CASE REPORT Cervical pregnancy Paola Bianchi, M.D., Massimo Maria Salvatori, M.D., Francesco Torcia, M.D., Giuliana Cozza, M.D., and Bruno Mossa, M.D. Dipartimento Salute della Donna e Medicina Territoriale, ‘‘Sapienza’’ Universita di Roma, Azienda Ospedaliera Sant’Andrea Roma, Rome, Italy
Objective: To present a case of successful management of a heavily bleeding cervical ectopic pregnancy with ultrasound-guided termination procedure of evacuation. Design: Case report. Setting: University hospital. Patient(s): A 34-year-old woman, secundigravida with one previous full-term natural childbirth and history of one spontaneous abortion, with a cervical pregnancy. Intervention(s): Prophylactic suture ligation of the cervicovaginal branches of the uterine artery, with absorbable sutures at the 3 and 9 o’clock positions of the cervix. Evacuation, with dilatation and curettage, under transabdominal ultrasound guidance was performed. Control of hemorrhage by placing a running-lock absorbable suture around the entire edge of the cervix followed by cervical packing with iodoform gauze medicated with anticoagulant drugs. 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 succesfully evacuated, and the reproductive capability of the patient was preserved. Conclusion(s): Ultrasound-guided evacuation with prophylactic closure of the cervical branches of the uterine artery and application of a running-lock suture around the cervix can be used in case of heavily bleeding cervical ectopic pregnancy. (Fertil Steril 2011;95:2123.e3–e4. 2011 by American Society for Reproductive Medicine.) Key Words: Cervical pregnancy, fertility-sparing, ectopic pregnancy
CASE REPORT A 34-year-old woman, secundigravida with one previous full-term natural childbirth and history of one spontaneous abortion, treated with dilatation and curettage, was admitted to our gynecology department with acute, heavy, painless, and profuse vaginal bleeding. She referred her last menstrual period as 6 weeks before. No pregnancy test was performed by the patient before the admission to first aid. Quantitative b-hCG level was 100.685 mIU/mL, hemoglobin 8.1 g/dL, and hematocrit 24%. Gynecologic examination revealed a soft barrel-shaped cervix and normal uterine size in the presence of uncontrolled hemorrhage. Transvaginal ultrasonography showed an empty uterine cavity and the presence of a gestational sac with a live embryo at the level of the cervix below the internal os. Crown-rump length was 21 mm, corresponding to 8–9 weeks of gestation. Embryo cardiac activity was present (Fig. 1). Because the patient was hemodynamically instable, she was taken to the operating room. Treatment modalities, Received August 13, 2010; revised December 14, 2010; accepted January 6, 2011; published online February 3, 2011. P.B. has nothing to disclose. M.M.S. has nothing to disclose. F.T. has nothing to disclose. G.C. has nothing to disclose. B.M. has nothing to disclose. Reprint requests: Paola Bianchi, M.D., Department of Women’s Health, University of Rome ‘‘Sapienza,’’ Ospedale Sant’ Andrea Roma, Via di Grottarossa 1035, Rome, Italy (E-mail:
[email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.01.016
with the potential risks, were discussed with the patient. To preserve fertility, the patient underwent a conservative pregnancy termination procedure of evacuation under ultrasound guidance. We could not perform methotrexate local injection because of the profusion of bleeding. Four units of blood were prepared. Under general anesthesia in consideration of the possibility of laparotomy, the patient was placed into the lithotomy position. Before performing the evacuation, the patient underwent prophylactic suture ligation of the cervicovaginal branches of the uterine artery, with absorbable sutures at the 3 and 9 o’clock positions of the cervix, at a depth of 1 cm. This ligature temporarily stopped the bleeding, allowing an optimal vision of surgical field. Then the evacuation, with dilatation and curettage, under transabdominal ultrasound guidance was performed, and the products of conception were sent for histologic examination. The hemorrhage was controlled by placing a running-lock absorbable suture around the entire edge of the cervix, followed by cervical packing with iodoform gauze medicated with tranexamic acid. The patient received 2 units of packed red blood cells by intraoperative transfusion when hemoglobin level was 5.3 g/dL and hematocrit 16%. The patient received another 2 units during her hospitalization in intensive care (postoperative period). Quantitative serum b-hCG level decreased progressively from 100,685 mIU/mL before surgical treatment to 2,514 mIU/mL on day 7 and 598 mIU/mL on day 9. On the 9th postoperative day, hemoglobin level was 8.8 g/dL and hematocrit 28%. Transvaginal
Fertility and Sterility Vol. 95, No. 6, May 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
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FIGURE 1 Longitudinal transvaginal ultrasound scan showing the empty uterus and a gestational sac with a live embryo at the level of the cervix.
