Delayed spontaneous expulsion of a cervical ectopic pregnancy: a case report

Cervical ectopic pregnancy is an uncommon event. Modern diagnostic and treatment options provide an opportunity for conservative treatment of this condition. A case of a profuse hemorrhage associated with delayed spontaneous expulsion of a cervical ectopic pregnancy is described, and the management is discussed. In this patient, the cervical ectopic pregnancy was treated successfully using systemic methotrexate and selective uterine artery embolization. The patient returned 1 week later with spontaneous expulsion of the ectopic pregnancy associated with profuse hemorrhage. The bleeding subsided following tamponade using a transcervical Foley catheter. We conclude that conservative treatment of cervical ectopic pregnancy is feasible, with careful posttreatment surveillance.     

Cervical Incompetence in a Pregnancy Following a Cervical Ectopic Pregnancy

Summary: A case of cervical incompetence is reported which occurred in a pregnancy which followed soon after treatment of a cervical ectopic pregnancy using a Foley catheter. Very few pregnancies following cervical pregnancy have been reported. Although this isolated case is clouded by other risk factors, cervical incompetence should be considered as a potential complication of such pregnancies.     

Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound-guided aspiration and single-dose methotrexate

OBJECTIVE: To present a case of cervical ectopic pregnancy successfully treated with ultrasound-guided aspiration and single-dose methotrexate administered systemically. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old nulliparous woman with a cervical ectopic pregnancy. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical ectopic pregnancy followed by single-dose methotrexate administered systemically. MAIN OUTCOME MEASURE(S): Recovery of the patient, successful conservative treatment of the cervical ectopic pregnancy, with preservation of the uterus. RESULT(S): The cervical ectopic pregnancy was successfully aborted, and the reproductive capability of the patient was preserved. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with single-dose methotrexate administered systemically can be safely used to treat cervical ectopic pregnancies.     

Embarazo ectópico cervical: a propósito de 3 casos. Revisión de la práctica clínica

Three cases of cervical ectopic pregnancy treated medically are described. The first case with selective uterine artery embolization and methotrexate dose single, the second case with selective uterine artery embolization and methotrexate dose multiple, and the third case intraamniotic puncture and instillation of KCl due to persistent embryonic heartbeat was necesary, before selective uterine artery and methotrexate dose unique. A spontaneous evacuation of the cervical pregnancy occurred in all patients treated conservatively. We postulate that the preventive use of uterine artery embolization in combination with standard MTX treatment could contribute to reduce the risk of excessive bleeding and facilitate spontaneous expulsion. The diagnostic and therapeutic methods are discussed and the literature is reviewed.     

Suction curettage as first line treatment in cases with cesarean scar pregnancy: feasibility and effectiveness in early pregnancy

Objective: A cesarean scar pregnancy (CSP) is an extremely rare form of an ectopic pregnancy, which is defined as the localization of a fertilized ovum surrounded by uterine muscular fiber and scar tissue. The objective of this study was to discuss the management options for CSPs in a singleton center. In the current study, we discussed the current management options for CSPs based on our 6 years of experience.

Material and methods: A retrospective evaluation of diagnosed and treated 26 patients with CSPs in Istanbul Kanuni Sultan Suleyman Training and Research Hospital during a 6-year period was discussed. Suction curettage was performed as first-line treatment in patients with a gestation <8 weeks and myometrial thickness >2?mm.

Results: Twenty-two (84.6%) patients with CSPs were initially treated surgically (curettage and hysterotomy) and four (15.4%) patients were treated medically with methotrexate injections. Vacuum aspiration was performed in 19 patients as a first-line treatment, six of them needed an additional Foley balloon catheter to be inserted for tamponade because of persistent vaginal bleeding. Suction curettage was successful in 12 patients. The treatment rate for suction curettage with or without Foley balloon catheter tamponade was 16 of 19 (84.2%).

Conclusion: The early diagnosis of a CSP (7–8 weeks gestation) with a β-hCG level <17.000?mIU/ml and a myometrial thickness >2?mm can be treated with suction curettage with or without placement of a uterine Foley balloon as curative treatment.     

