Heterotopic cervical pregnancy successfully treated with transvaginal ultrasound-guided aspiration and cervical-stay sutures

OBJECTIVE: To present a case of a heterotopic cervical pregnancy successfully treated with transvaginal ultrasound-guided aspiration and cervical-stay sutures. DESIGN: Case report. SETTING: Tertiary academic IVF program. PATIENT(S): A 35-year-old woman who conceived from IVF-ET treatment at 5.5 weeks of gestation. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical pregnancy followed by cervical-stay sutures to control hemorrhage after aspiration. MAIN OUTCOME MEASURE(S): Recovery of the patient, preservation of the intrauterine pregnancy, and sequelae. RESULTS(S): The cervical pregnancy was successfully aborted, and the intrauterine pregnancy progressed to term. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with hemostatic cervical-stay sutures can be safely used to manage heterotopic cervical pregnancies.     

Cervical twin ectopic pregnancy after In Vitro fertilization-Embryo transfer (IVF-ET): case report

Introduction.?Cervical twin ectopic pregnancy after IVF-ET is rare and catastrophic complication. However, here is no consensus on the best treatment strategy.

Patient and method.?Case report of cervical twin ectopic pregnancy after IVF-ET treated by transvaginal ultrasound guided aspiration plus systemic single injection of methotrexate, which followed by full-term delivery in next IVF-ET cycle.

Conclusion.?Transvaginal ultrasound-guided aspiration and systemic methotrexate administration can be safely and easily used to treat cervical ectopic pregnancies and to preserve the fertility of the patient without any major complications.     

Methotrexate in local treatment of cervical heterotopic pregnancy with successful perinatal outcome: case report

This case report describes a case of heterotopic cervical ectopic pregnancy in a nulliparous woman that was successfully treated with single-dose local, intra-amniotic methotrexate injection in the gestational sac. Pregnancy was achieved spontaneously. The patient had previously undergone hysteroscopic myomectomy. By using local, single-dose treatment we avoided the continued effects of the drug on the intrauterine pregnancy and the possible adverse effect of systemically applied methotrexate. The treatment resulted in the term vaginal delivery of a healthy child and preserved the patient's fertility for future pregnancies.     

宫颈妊娠及宫内孕合并宫颈妊娠的保守治疗

目的:探讨宫颈妊娠的病因、诊断及保守性治疗方法。方法:回顾分析我院1996年1月1日至2010年12月31日收治的宫颈妊娠及体外授精胚胎移植术后宫内孕合并宫颈妊娠患者36例,探讨宫颈妊娠保守治疗方式的选择,并随访患者术后情况。结果:29例单纯宫颈妊娠:6例外院误诊为"难免流产",误诊率20.69%;10例经阴道B超引导下宫颈妊娠囊局部穿刺+MTX注射治疗,6例行子宫动脉栓塞术,6例MTX肌内注射治疗,7例腰麻下宫腔镜检查宫颈妊娠清除手术。7例宫内孕合并宫颈妊娠:1例阴道B超引导下局部妊娠囊穿刺注入KCl 1ml,3例期待疗法后清除宫颈妊娠物,3例腹部B超引导下宫颈妊娠物清除术。结论:阴道彩超用于宫颈妊娠的早期诊断有较大的价值,术前应充分评估,制定个体化的治疗方案。宫内孕合并宫颈妊娠的患者在腹部B超监测下清除宫颈妊娠物是有效的治疗方式之一,但要及时手术并且加强抗感染治疗。     

Transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose for treatment of unruptured tubal heterotopic pregnancy

Objectives To report a case of tubal heterotopic pregnancy (HP) treated conservatively with transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose. Methods Aspiration of the tubal ectopic pregnancy and hyperosmolar glucose instillation was performed with a 16-gauge needle under transvaginal ultrasound guidance. Results Unruptured tubal HP with positive cardiac activity was treated successfully without any further interventions, and intrauterine pregnancy has reached full-term without any complications. Conclusions Early diagnosis of this life-threatening condition is the key to its successful treatment. Transvaginal ultrasound-guided aspiration and hyperosmolar glucose injection can be safely performed for the treatment of unruptured tubal HP.     

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.     

