Uterine artery embolization along with the administration of methotrexate for cervical ectopic pregnancy: technical and clinical outcomes. AJR Am J Roentgenol. 2009;192:1601-1607. [PMID: 19457824 DOI: 10.2214/ajr.08.1921]

Local Methotrexate Plus Uterine Artery Embolization for High-Risk Interstitial Ectopic Pregnancy

Interstitial ectopic pregnancy involves the interstitial portion of the fallopian tube and is among the most hazardous of all ectopic pregnancies, with the highest risk of uterine rupture and maternal mortality. Unlike tubal ectopic pregnancy, management of interstitial pregnancy is not well standardized. Systemic methotrexate (MTX) and surgical resection are the primary treatment options; however, failure rates and risk of bleeding remain high. Alternative minimally invasive techniques have been described-including uterine artery embolization (UAE) and local injection of MTX or potassium chloride-and may confer improved success rates. We report a case of a high-risk 28-year-old female with an interstitial ectopic pregnancy successfully treated with combined local injection of MTX plus UAE. We describe our technique and the unique medical management in the setting of a known bleeding disorder.

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.

Uterin artery embolisation: a rescuer in cervical ectopic pregnancy

Cervical ectopic pregnancy is an extremely rare form of ectopic pregnancy with potential risk of massive bleeding and associated morbidity. Managing this condition is challenging for clinicians due to the serious risk to patient and dilemma faced in deciding the appropriate management plan. This case report describes the role of uterine artery embolisation in managing a case of cervical ectopic pregnancy with heavy bleeding per vaginum post methotrexate treatment with falling beta human chorionic gonadotropin (HCG) levels. It highlights the unpredictable nature of this condition and need for prompt intervention in an emergency situation.

Endovascular uterine artery interventions

Percutaneous vascular embolization plays an important role in the management of various gynecologic and obstetric abnormalities. Transcatheter embolization is a minimally invasive alternative procedure to surgery with reduced morbidity and mortality, and preserves the patient's future fertility potential. The clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as fibroid, adenomyosis, and arteriovenous malformations (AVMs), as well as intractable bleeding due to inoperable advanced-stage malignancies. The most well-known and well-studied indication is uterine fibroid embolization. Uterine artery embolization (UAE) may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage (PPH), placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury. This article discusses these gynecologic and obstetric indications for transcatheter embolization and reviews procedural techniques and outcomes.

Identifying the deceiver: the non-neoplastic mimickers of genital system neoplasms

Tumors of the genital system are common and imaging is of crucial importance for their detection and diagnosis. Several non-neoplastic diseases may mimic these tumors and differential diagnosis may be difficult in certain cases. Misdiagnosing non-neoplastic diseases as tumor may prompt unnecessary medical treatment or surgical interventions. In this article, we aimed to present the imaging characteristics of non-neoplastic diseases of the male and female genital systems that may mimic neoplastic processes. Increasing awareness of the imaging specialists to these entities may have a severe positive impact on the management of these patients.

Ectopic Cervical Pregnancy: Treatment Route

Background and objectives: Cervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) in which the embryo implants and grows inside the endocervical canal. Early diagnosis is essential in order to allow conservative medical and surgical treatments. Although many treatment approaches are disponible, the most effective is still unclear. The aim of this study is to evaluate the efficacy of hysteroscopic management in early CP in order to preserve future fertility. Materials and Methods: This is a retrospective observational case series. Five patients with a diagnosis of CP, hemodynamically stables and managed conservatively between 2014 and 2019 at the Institute of Child and Maternal Health Burlo Garofolo in Trieste, Italy, were included. Four patients, with βhCG levels > 5000 mUi/mL were managed by hysteroscopy, with or without a previous systemic Methotrexate (MTX). One case with βhCG levels < 5000 mUi/mL was treated using MTX combined to Mifepristone and Misoprostol. Results: In one patient treated by hysteroscopy alone it occurred a profuse vaginal bleeding with necessity for blood transfusion. Haemorrhage was controlled by a second hysteroscopic procedure. No complications, such as vaginal bleeding, were recorded in the other cases. Serum β-hCG levels become undetectable in a range of 15–40 days after hysteroscopic management; after medical treatment it become undetectable after 35 days. Serum βhCG levels had a faster drop the day after hysteroscopy than post medical management. The onset of a spontaneous pregnancy at the normal implantation site occurred after five months in one case treated by hysteroscopy. Conclusions: Many therapeutic approaches are effective for CP treatment. Hysteroscopy, alone or in combination with MTX, may provide a greater effect on the descent of βhCG, leading to a reduction of the hospitalization stay, decreasing costs and period for attempt pregnancy. Further prospective studies on larger samples are needed to define therapeutic protocols for CP management.

Uterine Artery Embolization and Methotrexate Infusion as Sole Management for Caesarean Scar and Cervical Ectopic Pregnancies: A Single-Center Experience and Literature Review

Introduction

The incidence of caesarean scar pregnancy (CSP) and cervical pregnancy (CP) has increased significantly in recent years. The related hemorrhage can be lethal and often needs hysterectomy. This study aims to assess the technical and clinical results of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for CSP and CP.