Reproductive outcome after methotrexate treatment of tubal pregnancies

OBJECTIVE: To evaluate reproductive outcome after ectopic pregnancy (EP) treated with methotrexate (MTX) and to assess the relative contribution of various risk factors to future fertility. DESIGN: Telephone follow-up interviews in a cohort of patients treated for EP. SETTING: University hospital. PATIENT(S): A cohort of 158 patients treated with MTX for tubal pregnancies between April 1991 and March 1999. INTERVENTION(S): Assessment of fertility outcomes. MAIN OUTCOME MEASURE(S): Cumulative pregnancy rates for intrauterine and ectopic pregnancies. RESULT(S): Thirty-two patients (20.2%) were lost to follow-up. Of 126 patients, 93 (73.8%) sought to become pregnant, and of these 93 women, 76 (81.7%) did. Sixty-four pregnancies were spontaneous, and 12 resulted from in vitro fertilization (IVF). No pregnancies occurred in the group not trying to become pregnant. Of the 64 spontaneous pregnancies, 52 (81.2%) were intrauterine, with 12 (18.7%) resulting in miscarriages, and 12 (18.7%) were recurrent ectopic pregnancies. The cumulative intrauterine pregnancy rate was 57.5% after 1 year and 66.9% after 2 years. The cumulative ectopic pregnancy rate was 15.4% after 1 year and 23.7% after 2 years. After adjusting for factors associated with fertility with a Cox regression, only one factor was associated with poor reproductive performance: previous history of infertility. CONCLUSION(S): Within 1 year of seeking to become pregnant, more than half the women previously treated medically for EP conceived and had ongoing pregnancies. Our analysis indicates that fertility depends more on the patients' previous medical history than on her treatment for EP.     

Efficacy and Patient Satisfaction with Outpatient Prostaglandin E2 versus Foley Catheter for Cervical Ripening—A Randomized Trial

Introduction: an important factor in the success of labour induction is the presence of a ripe cervix. The safety and efficacy of outpatient prostaglandin E₂ (PGE₂) administered intracervically compared to extra-amniotic cervical Foley catheter placement to ripen the cervix were studied. Patient satisfaction and overall cost with both methods were reported for the first time.Methods: pregnant women with uncomplicated term pregnancies having an indication for induction of labour were enrolled. Singleton pregnancies with intact membranes and cervical Bishop scores < 5 were randomized blindly to receive .5 mg intracervical PGE2 (n=67) every six to eight hours or intracervical Foley catheter (extra-amniotic) (n=62) insertion overnight. Cervical assessments were carried out prior to treatment and again before induction of labour. Patients filled out a post-treatment Likert questionnaire.Results: overall change in Bishop score did not differ between the two groups. The Foley treatment group were more likely to have Mated to three to four cm (χ²=5.48 DF=1 p=.02). Intrapartum variables, mode of delivery and post-partum complications were similar. For patients completing the questionnaire, pain experienced during insertion was similar, however, fewer patients would recommend the Foley catheter treatment to a pregnant friend (F[1,64]=5.53 p=.02). The price of the Foley catheter is much less than the PGE₂.Conclusion: both methods lead to similar changes in overall Bishop score although the intracervical Foley catheter was more likely to lead to cervical dilatation of three centimetres or more—a dilatation which facilitates amniotomy. There were no differences in the mode of delivery, maternal or neonatal outcomes. Patients reported the same amount of pain with both treatments but patients seem to prefer the more expensive PGE₂.     

Cost-effectiveness of presumptively medically treating women at risk for ectopic pregnancy compared with first performing a dilatation and curettage