Methotrexate for cervical pregnancy. A case report

BACKGROUND: The incidence of cervical pregnancy is 1:1,000-95,000 pregnancies and represents < 1% of all ectopic pregnancies. Evacuation of the pregnancy by curettage does not always stop the bleeding because there is little contractile muscle in the cervix. If there is uncontrollable bleeding, hysterectomy is necessary. In selected cases, nonsurgical management offers high success rates. Among medical treatments, the most common is systemic or local administration of methotrexate. CASE: A 36-year-old woman, gravida 2, para 2, presented with vaginal bleeding and subacute pain in the lower abdomen. The patient was 7 weeks' pregnant according to her last menstrual period. Transvaginal ultrasonography showed a gestational sac of approximately 5 weeks' gestational age implanted in the wall of the cervix. Fifty milligrams of methotrexate was injected into the gestational sac and another 50 mg administered intramuscularly. The hCG level decreased continuously and was no longer detectable after 35 days. CONCLUSION: The use of methotrexate for cervical pregnancy is safe and effective and preserves fertility.     

Spontaneous twin cervico-isthmic pregnancy in a grand multiparous woman

Cervico-isthmic pregnancy is a rare form of ectopic pregnancy and is defined as the implantation of a fertilized ovum in the cervico-isthmic portion. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role, given an apparent association with a prior history of curettage or cesarean delivery. Transvaginal ultrasonography and β-human chorionic gonadotrophin assays are useful for diagnosis. Here we report a case of spontaneous twin cervico-isthmic pregnancy in a grand multiparous patient who was diagnosed early in the first trimester with transvaginal ultrasonography. The pregnancy was terminated successfully with methotrexate. Methotrexate seems to be most successful at early gestational ages.     

经阴道超声引导下减胎术在输卵管间质部妊娠合并宫内孕中的应用——减胎成功2例报告

目的探讨孕早期采用经阴道超声引导下减胎术减灭宫外妊娠胚芽的临床治疗效果。方法通过阴道超声减胎抽吸宫外妊娠组织。结果对2例诊断为未破裂输卵管间质部的早期异位活胎妊娠,通过经阴道超声引导下减胎穿刺治疗,被保留的宫内胎儿持续妊娠至足月分娩。结论孕早期采用经阴道超声引导下减胎术选择性抽吸输卵管间质部胚芽,可获得理想的临床治疗效果。但是本方法仅去除胚芽组织,对残余的绒毛组织,需密切追踪随访。     

Comparison of multidose and single-dose methotrexate protocols for the treatment of ectopic pregnancy

OBJECTIVE: The purpose of this study was to compare success rates of 643 patients who had ectopic pregnancy from the same database who were treated with multidose or single-dose methotrexate protocols. STUDY DESIGN: We compared demographics, gestational age, serum human chorionic gonadotropin, progesterone levels, ectopic sac size and volume, overall ectopic mass size and volume, ectopic cardiac activity, history of ectopic pregnancy, number of treatment days, methotrexate doses, and outcome in consecutive patients with ectopic pregnancy who were treated with methotrexate. RESULTS: Success rates were comparable between patients with multidose and single-dose therapy (95% vs 90%, respectively) as were human chorionic gonadotropin and progesterone levels, history of ectopic pregnancy (21.4% vs 21.7%, respectively), number of treatment days, gestational age, ectopic size, ectopic volume, and ectopic mass volume. Patients who received single-dose therapy were significantly heavier (146 vs 159 pounds), had greater ectopic cardiac activity (3.1% vs 10.3%), and received fewer methotrexate doses. CONCLUSION: This study suggests single-dose methotrexate therapy is as effective as multidose methotrexate therapy for the treatment of ectopic pregnancy.     

Consecutive cervical pregnancies

OBJECTIVE: Report of a rare case of consecutive spontaneous cervical pregnancies. DESIGN: Case study. SETTING: Teaching hospital. PATIENT(S): One healthy nulliparous woman in the early years of her fourth decade. INTERVENTION(S): The first of two cervical pregnancies was treated with two doses of methotrexate and subsequent uterine artery embolization. The second was treated with methotrexate, intracervical Foley catheter placement, hysteroscopic ablation of the bleeding cervical bed, and replacement of the Foley catheter with gradual deflation of balloon. MAIN OUTCOME MEASURE(S): Recognition and successful treatment of cervical ectopic pregnancy. RESULT(S): Each of the two cervical pregnancies was successfully treated. The patient subsequently carried a spontaneous intrauterine pregnancy to term. CONCLUSION(S): A comprehensive MEDLINE search revealed that this appears to be the first reported case of recurrent spontaneous cervical pregnancies, and only the second known case of recurrent cervical pregnancy. Cervical pregnancies have generally been treated with hysterectomy because of the potential for massive hemorrhage. However, current treatment options permit effective conservative management in women who desire continued fertility. This case illustrates various treatment options, under different circumstances, in the same individual.     

