Angiographic uterine artery embolization followed by immediate curettage: An efficient treatment for controlling heavy bleeding and avoiding recurrent bleeding in cervical pregnancy

Neo-adjuvant methotrexate to aid minimally invasive surgery in cervical ectopic pregnancy: A case report

Cervical ectopic pregnancies account for <1% of ectopic pregnancies. Early diagnosis may reduce the morbidity and mortality associated with treatment. A 43-year-old woman, gravida 4 para 2, presented at 5 + 6 weeks of gestation of pregnancy via in vitro fertilisation with painless vaginal bleeding. Her initial serum β-hCG level was 51,495 mIU/mL. Ultrasound showed a live ectopic pregnancy within the upper cervical canal with no sliding sign. Surgery was avoided initially due to risk of haemorrhage. Multi-dose systemic intramuscular methotrexate was used in an alternate-day regimen with rescue folic acid to arrest further pregnancy development. Repeat ultrasound seven days later showed absent cardiac activity. Serum β-hCG remained high at 91,764 mIU/mL. A suction dilatation and curettage was performed to remove the pregnancy from the cervix, with an estimated blood loss of 50 mL. The patient was discharged and her serum β-hCG declined to an undetectable level over three months of follow-up. This case adds to the small body of evidence in the management of live cervical ectopic pregnancy. Neo-adjuvant multi-dose methotrexate was successfully used to reduce the risk of haemorrhage associated with surgical management.

An Efficient Conservative Treatment Option for Cervical Pregnancy: Transcatheter Intra-Arterial Methotrexate Infusion Combined with Uterine Artery Embolization Followed by Curettage

BACKGROUND The aim of this study was to assess the clinical outcomes of conservative treatments for cervical ectopic pregnancy (CEP). MATERIAL AND METHODS The series of CEP cases at our hospital between 2009 and 2016 were reviewed retrospectively. The patients were treated using systemic methotrexate infusion (MTX group, n=9), angiographic uterine artery embolization (UAE group, n=11), or transcatheter intra-artery methotrexate infusion combined with UAE (UAE+MTX group, n=13). Clinical outcomes, complications, and fertility were evaluated. RESULTS The median serum β-hCG was 6449 mIU/mL for MTX group, 17384 mIU/mL for UAE group, and 21361 mIU/mL for UAE+MTX group. The difference was statistically significant. In the MTX group, 1 patient developed hepatotoxicity and 2 patients occurred continuous vaginal bleeding during curettage. These 3 patients were successfully treated with emergency UAE. In the UAE group, 2 patients had vaginal re-bleeding on postoperative day 17 and 26, respectively, and received a second UAE procedure. In the UAE+MTX group, no patients developed severe complications. Moreover, a quick regression of serum β-hCG level, shortened recovery of normal menstruation, rapid cervical mass elimination, and a short hospital stay were observed in patients of the UAE+MTX group. CONCLUSIONS The triple therapy of transcatheter intra-arterial methotrexate infusion combined with UAE followed by immediate curettage is feasible and advantageous in treating CEP.

Successful conservative treatment of cervical pregnancy with uterine artery embolization followed by curettage: a report of 19 cases

OBJECTIVE

The purpose of this retrospective study was to evaluate the safety and efficacy of uterine artery embolization (UAE) followed by curettage for conservative management of cervical pregnancy.

DESIGN

Retrospective review.

SETTING

Peking University First Hospital.

SAMPLE

Patients with cervical pregnancy diagnosed by trans-vaginal ultrasound at Peking University First Hospital between January 2003 and December 2014.

METHODS

We retrospectively reviewed the clinical background and outcomes of patients with cervical pregnancy who underwent UAE followed by curettage for prevention of massive vaginal bleeding and removal of gestational tissue from the cervix. We also reviewed the literature on the role of UAE in the treatment of cervical pregnancy.

MAIN OUTCOME MEASURES

Clinical assessments included gestational age, gravidity, endocervical canal mass, serum beta-human chorionic gonadotrophin (β-HCG) level, blood loss, hospitalisation stay and expenses, time of resumption of menstruation and subsequent pregnancy outcomes.