OBJECTIVE: To compare the cost and complication rate of two alternative strategies for the diagnosis and medical management of ectopic pregnancy when ultrasound is nondiagnostic. DESIGN: A decision tree was constructed to compare [1] dilatation and curettage (D&C) followed by treatment of all ectopic pregnancies with methotrexate versus [2] empiric treatment of all patients with possible ectopic pregnancies with methotrexate without D&C. SETTING: University setting. PATIENT(S): Ten thousand hypothetical women with nonviable pregnancies and a known incidence of ectopic pregnancy were entered into a computer model. MAIN OUTCOME MEASURE(S): The two approaches were compared with respect to the number of missed ectopic pregnancies, complications, procedures performed, admissions to the hospital, and cost. RESULT(S): The D&C group had 1% more failed managements of ectopic pregnancies and 13.4% fewer patients with a miscarriage undergo a second treatment for resolution. The D&C group had 13.7% fewer complications including 6.3% fewer hospitalizations. D&C costs $173 to $223 more than empiric use of methotrexate per patient. CONCLUSION(S): Empirically treating women at risk for ectopic pregnancy with methotrexate does not reduce complications or save money. In the absence of such savings, the desire to make an accurate and definitive diagnosis, allowing objective prognosis on future fertility and risk of repeat ectopic pregnancy, supports the need to distinguish a miscarriage from ectopic pregnancy before treatment with methotrexate.     

Preinduction cervical ripening with the Foley catheter and the risk of subsequent preterm birth

OBJECTIVE: The Foley catheter is a safe and effective form of preinduction cervical ripening and is quickly growing in popularity. Its major effect appears to be through mechanical dilation, which has raised the concern that the use of the Foley catheter for cervical ripening may damage the cervix and result in a higher rate of subsequent preterm birth. STUDY DESIGN: We conducted a review of all induction of labor at our institution from July 1998 to July 2001 that required preinduction cervical ripening and had a subsequent birth. The primary outcome variable was preterm birth at <35 weeks of gestation. Demographic and potential confounding variables were analyzed. A probability value of <.05 was considered significant. RESULTS: The cases of 126 women (63 women in the Foley group and 63 women in the prostaglandin group) were studied. Women in the prostaglandin group had a prostaglandin agent used. There was no difference in maternal age, gravidity, parity, Bishop score, total time of induction, gestational age, oxytocin use, maximum oxytocin level, tobacco or drug use, or type of delivery in the index pregnancy between the groups. In the subsequent pregnancies, there were no differences in maternal age, gravidity, parity, spontaneous abortions, terminations, cone or Loop Electrosurgical Excision Procedure (LEEP) procedures, history of cervical manipulation, tobacco or drug use, stillbirth, need for induction, mode of delivery, episiotomy, gestational age at delivery, Apgar scores, labor duration, use of oxytocin, or birth weight. There were no differences in preterm birth at 37, 35, or 32 weeks of gestation between the groups. CONCLUSION: The use of the Foley catheter for preinduction cervical ripening does not appear to increase the risk of preterm birth in a subsequent pregnancy.     

甲氨蝶呤治疗输卵管妊娠后的生殖状态

目的 总结甲氨蝶呤(MTX)治疗输卵管妊娠后的生殖状态。方法 收集我院1997年3月-2002年8月确诊为输卵管妊娠并符合保守条件的患者6l例，应用MTX全身治疗，对其中46例随诊1-7年。结果 MTX治疗后宫内妊娠率71．7％，异位妊娠率8．7％。初孕即为输卵管妊娠者，保守治疗后宫内妊娠率为74．2％，再次异位妊娠率6．5％；第2次为输卵管妊娠者，保守治疗后宫内妊娠率为58．3％，再次异位妊娠率16．7％；第3次为输卵管妊娠者，保守治疗后无妊娠。结论 选择合适的早期患者采用MTX治疗是安全、价廉、可靠的治疗方法，也可获得满意的远期生殖状态。     

