Multidose Methotrexate Treatment of Cervical Pregnancy

Clinical efficacy and safety analysis of different treatment options for Cervical pregnancy

OBJECTIVE

To compare the efficacy and safety of different treatment options for cervical pregnancy (CP).

MATERIALS AND METHODS

A total of 74 patients diagnosed with CP at Hunan Provincial Maternal and Child Health Care Hospital between January 2016 and September 2022 were retrospectively analyzed. Among them, 31 were treated with uterine artery embolization (UAE) followed by hysteroscopic curettage, 34 were treated with hysteroscopic curettage alone, and nine were treated with high-intensity focused ultrasound (HIFU) followed by hysteroscopic curettage. Medical records and pregnancy outcomes were analyzed.

RESULTS

There were no significant differences in age, gravidity, parity, abortion, or preoperative hemoglobin levels among the patients in the three groups; however, significant differences in gestational age, gestational sac diameter, preoperative β-hCG, and presence of cardiac pulsation were observed (p < 0.05). After treatment, there was no conversion to laparotomy, and the uterus was preserved in all patients. Significant differences in blood loss during curettage, hospitalization costs, hospital days, menstrual recovery interval, β-hCG decline rates, retained products of conception, and intrauterine adhesions rate among the three groups were observed (p < 0.05). There were no significant differences in the placement of the uterine Foley balloon, effective curettage rate, pre-and postoperative hemoglobin decline, live birth rate, or proportion of subsequent pregnancies among the three groups.

CONCLUSION

Our results showed that hysteroscopic curettage, HIFU, and UAE followed by hysteroscopic curettage are safe and effective for treating patients with CP. Compared with the UAE, HIFU has the advantages of lower hospitalization costs, shorter hospital stays, and shorter menstrual recovery intervals.

Experience of a Tertiary Service in the Treatment of Women with Cervical Pregnancy

OBJECTIVE

 Cervical pregnancy is challenging for the medical community, as it is potentially fatal. The treatment can be medical or surgical; however, there are no protocols that establish the best option for each case. The objective of the present study was to describe the cases of cervical pregnancy admitted to a tertiary university hospital over a period of 18 years.

METHODS

 A retrospective study based on a review of the medical records of all cervical pregnancies admitted to the Women's Hospital at Universidade Estadual de Campinas, Southeastern Brazil, from 2000 to 2018.

RESULTS

 We identified 13 cases of cervical pregnancy out of a total of 673 ectopic pregnancies; only 1 case was initially treated with surgery because of hemodynamic instability. Of the 12 cases treated conservatively, 7 were treated with single-dose intramuscular methotrexate, 1, with intravenous and intramuscular methotrexate, 1, with intravenous methotrexate, 1, with 2 doses of intramuscular methotrexate, and 2, with intra-amniotic methotrexate. Of these cases, one had a therapeutic failure that required a hysterectomy. Two women received blood transfusions. Four women required cervical tamponade with a Foley catheter balloon for hemostasis. There was no fatal outcome.

CONCLUSION

 Cervical pregnancy is a rare and challenging condition from diagnosis to treatment. Conservative treatment was the primary method of therapy used, with satisfactory results. In cases of increased bleeding, cervical curettage was the initial treatment, and it was associated with the use of a cervical balloon for hemostasis.

Effectiveness and safety of ultrasound-guided intramuscular lauromacrogol injection combined with hysteroscopy in cervical pregnancy treatment: A case report

BACKGROUND

Cervical pregnancy is increasing in morbidity, and a definite diagnosis in early stages is challenging due to its specific onset site. Surgery is the mainstay of treatment for cervical pregnancy, but it may result in the loss of natural fertility. Therefore, it is a great challenge to pursue a safe and effective treatment for cervical pregnancy.

CASE SUMMARY

We report the case of a cervical pregnancy successfully treated by ultrasound-guided cervical-intramuscular lauromacrogol injection combined with hysteroscopy. A 23-year-old woman with minor irregular vaginal bleeding was admitted to our department with suspected ectopic pregnancy. Transvaginal ultrasound revealed a gestational sac (approximately 22 mm x 13 mm) situated in the cervical canal with a yolk sac and blood flow signals. No cardiac activity was detected. Serum beta progesterone was 17.06 ng/mL, and serum beta human chorionic gonadotropin (β-HCG) was 5077.0 IU/L. The patient was diagnosed with cervical pregnancy. She was treated by ultrasound-guided cervical-intramuscular injections of lauromacrogol (3 mL) in combination with aborting under hysteroscopic visualization. A gradual decrease in β-HCG levels and normal ultrasound findings were observed. Postoperative pathologic examination showed the presence of villi and changes in the endometrium in the secretory phase. The patient was discharged on day 6, and her β-HCG level was 0.67 mIU/mL after 1 wk. There was no statistical difference between baseline and 1-week postoperative data in terms of serum indices including liver function, renal function, and routine blood analysis after treatment. The patient subsequently became pregnant 2 mo later and no abnormalities were detected on routine screening during pregnancy.