Methods

A retrospective study was conducted for 11 patients (age range from 25–40 years, mean; 31.8 y) with CSP (7/11) and CP (4/11). The diagnosis was confirmed by elevated b-hCG levels (mean 31.245 mIU/mL) with sonography and/or magnetic resonance imaging. They were treated with UAE using particulate embolic material. In all patients, the infusion of MTX (50 mg/m2) was performed before UAE. Follow-up periods after UAE ranged between 6-24 months included weekly sonography and b-hCG level assessment. A literature review was performed using standard online search tools.

Results

In 10 patients, UAE controlled active vaginal bleeding and reduced post-procedural b-hCG levels significantly by the second week. One patient presented with persistent elevated b-hCG level and vaginal rebleeding. The rebleeding was successfully controlled by second UAE procedure. The ectopic pregnancies were resolved, and the uterus was preserved in all patients. No major complications were detected. Normal menses resumed within 2 months after UAE. Two patients had subsequent natural successful intrauterine pregnancies.

Conclusion

UAE combined with intra-arterial MTX infusion resulted in resolution of ectopic pregnancies with control of hemorrhage and without hysterectomy in this small group of patients.

Analysis on clinical effects of dilation and curettage guided by ultrasonography versus hysteroscopy after uterine artery embolization in the treatment of cesarean scar pregnancy

Purpose

The purpose of this study was to investigate the efficiency, complications, and subsequent fertility outcomes of two methods in treating patients with cesarean scar pregnancy (CSP) after receiving uterine artery embolization (UAE) treatment.

Patients and methods

A total of 62 CSP patients who visited our hospital and underwent UAE from January 2013 to January 2018 were retrospectively analyzed. Patients were either treated by dilation and curettage (D&C) guided by ultrasonography or hysteroscopy. The differences of related clinical indicators, clinical efficacy, complications, and subsequent fertility outcomes between the two groups were analyzed.

Results

The rates of therapeutic success of the ultrasonography group and hysteroscopy group were 84.6% and 95.7%, respectively, the difference was not statistically significant (P=0.243). However, the intraoperative blood loss, duration of hospitalization, and overall complications were significantly lower in hysteroscopy group compared with D&C guided by ultrasonography group (P<0.05 for all). Meanwhile, hysteroscopy had the advantage of discovering potential diverticulum in the lower segment of anterior wall of uterus (P<0.001).

Conclusion

D&C guided by ultrasonography or hysteroscopy for the treatment of CSP after UAE resulted in similarly good clinical outcomes. Compared with treatment of D&C guided by ultrasonography, hysteroscopy had less complications and had the advantages of discovering diverticulum. It can be used as an effective way for the treatment of CSP.

Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study

BACKGROUND

To investigate the use of uterine artery embolization (UAE) to manage ectopic pregnancies that are refractory to systemic methotrexate (MTX) therapy and plagued by persistently high serum β-human chorionic gonadotrophin (hCG) levels and vaginal bleeding. The safety and efficacy of UAE were addressed.

MATERIALS AND METHODS

A retrospective review was conducted for thirteen patients (mean age 35.2 years; range 28-41 years), who were treated between December 2006 and June 2016. Each was subjected to UAE due to persistently high serum β-hCG levels and vaginal bleeding after systemic MTX therapy for ectopic pregnancy. Embolic agents used were non-spherical polyvinyl alcohol or gelatin sponge particles. Post-treatment follow-up was performed by monitoring for clinical signs of vaginal bleeding, serum β-hCG testing, and transvaginal US. Outcomes were technical success, clinical success, and complications.

RESULTS

Median follow-up period was 172.5 days (range 30-600 days). Technical success was achieved in all 13 patients (100%). In 10 patients, vaginal bleeding resolved after one UAE attempt (clinical success 76.0%). Rebleeding in other three (23.1%) was controlled through repeat UAE. Seven patients (53.8%) had additional dilatation and curettage to remove gestational sac remnants. All ectopic pregnancies were successfully treated by UAE, with normalization of serum β-hCG levels during follow-up monitoring (P = 0.01). Uterine preservation was achieved in all 13 patients, without major procedural complications.

CONCLUSION

UAE appears safe and effective as treatment of ectopic pregnancies marked by persistently high serum β-hCG levels and vaginal bleeding after systemic MTX treatment.

Incorporating uterine artery embolization in the treatment of cesarean scar pregnancy following diagnostic ultrasonography

OBJECTIVE

To evaluate combining uterine artery embolization (UAE) with other treatments for cesarean scar pregnancy (CSP).

METHODS

A retrospective study included patients attending the First affiliated Hospital of Xi'an Jiaotong University, China, between March 1, 2009 and March 31, 2014, who were diagnosed with CSP. Patients were classified by ultrasonography as having endogenous CSP (CSP type I [CSP-I]) or exogenous CSP (CSP type II [CSP-II]). Patient outcomes were compared between patients who underwent treatment that included or excluded UAE. Patient records were reviewed and patients were interviewed by telephone to report on recovery following treatment.