30 mL和60 mL容量宫颈扩张球囊对足月妊娠促宫颈成熟效果比较

目的：探讨两种不同容量的宫颈扩张球囊用于足月妊娠促宫颈成熟的临床疗效观察,为提高引产成功率,降低产后不良影响提供临床依据。方法：随机抽取2017年6月-2017年12月同济大学附属第一妇婴保健院收治的具有引产指征且宫颈评分＜6分的足月单胎孕妇400例作为观察对象,根据不同的球囊注水容量随机分为2组,Foley单球囊注水30 mL促宫颈成熟组（F30组）200例,Foley单球囊注水60 mL促宫颈成熟组（F60组）200例,比较2组患者的促宫颈成熟效果、引产效果以及孕产妇和新生儿转归情况。结果：2组患者治疗前Bishop评分比较,差异无统计学意义（χ2=1.280,P=0.201）,治疗后2组患者Bishop评分均上升,治疗后Bishop评分比较,差异有统计学意义（χ2=-4.137,P=0.000）。2组初产妇的引产-分娩时间比较差异有统计学意义（t=4.204,P=0.000）。多因素分析显示球囊容量是初产妇24 h内成功阴道分娩的影响因素（OR=1.990,95%CI：1.444～2.742,P=0.000）。研究中20例瘢痕子宫孕妇用宫颈扩张球囊促宫颈成熟,其中18例顺利阴道分娩,无相关并发症。2组孕产妇和新生儿结局比较,差异均无统计学意义（均P＞0.05）。结论：对足月宫颈条件不成熟的孕妇（包括剖宫产术后再次妊娠者）采用宫颈扩张球囊引产,安全有效,Foley 60 mL球囊在促宫颈成熟方面效果更好,且适当缩短引产-分娩时间。     

Conservative treatment by angiographic artery embolization of an 11-week cervical pregnancy after a period of heavy bleeding

OBJECTIVE: To describe a rare case of conservative treatment of an 11-week cervical pregnancy after a period of heavy bleeding. DESIGN: Case report. SETTING: A university hospital. PATIENT(S): A 33-year-old woman was admitted to our hospital for treatment of a cervical pregnancy. Two-and-a-half years thereafter, she gave birth to a healthy baby by vaginal delivery at 38 weeks of gestation. INTERVENTION(S): Systemic methotrexate treatment, ligation of descending branches of uterine arteries, cervical cerclage, and unilateral internal iliac artery embolization. MAIN OUTCOME MEASURE(S): Transvaginal ultrasound, magnetic resonance imaging, and arteriography findings. RESULT(S): The patient was successfully treated with unilateral internal iliac artery embolization on the same side as the pregnancy in the 11th gestational week. CONCLUSION(S): After failed methotrexate and vessel ligation in cervical pregnancy, unilateral internal iliac artery embolization is an effective and conservative treatment that allows preservation of reproduction potential.     

Successful treatment of a viable cervical pregnancy with methotrexate

Cervical pregnancies usually result in early spontaneous abortion, and most forms of conservative treatment are not recommended beyond 8 weeks' gestation. We present a case of a 9-week viable cervical pregnancy that is successfully managed with methotrexate.     

Cervical pregnancy managed without hysterectomy. A case report

A woman with a cervical pregnancy was treated without a hysterectomy. Hemorrhage from the implantation site was controlled by placement of a Foley catheter balloon in the cervix. Placement and inflation of a Foley catheter balloon in the cervix after cervical dilation and curettage appears to be a simple and effective means of managing postoperative hemorrhage secondary to cervical pregnancy.     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies

OBJECTIVES: This retrospective study examined the overall efficacy of methotrexate chemotherapy in the treatment of cervical pregnancy and attempted to determine whether differences in the response to methotrexate therapy exist between patients with viable and nonviable cervical pregnancies. STUDY DESIGN: A MEDLINE database search and a bibliographic review of the relevant literature were conducted to find reported cases of cervical pregnancy treated with methotrexate administration during the period from 1983 to 1997. Clinical and demographic characteristics, methotrexate regimen, concomitant invasive procedures, complications, and outcomes in viable and nonviable pregnancy groups were analyzed and compared. RESULTS: A total of 62 reported cases of cervical pregnancy were assessed. There were no statistically significant differences in demographic data, transfusion rate, and human chorionic gonadotropin remission time between viable and nonviable cervical pregnancy groups. Among the 35 cases of viable pregnancy 63% of women received systemic injection alone or a combination of systemic and local (intra-amniotic or intracervical) injection with methotrexate or potassium chloride and 37% had local injection of methotrexate (with or without potassium chloride) alone. Among the 23 cases of nonviable cervical pregnancy 96% of women received systemic methotrexate injection only. The need for >/=1 concomitant surgical procedure (such as simple curettage, dilation and curettage, cervical blocking, or uterine artery embolization) in conjunction with methotrexate therapy was significantly higher (P =.021) in the viable pregnancy group (43%) than in the nonviable pregnancy group (13%). The 94% success rate of preservation of the uterus in the viable pregnancy group was not significantly different from the 91% preservation rate in the nonviable pregnancy group. All patients who had successful uterine preservation returned to normal menstrual patterns. CONCLUSION: This retrospective study found that conservative treatment with methotrexate chemotherapy of patients with either viable or nonviable cervical pregnancies at <12 weeks' gestation carries a 91% success rate for preservation of the uterus. The structure of the cervix was restored and menstruation returned for all patients in whom the uterus was preserved after treatment. There was no evidence to suggest that the reproductive performance of these patients was affected by the treatment.     

