Cervical ectopic pregnancy: medical conservative management

Amaç

Cervical pregnancy is a very rare form of ectopic pregnancy. There are various treatment modalities, however the experience is limited to suggest any firm criteria. Here we present a case successfully managed with multidose methotrexate.

Bulgular

A 38-year-old woman, gravida 2 para 1 (one cesarean section) admitted to our clinic with amenorrhea and positive urinary pregnancy test. Her menstrual periods were regular before. She and her husband have been using withdrawal as contraceptive method. According to her last menstrual period, her gestational age was calculated to be 5 weeks. Transvaginal ultrasound revealed empty uterus with thickened endometrium and cervical ectopic pregnancy below the level of internal os. Embryonic crown-rump length (CRL) of 11 mm (7 weeks 2 days) with cardiac activity was seen. She was hemodynamically stable and did not have any complaints. She had history of one cesarean section and appendectomy. Quantitative b-hCG level was 59.524 mIU/mL on admission. She was admitted to hospital for observation and intramuscular (IM) multidose methotrexate (MTX) treatment. Hemogram demonstrated a hemoglobin level of 12.5 mg/dl without leukopenia or thrombocytopenia. Liver function tests, blood urea nitrogen and serum creatinine levels were all between normal ranges. Four units of packed red blood cells were cross-matched. Multidose MTX treatment (1 mg/kg) on days 1, 3, 5, 7 alternating with leukovorin (0.1 mg/kg) was started. Four days after completion of MTX treatment, there was no fetal cardiac activity on sonogram. She did not experience any massive bleeding, her laboratory tests were in normal range during this time and she was discharged with the plan of weekly serial sonogram and quantitative b-hCG level monitorization. During the follow up, b-hCG level decreased below 5 mIU/mL 67 days after beginning of the multidose MTX treatment. She did not have any complaints besides minimal vaginal spotting and sonogram became normal 81 days after.

Sonuç

Cervical ectopic pregnancy is a rare and dangerous condition. It comprises less than 1% of all ectopic pregnancies with an estimated incidence of 1 in 9000 deliveries. The condition by itself or medical and surgical interventions are associated with massive hemorrhage that could lead to significant morbidity and mortality. Risk factors thought to be associated with cervical ectopic pregnancy are pregnancies conceived thorough assisted reproductive technologies, previous uterine curettage and cesarean delivery. However, the pathophysiology and causes remain to be elucidated. The most common symptom of cervical pregnancy is vaginal bleeding (often painless). The pathologic, clinical and sonographic criteria for diagnosis of cervical pregnancy have been established. However, the diagnosis is more frequently made incidentally by first trimester sonogram or interventions for cases considered to be abortions. Since the experience is limited to case series, treatment of cervical pregnancy has not been clarified. There are wide variety of treatment modalities with different outcomes and complications. In terms of conservative treatment to be effective, early diagnosis is important. In their review; Hosni et al. (2014) stated, other than hemodynamic instability; serum b-hcg level above 10.000 mIU/mL, gestational age more than 9 weeks, presence of fetal heart beat and CRL greater than 10 mm as poor prognostic factors for primary methotrexate treatment. However, those criteria have not been established as those for tubal ectopic pregnancies. We are in the opinion that, patients’ compliance on the therapy is one of the most important aspects regarding conservative treatment options. High morbidity rates associated with surgical treatment modalities should be kept in mind. It was demonstrated that the rates of major hemorrhage and hysterectomy were 11 and 3% in the medically treated patients, respectively. The rate of major hemorrhage was 35% and of hysterectomy was 15% in the surgical treatment group. Methotrexate (MTX) treatment for cervical pregnancy was first reported by Farabow et al. (1983). For early cervical pregnancies without fetal cardiac activity, intramuscular multidose MTX is reported to be effective in most cases. On the other hand, there are reports which recommend intramuscular MTX (single dose or multidose) in conjunction with intraamniotic or intrafetal injection of potassium chloride (KCl) for more advanced cervical ectopic pregnancies with fetal cardiac activity. Whether combination of two conservative methods do increase effectiveness of treatment or hastens recovery has not been proven by randomized studies. Besides, intraamniotic injection of MTX or KCl carries risk of hemorrhage during the procedure. Our case has the risk factors that could lead failure of exclusive MTX treatment like gestational age, fetal cardiac activity, and high b-hCG level. Despite those conditions, option of medical conservative treatment was offered to our patient. Eventually, we avoided serious complications associated with surgical interventions and successfully managed the case. Considering the lack of established criteria and randomized studies, our experience could contribute to the literature in the context of avoiding complications associated with further interventions. We are in the opinion that there is need for further studies to delineate the conditions, indications and factors associated with failure of various treatment modalities.

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