Bianchi. Cervical pregnancy. Fertil Steril 2011.
ultrasonography showed a regular cavity of the uterus, and echogenic material was noted at the level of the cervical canal such as for the presence of minimal fluid effusion. The patient was discharged.
DISCUSSION At present the following dignostic criteria using transvaginal ultrasonography are: 1) empty uterus; 2) barrel-shaped cervix; 3) gestational sac present below the level of the uterine arteries; 4) the absence of the ‘‘sliding sign’’ (when pressure is applied to the cervix using the probe in a miscarriage, the gestational sac slides against the endocervical canal but not in an implanted cervical pregnancy; and 5) blood flow around the gestation sac using color Doppler. General principles in the management of cervical pregnancy should include the following: 1) minimize the risk of hemorrhage; 2) eliminate the gestational cervical product; 3) spare fertility. Choice of the method should depend on the gestational age, presence of active bleeding and its severity, desire for preservation of future fertility, presence of coexisting viable intrauterine pregnancy, and experience of the physician in charge. Management options for treatment of cervical ectopic pregnancy range from conservative drug therapies to radical surgical proce-
dures. Conservative management includes chemotherapy, uterine artery embolization, Foley catheter balloon tamponade, dilatation and curettage, and uterine artery ligation with Shirodkar suture (1, 2). As with interstitial pregnancies, methotrexate has revolutionized the management of cervical pregnancies. The choice of regimen depends on the serum hCG level, the size of the ectopic mass, and the presence or absence of fetal cardiac activity. The antimetabolite cytotoxic drug methotrexate administered intravenously, intramuscularly, intracervically, or intramniotically plays an important role in the conservative management of cervical ectopic pregnancy even if many factors are responsible for unsatisfactory primary treatment. These factors are: serum b-hCG R10.000 IU/L, gestational age R9 weeks, the presence of fetal heart beat, fetal crown-rump length >10 mm (3, 4). KCl instillation under ultrasound guidance has been considered to be a safer alternative to methotrexate, especially in the case of heterotopic pregnancies to avoid exposure of coexisting intrauterine pregnancy to methotrexate (5). In addition to methotrexate and KCl therapy, 43% of viable and 13% of nonviable cervical pregnancies required more than one of the following concomitant procedures: uterine artery embolization, cervical cerclage, endocervical curettage, and ligature of the uterine artery. After failure of medical treatment to reduce the risk of massive blood loss, angiographic embolization of uterine arteries can be performed before evacuation and curettage of the cervical canal (6, 7). Conservative management by cervical cerclage was first described by Scott et al. in 1978 (8). In the case of profuse bleeding, Shirodkar-type cervical cerclage can be performed. During surgical treatment of cervical pregnancy the main problem is to achieve an adequate hemostasis. Another important conservative approach consists of evacuation of pregnancy after transvaginal suture ligation of the cervicovaginal branches of the uterine arteries at the 3 and 9 o’clock positions of the uterine cervix (9). Today no one center or gynecologist has accumulated enough data and experience on the ideal treatment of cervical pregnancy. Clinical practice guidelines are not available. The treatment of cervical pregnancy should be tailored to take into account the needs and the desire of the patient, the characteristics of the pregnancy and above all the presence of profuse hemorrhage. We treated our patient with transvaginal ligature of the descending branches of the uterine arteries with absorbable sutures at the 3 and 9 o’clock positions of the cervix. After the ligature, pregnancy evacuation was performed under ultrasound guidance The hemorrhage was controlled by placing a running-lock absorbable suture around the entire edge of the cervix followed by cervical packing with iodoform gauze.
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transvaginal ultrasound-guided aspiration and single dose methotrexate. Fertil Steril 2004;81: 1130–2. 5. Cheb D, Kligman I, Rosenwaks Z. Heterotopic cervical pregnancy successfully treated with transvaginal ultrasound-guided aspiration and cervical-stay sutures. Fertil Steril 2001;75:1030–3. 6. Suzumori N, Katano K, Sato T, Okada J, Nakanishi T, Muto D, et al. Conservative treatment by angiographic artery embolization of an 11-week cervical pregnancy after a period of heavy bleeding. Fertil Steril 2003; 80:617–9.
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7. Nappi C, d’Elia A, Di Carlo C, Giordano E, De Placido G, Iaccarino V. Conservative treatment by angiographic uterine artery embolization of 12 week cervical ecotpic pregnancy. Hum Reprod 1999;14:1118–21. 8. Scott J, Diggory P, Edelman P. Management of cervical pregnancy with circumsuture and intracervical obturator. BMJ 1978;1:825. 9. Saygili Yilmaz ES, Aydin D, Ylmaz Z. Conservative treatment of cervical pregnancy by evacuation after transvaginal suture ligation of cervicovaginal branches of uterine arteries. Acta Obstet Gynecol Scand 2002;81:988–90.
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