CONCLUSION

Ultrasound-guided cervical-intramuscular lauromacrogol injection combined with hysteroscopy may be effective and safe in the treatment of cervical pregnancy.

Conservative management of a viable cervical ectopic pregnancy with systemic and multiple local methotrexate injections. A case report

PURPOSE

Cervical ectopic pregnancy is rare and has serious haemodynamic implications, usually requiring a hysterectomy. However, the patient's haemodynamic profile and reproductive history may warrant medical management with methotrexate. We present a case report of a 33-year-old primigravida managed conservatively (patient insisted) for cervical ectopic pregnancy.

MATERIALS AND METHODS

A 10-weeks pregnant lady suffered from cervical pregnancy as confirmed by ultrasonography with initial β-HCG titre = 65,928 mIU/mL. She received a methotrexate IM-injection followed by multiple transabdominal-ultrasound-guided local doses. Serial sonography to monitor gestational sac size and β-HCG levels were done weekly.

RESULTS

β-HCG levels declined satisfactorily over 4 weeks: 19,166 mIU/mL, 6900 mIU/mL and 1104 mIU/mL on days 14, 21 and 28, respectively. She remained haemodynamically stable throughout admission. On day-35, β-hCG titre reached 400 mIU/mL, and products of conception seen on ultrasound (20 × 25 mm), that were later complicated by secondary infection, necessitated evacuation curettage. β-HCG titre was 2 mIU/mL by 48th day.

CONCLUSIONS

Live cervical ectopic pregnancy with high β-hCG titres can be conservatively managed with multidose methotrexate injection administered systemically and locally. However, the efficacy of the applied dose of 25 mg or using higher doses should be evaluated to avoid occurrence of residual lesion.

Use of haemostatic gel in the management of cervical pregnancy: a case report

PURPOSE

This case report aimed to describe haemostatic agents with systemic methotrexate (MTX) as an effective management for cervical pregnancy with bleeding.

CASE PRESENTATION

A 34-year-old nulligravida patient was referred due to vaginal spotting and lower abdominal discomfort, and was diagnosed with a cervical pregnancy at 6 weeks of gestation. The patient was treated with a multi-dose MTX regimen, and the bleeding was successfully controlled with haemostatic agents, which were applied at the bleeding site of the cervix. After completion of MTX treatment, beta human chorionic gonadotropin (β-hCG) decreased to undetectable range. Furthermore, patients could preserve her uterus and maintain fertility.

CONCLUSION

Haemostatic agents can be regarded as an effective option for vaginal bleeding due to cervical pregnancy.

Conservative management in a patient with cervical ectopic pregnancy in Nariño, Colombia: Case report and review of the literature

Objectives

To report a case of cervical pregnancy (CP) treated successfully with a conservative approach, and to conduct a review of the literature regarding conservative medical and surgical treatment.

Materials and methods

Patient with cervical pregnancy treated pharmacologically with methotrexate (MTX) followed by dilation and curettage, with a satisfactory clinical course. A search of articles was conducted in Medline via PubMed, LILACS, SciElo and Google Scholar using the terms "cervical ectopic pregnancy," "conservative treatment," "curettage,» "methotrexate," "uterine artery embolization," "hysteroscopy." Reports and case series were selected of patients with cervical pregnancy diagnosed on ultrasound at any gestational age, subjected to conservative medical or surgical treatment.

Results

A total of 22 studies were included; 95 patients with CP treated with MTX were identified, 93 of them successfully treated. The most frequent complication was bleeding in 12%; 26% required complementary surgical treatment. Increasingly, uterine artery embolization (UAE) is carried out preventatively (7 cases) before curettage or treatment with MTX. The hysteroscopy is another recent alternative (20 cases). Abdominal hysterectomy was required in two cases, one of which was a cervico-isthmic pregnancy.