RESULTS

A total of 19 patients with cervical pregnancy treated with UAE followed by curettage were identified. Curettage was performed 24-72 hours after UAE in 16 patients, within 24 hours after UAE in three patients. None of the patients underwent a hysterectomy as a result of cervical pregnancy. Of the nine patients with available follow-up information (median follow-up time 59 months), eight resumed normal menstruation and one had a term pregnancy with a normal vaginal delivery. Quick regression of serum β-HCG level, low blood loss and short hospital stay were observed.

CONCLUSION

UAE combined with curettage is a safe, effective and fertility-sparing choice for treatment of patients with cervical pregnancy.

TWEETABLE ABSTRACT

A serial of 19 patients with cervical pregnancy treated with UAE followed by curettage showed a good prognosis.

Evidence-based management of non-tubal ectopic pregnancies

Recent advances in ultrasonography and the use of other modalities including magnetic resonance imaging scans have led to the early and more accurate diagnosis of non-tubal ectopic pregnancies (NTE). As a result, the management of these pregnancies has evolved. This article addresses the management options currently available for NTE. While surgical management remains the mainstay of treatment for ovarian, abdominal and cornual ectopics, there is growing evidence that some of these can be managed medically. Many authors have utilised a combination of medical and surgical approaches in the management of cervical and caesarean section (CS) scar ectopic pregnancies with good outcome. The availability of dedicated early pregnancy units has further improved diagnosis and more importantly the follow-up care for these patients. The rarity of cases and the difficulty of ethically organising randomised trials for NTE remain a problem in formulating consistent pathways for optimum management of women with NTE.

Efficacy comparison of transcatheter arterial embolization with gelatin sponge and polyvinyl alcohol particles for the management of cesarean scar pregnancy and follow-up study

AIM

The aim of this study was to compare the therapeutic efficacy of transcatheter arterial embolization (TAE) with gelatin sponge (GS) and polyvinyl alcohol (PVA) particles for cesarean scar pregnancy (CSP).

METHODS

A total of 35 patients with CSP, who were classified into either the GS group (n = 22) or the PVA group (n = 13), underwent TAE and postoperative ultrasound-guided curettage. Their hospital stay, first-scheme success rate, intra-curettage blood loss, serum β-human chorionic gonadotropin (hCG) level, and other indicators were simultaneously recorded. During the follow-up period, time for the serum β-hCG level to return to normal, time for the return of menstrual cycle, and menstrual blood volume were recorded.

RESULTS

Compared with the GS group, patients in the PVA group: (i) were older; (ii) had greater number of abortions or curettages, and had longer times since last cesarean (P < 0.05); (iii) had similar hospital stay and first-scheme success rate (P > 0.05); (iv) had lower, but not significantly different, hemorrhage rate (7.7% vs 36.4%, P = 0.066); (v) had a significantly higher serum β-hCG level at discharge and a smaller drop in serum β-hCG level from admission to discharge (P < 0.05); (vi) had a similar time for the serum β-hCG level to return to normal (P > 0.05); (vii) had a shorter time for the return of menstrual cycle (P = 0.012); and (viii) had a significantly higher incidence of abnormal menstrual blood volume reduction (50.0% vs 8.3%, P = 0.034).

CONCLUSION

TAE with either GS or PVA particles for CSP treatment had relatively good efficacy. During the selection of the ideal embolic agent, the patient's age, hemorrhage risk, and requirement for protecting ovarian function and reserving fertility should be comprehensively considered.

Uterine artery embolization for cervical ectopic pregnancy

A 36-year-old woman with 3 prior C-sections is diagnosed with a caesarean scar ectopic pregnancy. Despite receiving intramuscular and transvaginal methotrexate injection 2 months before presentation, the beta human chorionic gonadotropin was recorded to be 73 mIU/mL at the time of encounter. The patient complained of vaginal bleeding with a significant drop in hematocrit from 40% to 33%. Transvaginal ultrasound confirmed retroplacental hemorrhage and because of the patient's desire to retain fertility, interventional radiology was consulted to perform an uterine artery embolization. The uterine artery embolization was successful in achieving hemostasis and resulted in a decrease of betaHCG to 46 on postprocedure day 1 to <1 mIU/mL by postoperative week 3.

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 embryonic heart activity by ultrasound-guided local injection: an eight case series

OBJECTIVE

To evaluate the efficacy of conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection.

