hemodynamically unstable and underwent an emergent total abdominal hysterectomy (TAH). Results: Surgical pathology testing confirmed an intracervical pregnancy with a placenta accreta. Conclusions: This case highlights the difficulty in differentiating cervical ectopic pregnancy with a spontaneous abortion in process. In order to prevent loss of reproductive function, massive hemorrhage, and possibly maternal mortality, the current authors recommend that, in patients with histories of multiple cervical instrumentations, the risk of cervical ectopic pregnancy and even abnormal cervical placentation must be considered in the preoperative differential. In the unstable patient, the “gold standard” treatment for abnormal placentation—TAH—is warranted when conservative measures, such as balloon tamponade, fail. (J GYNECOL SURG 33:215)

A case of heterotopic pregnancy with selective reduction of the ovum cervical localization and preservation of intrauterine pregnancy

Failure of implantation with the formation of heterotopic pregnancy is, unfortunately, continues to accompany the IVF. This may be due to the inability of the impact on endometrial receptivity. Changing characteristics of endometrial receptivity in conducting IVF determines the probability of formation of this kind of complications. The lack of standards for the conduct of heterotopic uterine and cervical pregnancy include the woman to the group at high risk for bleeding, a subsequent hysterectomy and loss of fertility. Promptly detection of ectopic localization of the ovum by means of methods of ultrasonic diagnostics allows in some cases to carry out organ-sparing surgery. Currently, there is a need for improved approaches to preimplantation training. The article describes a clinical case of heterotopic pregnancy with successful selective reduction of cervical localization of one of the two fertilized eggs and preservation of intrauterine pregnancy.