Changes in the frequency of genital herpes recurrences as a function of time

To obtain objective information regarding changes in the frequency of recurrent genital Herpes simplex infections, the data from two consecutive pregnancies in 22 women with culture-proved genital Herpes simplex infections were reviewed. The pregnancies studied were separated by a mean of 2.0 years. When only culture-proved recurrences were considered, nine women had fewer recurrences in their second pregnancy than in their first, four had more recurrences in their second than in their first, and nine had the same number of recurrences in both pregnancies. The mean interval between culture-proved recurrences was 58.5 +/- 36.1 (SD) days in first pregnancies and 51.7 +/- 28.6 days in second pregnancies. Mean duration of viral shedding during 14 recurrences in first pregnancies was 4.6 +/- 3.4 days, and 3.2 +/- 2.2 days in 14 recurrences in second pregnancies (differences not significant by Mann-Whitney). Cervical Herpes simplex shedding in asymptomatic women occurred in four of 200 (2.0%) of first pregnancy cultures and zero of 167 second pregnancy cultures (NS). During culture-positive recurrent vulvar infections, 18 of 55 (32.7%) cervical cultures in first pregnancies were positive compared with four of 50 (8%) cervical cultures in second pregnancies (P less than .025). Route of delivery was very similar in the first and second pregnancies with vaginal delivery in 63.6% of first pregnancies and 72.7% of second pregnancies. Overall there was no appreciable difference in the frequency or severity of recurrent genital Herpes simplex infections over time, but more data are needed.     

Isthmic pregnancy located in a previous caesarean section scar treated with methotrexate. A case report

We report a case of a patient who presented an isthmic pregnancy successfully treated with an intramuscular injection of methotrexate. The diagnosis of isthmic pregnancy was made clinically (cervical colour was normal, inferior segment soft and enlarged) and echographically (long cervix, foetal sack situated in the isthmus and the uterine body was empty). An isthmic full term pregnancy is possible but would carry major haemorrhagic risk. There are several therapeutic options if the pregnancy is interrupted: medical treatment of methotrexate, curettage, curettage with embolisation of the uterine arteries and as a last resort, hysterectomy. The success of conservative treatment seems to be related to the criteria known for the cervical pregnancy, which are cardiac activity, the level of HCG, gestational age and cranial-caudal length.     

Recurrent cornual pregnancy after heterotopic cornual pregnancy successfully treated with systemic methotrexate

This report concerns a recurrent spontaneous cornual pregnancy 2 years after selective feticide of a heterotopic cornual pregnancy which occurred after IVF for tubal pathology. The recurrent cornual pregnancy was treated successfully with systemic methotrexate. Assisted reproductive techniques, especially in patients with tubal pathology, and non-invasive management of cornual pregnancies may lead to a higher incidence of recurrence.     

Surgical treatment of ectopic pregnancy

In most cases of ectopic pregnancy, medical treatment with methotrexate is successful. However, some cases still require surgery and laparoscopy is an effective approach. The candidates for surgical treatment include women who are not suitable to or have failed methotrexate treatment, those with heterotopic pregnancy, or those who are hemodynamically unstable. In women of reproductive age with tubal pregnancy, salpingostomy is the preferred surgical method. Conversely, salpingectomy is a better treatment for women with severely damaged fallopian tube, recurrent ectopic pregnancy in the same tube, uncontrolled bleeding after salpingostomy, large tubal pregnancy (> 5 cm), heterotopic pregnancy, and for those who have completed their family. Similar to treatment of a tubal pregnancy, cervical and interstitial pregnancy could be treated medically first. Most abdominal pregnancies are diagnosed late in pregnancy. However, when the diagnosis is made early, laparoscopic removal of the pregnancy should be performed.