Second Trimester Cervical Ectopic Pregnancy and Hemorrhage: A Case Report and Review of the Literature

Cervical ectopic pregnancy - the first case of live birth and uterus-conserving management

A 37-old III gravida II para with two previous cesarean sections (CS) presented in 7 + 3 weeks of pregnancy with cervical ectopic pregnancy (CEP). At 12th week of pregnancy, a cerclage was performed to avoid cervical distention by the expanding placenta. Due to missing experience in CEP management and to avoid emergency operation, we recommended CS in 30th week of pregnancy due to unspecific pain of the patient. Vaginal bleeding never occured.After transverse laparotomy, the urinary bladder was sharply dissected from the anterior uterine and cervical wall. The baby was delivered by transverse cervicotomy caudally of the placenta. The placenta was left in situ. The patient then got prophylactic embolization of the uterine arteries to prevent further severe hemorrhage. 48 h later, ultrasound showed a floating, avascular placenta within a poor echogenic fluid-filled cervical space as well as macrohematuria. After re-laparotomy and cervicotomy at the same day, the placenta was completely and easily evacuated. A bladder injury was recognized and closed. We performed a cervical internal os plasty by inverting the cervical lips and suturing their distal ends on the proximal cervical tissue, resulting in complete bleeding cessation. Although, the patient got 8 erythrocyte concentrates at all, she was always in a stable condition without hemorrhagic shock.This case demonstrates for the first time a live-birth with uterus-conserving management in CEP.

Single-dose intramuscular methotrexate for treatment of cervical ectopic pregnancy: A case report

Introduction

Cervical ectopic pregnancy (CEP) is a rare but potentially life-threatening phenomenon, and conclusive management guidelines have not been elucidated. Patients undergoing assisted reproductive technologies (ART) are at increased risk of CEP and noninvasive, fertility-sparing treatments are necessary for this population. This case report demonstrates the safety and efficacy of a single dose of intramuscular methotrexate for CEP in early gestation.

Case Description

A 45-year-old patient (G3P0030) presenting with painless vaginal bleeding was found to have CEP on transvaginal ultrasound at 5 weeks and 1 day of gestation after undergoing day-5 frozen embryo transfer. She was given one 50 mg/m² dose of intramuscular methotrexate and she remained in a stable condition while being observed in the hospital. Her beta-hCG level decreased 38.2% between day 4 and day 7 after treatment and returned to nonpregnancy levels by day 28.

Discussion

A single dose of intramuscular methotrexate is an effective, noninvasive, fertility-sparing method of treatment for CEP in patients who are early in gestation and hemodynamically stable. This is a recommended option, especially for those undergoing fertility treatment. Further studies need to be performed to formulate national guidelines regarding the treatment of CEP.

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Cervical ectopic pregnancy (CEP) is rare and potentially life-threatening.

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Use of assisted reproductive technologies (ART) increases patients' risk of CEP.

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Most patients with CEP after the use of ART desire fertility-sparing treatment when possible.

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In the case described, single-dose methotrexate was used as a fertility-sparing treatment of CEP.