METHODS

Retrospective case series at University tertiary care Hospital. Eight patients diagnosed with cervical pregnancy with embryonic heart activity managed conservatively. The intervention was ultrasound-guided local injection of methotrexate (1 mg/kg) and potassium chloride (2 meq/mL). Measurements were occurrence of morbidity, necessity for further intervention, the initial titers of beta-hCG, interval of time in which the levels of beta-hCG became negative, period for regression of cervical pregnancy at ultrasound and future pregnancy.

RESULTS

All patients were treated successfully. The initial levels of beta-hCG ranged from 3013 to 71199 mUI/mL. One case evaluated with infection. There was no need for additional intervention in our series study. The interval of time for the levels of beta-hCG becomes negative range from 2 to 12 weeks. The period for the regression of the cervical pregnancy at ultrasound range from 3 to 14 weeks. In two cases intrauterine pregnancies occurred after the treatment.

CONCLUSION

Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided injection is an effective treatment avoiding the need of further intervention.

Conservative management of cervical ectopic pregnancy: systemic methotrexate followed by curettage

INTRODUCTION

Cervical ectopic pregnancy is among the rarest clinical conditions happening in women of reproductive age. Yet its management can cause a high rate of morbidity. Therefore, conservative treatment of this condition is a matter of debate.

MATERIAL AND METHODS

Hereby we present two cases of cervical ectopic pregnancies that were managed successfully with a conservative approach.

CONCLUSION

Cervical ectopic pregnancy can be managed successfully with systemic Metotroxsate followed by curettage.

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.

An efficient conservative treatment modality for cervical pregnancy: angiographic uterine artery embolization followed by immediate curettage

OBJECTIVE

We sought to evaluate a conservative treatment modality, angiographic uterine artery embolization (UAE) followed by immediate curettage, in the treatment of cervical pregnancy.

STUDY DESIGN

Sixteen patients with cervical pregnancy were first treated by UAE to control or prevent vaginal bleeding. Curettage of cervical canal was performed immediately after UAE to remove gestational tissue from the cervix. Clinical outcome assessments include vaginal bleeding, serum β-human chorionic gonadotropin level, cervical mass, menstruation, fertility, and hospitalization time.

RESULTS

Fifteen patients were successfully treated by UAE followed by immediate curettage. One patient at very early gestational age underwent UAE only. Quick regression of serum human chorionic gonadotropin level and cervical mass, fertility preservation, and a short hospital stay were observed.

CONCLUSION

UAE followed by immediate curettage is an efficient conservative treatment for cervical pregnancy. This procedure may become a useful alternative to other conservative approaches.

Uterine artery embolization along with the administration of methotrexate for cervical ectopic pregnancy: technical and clinical outcomes

OBJECTIVE

The objective of our study was to evaluate the technical and clinical outcomes of uterine artery embolization (UAE) along with the administration of methotrexate (MTX) for cervical ectopic pregnancy with vaginal bleeding as an alternative nonsurgical treatment to control bleeding and preserve fertility.

MATERIALS AND METHODS

Eight patients (age range, 24-37 years; mean age, 30.1 years) with cervical ectopic pregnancy were treated with UAE using gelatin sponge particles to control vaginal bleeding. In seven patients, the administration of MTX was performed before, after, or before and after UAE. The follow-up periods after UAE ranged from 4 to 46 months (median, 8 months). We evaluated the UAE technique, clinical outcomes, complications, and fertility.

RESULTS

In all patients, UAE could control active vaginal bleeding on gynecologic examination. In six patients, the cervical ectopic pregnancy was dramatically resolved. In the other two patients presenting with both fetal heartbeat before UAE and persistent high HCG levels, active vaginal rebleeding was observed. The rebleeding was successfully controlled by a second UAE procedure. No major complication related to UAE was detected. The uterus could be preserved in all patients. In seven patients, normal menses resumed within 2 months after UAE. In only one patient, amenorrhea continued 8 months after UAE. In all three patients who could be followed for 2 years or more, three had subsequent successful natural pregnancies, and two patients had live births.

CONCLUSION

UAE along with the administration of MTX is effective in treating cervical ectopic pregnancy with vaginal bleeding while allowing the preservation of fertility.