Conservative treatment of ectopic pregnancy in a cesarean scar

BACKGROUND: Pregnancy developing in a cesarean scar is a very rare but possibly life-threatening condition because of the risk of rupture and excessive hemorrhage. CASE: A 34-year-old woman presented with lower abdominal pain at 6 weeks of gestation. A cesarean delivery had been performed 3 years earlier. Transvaginal ultrasound examination revealed a viable pregnancy developing in the anterior wall of the uterus. The patient was treated successfully with systemic methotrexate and curettage. CONCLUSION: Conservative management with methotrexate and curettage can be considered in the treatment of ectopic cesarean scar pregnancy.     

Molar Ectopic Pregnancy in the Uterine Cornus

Cornual pregnancy is a rare form of ectopic pregnancy. The incidence of hydatiform molar pregnancy is 1 in 1000 to 2000 pregnancies. Molar cornual ectopic pregnancy is extremely rare. A 41-year-old nulliparous woman was admitted via the emergency department because of vaginal bleeding for 2 weeks. Transvaginal sonography exhibited a heterogeneous hypoechoic shadow in the endometrium that suggested a hematometra including blood clots and tissue, and a multicystic echogenic mass, with flow at color Doppler ultrasonography, in the lateral wall of the uterus. A laparoscopic cornuostomy was performed. Pathologic analysis demonstrated placental tissue with features consistent with a partial molar pregnancy. Systemic methotrexate therapy was administered to treat the possible remnants of the molar pregnancy. Molar cornual ectopic pregnancy can be successfully treated with laparoscopic cornuostomy and systemic methotrexate therapy.     

Previous ectopic pregnancy as a predictor of failure of systemic methotrexate therapy

OBJECTIVE: To investigate whether a history of previous ectopic pregnancy is an independent risk factor for failure of methotrexate therapy in subsequent ectopic pregnancies and whether the previous treatment method influenced failure. SETTING: Inner-city teaching hospital. DESIGN: Retrospective case review. PATIENT(S): Five hundred four consecutive patients treated with "single-dose" methotrexate for ectopic pregnancy. Nine patients electing surgery after beginning medical therapy were excluded from analysis. INTERVENTION(S): Systemic methotrexate 50 mg/m(2). MAIN OUTCOME MEASURE(S): Failure of methotrexate therapy. RESULT(S): Twenty-one (18.6%) of 113 of previous ectopic patients and 26 (6.8%) of 382 first-time ectopic patients failed methotrexate therapy (odds ratio, 3.12). The overall success rate was 90.5% (448/495 patients). Univariant analysis showed that treatment hCG and progesterone (P) levels and ectopic cardiac activity were significantly different between successful and failed therapy. Logistic regression analysis for these four variables showed that only hCG and history of previous methotrexate remained significant risk factors for failure of methotrexate therapy. The likelihood of failure in patients with a previous ectopic was not influenced by previous treatment with salpingostomy, salpingectomy, or medical treatment. CONCLUSION(S): A history of previous ectopic pregnancy appears to be an independent risk factor for failure of systemic methotrexate treatment, but failure is not affected by previous treatment method.     

Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate

OBJECTIVES: The objective of this study was to review the largest single series of ectopic pregnancies treated with single-dose methotrexate reported to date. STUDY DESIGN: A review of 315 patients with unruptured ectopic pregnancies treated with single-dose methotrexate 50 mg/m² from March 21, 1990, to March 1, 1997, was performed. RESULTS: Overall 287 patients were successfully treated with methotrexate for a success rate of 90.1%. Six patients electively withdrew and requested surgery within 1 week of starting therapy. Excluding withdrawals the overall success rate was 92.9%. Ten patients with an ectopic pregnancy >3.5 cm but ≤4 cm in size were treated for a 90% success rate. Forty-four patients with positive ectopic cardiac activity were treated with an 87.5% success rate. CONCLUSIONS: This large series indicates that single-dose intramuscular methotrexate for treatment of ectopic pregnancy is associated with an excellent overall success rate. (Am J Obstet Gynecol 1998;178:1354-8.)     

