Emergency surgical procedure for failed methotrexate treatment of cervical pregnancy: a case report

A Rare Case of Ectocervical Pregnancy and Its Successful Management: A Case Report and Review of the Literature

Cervical pregnancy is a very rare form of ectopic pregnancy, which can be life-threatening due to the potential risk of massive haemorrhage. The most likely site of cervical implantation is within the endocervical canal. We report here an unusual and another possible site of cervical pregnancy on the surface of the ectocervix (portio). The patient presented with vaginal bleeding after a period of six weeks of amenorrhea and a positive urinary pregnancy test. Clinical examination was suggestive of a cervical mass on the surface of the portio, which was successfully managed by local excision and the application of haemostatic sutures. Histopathology of the mass was suggestive of trophoblasts amidst cervical epithelium and stroma, which was cytokeratin positive in immunohistochemical staining, confirming the diagnosis of cervical ectopic pregnancy on the portio. Postoperatively, the patient recovered well and beta-human chorionic gonadotropin (βhCG) normalised within two weeks. Thus, the surface of the ectocervix is another possible site of cervical pregnancy, which can be successfully managed by total excision of the ectopic mass and local haemostatic measures.

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.

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.

Conservative management of cervical pregnancy with intramuscular administration of methotrexate and KCl injection: Case report and review of the literature

We report the case of a cervical pregnancy successfully treated with intramuscular injection of methotrexate (MTX) and intramniotic administration of potassium chloride. A 41-year-old woman was admitted to our Department with the suspicion of ectopic pregnancy. Transvaginal ultrasound revealed empty endometrial cavity, gestational sac within the cervical canal and embryonic echo measuring crown rump length 1.5 mm. Serum beta human chorionic gonadotropine (β-HCG) was measured 28590 IU/L. No cardiac activity was detected. The diagnosis of a cervical pregnancy was made. Patient was treated with intramuscular administration of methotrexate (50 mg/m²) in combination with ultrasound-guided intramniotic injection of KCl (2 meq/mL). Gradual decrease of β-HCG levels as well as ultrasound observation of collapsed gestational sac was observed. No curettage was necessitated. Patient was discharged on day 10^th and was set in follow-up on a weekly basis. β-HCG values were measured < 10 IU/L on 56^th day after MTX administration. Intramuscular administration of MTX may be effective in treatment of cervical pregnancy without additional interventional measures.

Theranostic applications: Non-ionizing cellular and molecular imaging through innovative nanosystems for early diagnosis and therapy

Modern medicine is expanding the possibilities of receiving "personalized" diagnosis and therapies, providing minimal invasiveness, technological solutions based on non-ionizing radiation, early detection of pathologies with the main objectives of being operator independent and with low cost to society. Our research activities aim to strongly contribute to these trends by improving the capabilities of current diagnostic imaging systems, which are of key importance in possibly providing both optimal diagnosis and therapies to patients. In medical diagnostics, cellular imaging aims to develop new methods and technologies for the detection of specific metabolic processes in living organisms, in order to accurately identify and discriminate normal from pathological tissues. In fact, most diseases have a "molecular basis" that detected through these new diagnostic methodologies can provide enormous benefits to medicine. Nowadays, this possibility is mainly related to the use of Positron Emission Tomography, with an exposure to ionizing radiation for patients and operators and with extremely high medical diagnostics costs. The future possible development of non-ionizing cellular imaging based on techniques such as Nuclear Magnetic Resonance or Ultrasound, would represent an important step towards modern and personalized therapies. During the last decade, the field of nanotechnology has made important progress and a wide range of organic and inorganic nanomaterials are now available with an incredible number of further combinations with other compounds for cellular targeting. The availability of these new advanced nanosystems allows new scenarios in diagnostic methodologies which are potentially capable of providing morphological and functional information together with metabolic and cellular indications.

Theranostic applications: Non-ionizing cellular and molecular imaging through innovative nanosystems for early diagnosis and therapy

Modern medicine is expanding the possibilities of receiving “personalized” diagnosis and therapies, providing minimal invasiveness, technological solutions based on non-ionizing radiation, early detection of pathologies with the main objectives of being operator independent and with low cost to society. Our research activities aim to strongly contribute to these trends by improving the capabilities of current diagnostic imaging systems, which are of key importance in possibly providing both optimal diagnosis and therapies to patients. In medical diagnostics, cellular imaging aims to develop new methods and technologies for the detection of specific metabolic processes in living organisms, in order to accurately identify and discriminate normal from pathological tissues. In fact, most diseases have a “molecular basis” that detected through these new diagnostic methodologies can provide enormous benefits to medicine. Nowadays, this possibility is mainly related to the use of Positron Emission Tomography, with an exposure to ionizing radiation for patients and operators and with extremely high medical diagnostics costs. The future possible development of non-ionizing cellular imaging based on techniques such as Nuclear Magnetic Resonance or Ultrasound, would represent an important step towards modern and personalized therapies. During the last decade, the field of nanotechnology has made important progress and a wide range of organic and inorganic nanomaterials are now available with an incredible number of further combinations with other compounds for cellular targeting. The availability of these new advanced nanosystems allows new scenarios in diagnostic methodologies which are potentially capable of providing morphological and functional information together with metabolic and cellular indications.

Cervical pregnancy: a case series and a review of current clinical practice

Five consecutive cases of cervical pregnancy (CP) are presented. In four cases, the diagnosis was made at routine check-ups and these were all treated conservatively. In the fifth case, an erroneous diagnosis of inevitable abortion was made, in a patient presenting with profuse vaginal bleeding. Persistent bleeding following curettage required an emergency hysterectomy, after failure of compressive methods. From the four cases treated conservatively, three received standard methotrexate i.m. (MTX) in combination with bilateral uterine artery embolization (UAE). In one case MTX was followed by intraamniotic puncture and instillation of KCl due to persistent embryonic heartbeat. 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. Possible detrimental effects of the treatment on subsequent reproductive capacities and obstetrical outcome are also pointed out. The diagnostic methods and therapeutic approaches are discussed and the literature is reviewed. With referral to the first case of our series, which required an emergency hysterectomy, we want to stress the importance of an early diagnosis for a correct management of this condition.

Exocervical pregnancy in a patient with intrauterine device: a case report

Cervical pregnancy (CP) is a rare and life-threatening ectopic pregnancy characterized by implantation of the fertilized ovum into the cervix, whereas exocervical pregnancy is an extremely rare CP with implantation of the fertilized ovum on the exocervix. Possible causative factors of CP such as tubal dysfunction, impaired sperm motility, previous uterine surgery, or the use of intrauterine device were not clearly associated with the development of CP until now. Diagnosis of CP is usually established by ultrasonography and by beta-human chorionic gonadotropin serum tests, but definitive diagnosis is by histologic examination. Current treatment strategies of CP, which were described in some reports, involve: medical treatment with methotrexate, surgical removal of ectopic trophoblastic tissues, cervical cerclage and vaginal packing, ligation of descending branches of uterine arteries or hypogastric arteries, and unilateral internal iliac artery embolization. We report a case of exocervical pregnancy contemporary to intrauterine device normally inserted, diagnosed by colposcopy, beta-human chorionic gonadotropin, and histology, and treated by a local excision without using methotrexate chemotherapy.