Conclusions

Treatment with MTX continues to be the most frequent strategy. Dilation and curettage with endocervical plugging may be an option to consider in the emergency management of EP in primary care institutions. In institutions equipped with high complexity technology, uterine artery embolization before the surgical procedure and histeroscopy are options to be considered. Considering that early diagnosis of EP is now possible, multi-center studies comparing different management options are needed for better assessment of their safety and effectiveness.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review

BACKGROUND

Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

FINDINGS

Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

CONCLUSION

This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

Diagnostic and therapeutic dilemmas of cervical ectopic pregnancy

IMPORTANCE

Cervical pregnancy is a rare variety of ectopic pregnancy. The etiology is obscure. Its diagnosis may be difficult, and its management has enormously changed during the last 10 years. Unfortunately, the most effective, fertility-sparing treatment is still unclear until now.

OBJECTIVES

The aim of this study was to explore the safety and efficacy of different treatment modalities of cervical pregnancy.

EVIDENCE ACQUISITION

A comprehensive systematic review of the literature was performed using the electronic databases MEDLINE and PubMed, using key words cervical, ectopic, and pregnancy, between January 2005 and June 2013. We included all case reports and case series reporting on cervical ectopic pregnancy.

RESULTS

A total of 252 cases of cervical ectopic pregnancy were analyzed. Eighty-eight cases (34.9%) had medical treatment, 69 cases (27.5%) had surgical treatment, and 95 cases (37.6%) had combined medical and surgical treatment. Various conservative treatment regimens have been introduced to preserve fertility in young women, with methotrexate being one of the most widely used and effective drugs.

CONCLUSIONS AND RELEVANCE

A high index of suspicion, combined with meticulous review of clinical and radiological findings, is essential to make an accurate diagnosis of cervical pregnancy. The success of conservative treatment depends mainly on early diagnosis. Such cases would be best managed at specialist tertiary referral centers and preferably, where available, Early Pregnancy Assessment Units, whether medical, surgical, or combined treatment modalities were attempted.

Cervical pregnancy: a report of four cases

Various conservative treatments for cervical pregnancy have been reported. However, unlike tubal ectopic pregnancy, the treatment of cervical pregnancy has not been well established. For patients who desire fertility preservation, treatment with methotrexate chemotherapy carries a high success rate for preservation of the uterus. When methotrexate is injected i.v. or i.m., expulsion of pregnant tissue occasionally takes up to 1 month. In this report, we present four cases of cervical pregnancy which were successfully managed by methotrexate injection into the bilateral uterine arteries. In cases presenting with massive bleeding, embolization of the bilateral uterine arteries was performed. Cervical pregnancy was aborted within 8 days safely, and fertility could be preserved without harmful side-effects.

Cervical pregnancy with massive bleeding after treatment with methotrexate

This report describes a catastrophic bleeding following methotrexate treatment of cervical pregnancy and dramatic response to Bakri surgical obstetric silicone (SOS) balloon tamponade in controlling massive bleeding. A 42-year-old woman was diagnosed for cervical pregnancy with a viable fetus at 12 weeks by transvaginal ultrasound. Conservative treatment with intrafetal potassium chloride injection and systemic methotrexate were instituted. On the sixth day of therapy, catastrophic bleeding lead to hypovolemic shock. After resuscitation and blood transfusion, we attempt to control the bleeding with evacuation and curettage but was unsuccessful. Bakri SOS balloon tamponade was applied with immediate and effective response. Nevertheless, total abdominal hysterectomy was performed. In conclusion, conservative treatment of cervical pregnancy with systemic methotrexate could be catastrophic in some patients. Control of active bleeding with Bakri SOS balloon tamponade may possibly be helpful in case of uncontrolled bleeding in selected cases.

A pragmatic and evidence-based management of ectopic pregnancy

The incidence of ectopic pregnancy is approximately 2% of all pregnancies, and it remains the leading cause of death in early pregnancy. Over 95% of ectopic pregnancies are tubal pregnancies, and the remainders are nontubal pregnancies. The highest risk factor for ectopic pregnancy is a previous tubal pregnancy followed by previous tubal surgery, tubal sterilization, tubal pathology, and current intrauterine device use. The apparent increase in the incidence of nontubal ectopic pregnancy including heterotopic pregnancy may be attributed to the increasing number of pregnancies because of in vitro fertilization treatment. In most cases, an ectopic pregnancy can be treated medically with a single dose of methotrexate. Surgical treatment is still needed in women who are hemodynamically unstable and in those who do not fulfill the criteria for methotrexate treatment. Usually surgical treatment can be performed by laparoscopy and in some cases by hysteroscopy. Laparotomy is rarely needed even in women with intraperitoneal bleeding.