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.     

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.     

Clinical and pregnancy outcome following ectopic pregnancy; a prospective study comparing expectancy, surgery and systemic methotrexate treatment

BACKGROUND: The improved possibility of an early diagnosis of ectopic pregnancy by use of serial quantitative beta-subunit human chorionic gonadotropin hormone levels together with transvaginal ultrasound has opened up options for conservative treatment. Systemic methotrexate treatment of unruptured ectopic pregnancy has emerged as a safe and effective alternative to surgical procedures. The aim of the present study was to investigate the effectiveness of methotrexate treatment in routine clinical practice, but also to assess pregnancy outcome during a 2.5-year follow-up period. METHODS: All patients presenting to the Department of Obstetrics and Gynecology, Ume? University Hospital, with signs and symptoms of ectopic pregnancy between January 1, 1995 and December 31, 1997 were included in this prospective study. Patients with ectopic pregnancy were either managed expectantly, treated with methotrexate or by laparoscopic or open surgery (salpingostomy/salpingectomy). Systemic methotrexate (Pharmacia & Upjohn, Stockholm, Sweden) was administered as an intramuscular injection of 50 mg/m(2). RESULTS: One hundred and seven patients presented with signs and symptoms of a possible ectopic pregnancy, of these 89 patients eventually were diagnosed as having an ectopic pregnancy. Twenty-six (29%) patients were treated with methotrexate, 46 (52%) patients with laparoscopy or laparotomy, and 17 (19%) patients by expectant management. Success rate in the methotrexate group, after one or more injections, was 77% (20 patients out of 26). The mean time to resolution was 24+/-9 days. There was no difference in pregnancy rate following methotrexate treatment compared to surgical treatment. CONCLUSIONS: Systemic single-dose methotrexate treatment is a safe treatment option with a reasonably high success rate, with similar probability of a later intrauterine pregnancy as conventional surgical treatment.     

Tratamiento del embarazo ectópico cervical con metotrexato y rescate con leucovorina

Objective

To present two cases of cervical ectopic pregnancy successfully treated with systemic methotrexate.

Subjects and methods

Two women with a cervical ectopic pregnancy. Interventions: alternative day regime of methotrexate 1 mg/kg (days 1,3,5 and 7) with folinic acid rescue (days 2, 4, 6, and 8). End points: successful treatment.

Results

Two cases of ectopic cervical pregnancy were successfully treated and preserved their reproductive capability.

Conclusions

Conservative medical treatment of cervical ectopic pregnancy with systemic methotrexate is safe and effective.     

Transvaginal ultrasound-guided treatment of cervical pregnancy

OBJECTIVE: To describe our experience with sonographically guided injection of methotrexate and potassium chloride (KCl) to treat early cervical pregnancy. METHODS: We prospectively reviewed all cases of cervical pregnancies treated conservatively through transvaginal ultrasound-guided therapy at our institutions. Thirty-eight cases were identified, from 1993 through 2004. All cases were managed with transvaginal intra-amniotic and intrachorionic injection of 50 mg of methotrexate under ultrasound guidance. An additional intracardiac fetal injection of 2 mL KCl was given for those cervical pregnancies with documented cardiac activity. Follow-up sonographic examinations and serum beta-hCG measurements were performed twice weekly for 2 weeks after the procedure, then weekly. RESULTS: The mean initial beta-hCG level was 38,948 milli-International Units/mL and ranged from 5,608 to 103,256 milli-International Units/mL for 22 cases with fetal heart activity and from 2,765 to 18,648 milli-International Units/mL for 16 cases without. Gestational age ranged from 5.4 to 14 weeks (mean 8.8 weeks). All cervical pregnancies were successfully aborted, with an average resolution of the cervical mass in 49 days. Postoperative beta-hCG declined to less than 5 milli-International Units/mL within a mean of 38 days. A mean 4.5-year follow-up showed that, of 21 patients who desired pregnancy, 18 had achieved subsequent successful pregnancies. CONCLUSION: Cervical pregnancies can be successfully managed without surgical intervention through local injection of methotrexate and KCl. This treatment not only ablates the ectopic pregnancy but also preserves the uterus for subsequent pregnancies.