RESULTS

In total, 52 patients met the inclusion criteria. In patients with CSP-I, the blood loss, length of hospital stay, and time before restoration of normal β human chorionic gonadotropin levels were significantly higher in patients who were treated with methotrexate combined with dilatation and curettage compared with those treated with UAE combined with dilatation and curettage (P<0.05). In patients with CSP-II, blood loss was lower in patients treated with UAE combined with excision compared with excision alone (P<0.001).

CONCLUSION

Incorporating UAE in the treatment of CSP-I and CSP-II was safe; CSP should be properly classified to select the appropriate treatment.

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.

Laparoscopic uterine artery occlusion before cervical curettage in cervical ectopic pregnancy: Safe and effective for preventing massive bleeding

Cervical ectopic pregnancy is associated with high risk for massive bleeding conditions. Cervical ectopic pregnancy can usually be treated by methotrexate injection or surgery. We present 4 cases of cervical ectopic pregnancy that were treated successfully with different uterine-conserving methods. By comparing our experience of 4 cases managed in different ways, we found that laparoscopic uterine artery occlusion before cervical curettage is more effective method for preventing massive bleeding.

Pelvic arterial embolization in obstetric hemorrhage

AIM: To analyze safety and efficacy of pelvic arterial embolization (PAE) in preventing and treating obstetrical hemorrhage.

METHODS: A consecutive study of eight cases undergoing pelvic artery embolization from January 2010 to October 2012 in Department of Obstetric and Gynecology of Maulana Azad Medical College for intractable obstetric hemorrhage was done. All embolization were carried out in cath lab of cardiology Department at associated GB Pant Hospital.

RESULTS: Clinical success was defined as arrest of bleeding after PAE without need for repeat PAE or additional surgery which was 75% in our series. PAE was successful in controlling obstetrical hemorrhage in all except one who had mortality. Other had hysterectomy due to secondary hemorrhage. Five resumed menstruation. None of the women intended to conceive, hence are practicing contraception.

CONCLUSION: PAE is minimally invasive procedure which should be offered early for hemostasis in intractable obstetrical haemorrhage unresponsive to uterotonic. It is a fertility sparing option with minor complications.

Invasive ultrasound in the management of cervical ectopic pregnancy

Invasive ultrasound management of a 6-week live cervical pregnancy in a 26-year old primipara is described. The patient was given methotrexate three times at seven-day intervals with no effect. Then 15% KCl was administered intra-amniotically via the transvaginal and transcervical route under ultrasound guidance. The procedure was successful, causing fetal death and loss of trophoblastic blood flow on Doppler examination. Over the subsequent four weeks, there was a steady decrease of serum β-hCG concentration. After four weeks, curettage of the cervical canal and uterine cavity was performed successfully. This method of treatment enabled avoidance of invasive surgical procedures, which might have limited future fertility.

Beyond hemostasis: spectrum of gynecologic and obstetric indications for transcatheter embolization

Percutaneous vascular embolization is a useful therapeutic option for a wide range of gynecologic and obstetric abnormalities. Transcatheter embolization procedures performed with the use of radiologic imaging for guidance are minimally invasive and may obviate surgery, thereby decreasing morbidity and mortality and safeguarding the patient's future fertility potential. To integrate this treatment method optimally into patient care, knowledge is needed about the clinical indications for therapeutic embolization, the relevant vascular anatomy, technical considerations of the procedure, and the potential risks and benefits of embolization. The most well-known and well-studied transcatheter embolization technique for treating a gynecologic-obstetric condition is uterine fibroid embolization. However, the clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as adenomyosis and arteriovenous malformations, as well as intractable bleeding due to inoperable advanced-stage malignancies. Uterine artery embolization may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage, placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury, and ovarian vein embolization has been shown to be effective for the management of pelvic congestion syndrome. The article discusses these and other gynecologic and obstetric indications for transcatheter embolization, provides detailed descriptions of imaging findings before and after embolization, and reviews procedural techniques and outcomes.

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.

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.

Intramural pregnancy presenting in a patient with tuberous sclerosis

Intramural pregnancies are a rare form of ectopic pregnancy located within the myometrium separate from the endometrial cavity. In an effort to prevent potential complications, diagnosis should be made early when more conservative approaches can be performed to preserve reproductive potential. The diagnosis of ectopic pregnancies can be successfully accomplished through sonography; however, intramural pregnancies may be difficult to diagnose as they can appear similar to other etiologies. We present a unique case of a ruptured intramural pregnancy diagnosed with sonography and pelvic MRI in a patient with tuberous sclerosis. Surgical enucleation of the intramural pregnancy was successfully performed with postoperative resolution of beta hCG levels.

The role of interventional radiology in obstetric hemorrhage

Obstetric hemorrhage remains a major cause of maternal morbidity and mortality worldwide. Traditionally, in cases of obstetric hemorrhage refractory to conservative treatment, obstetricians have resorted to major surgery with the associated risks of general anesthesia, laparotomy, and, in the case of hysterectomy, loss of fertility. Over the past two decades, the role of pelvic arterial embolization has evolved from a novel treatment option to playing a key role in the management of obstetric hemorrhage. To date, interventional radiology offers a minimally invasive, fertility-preserving alternative to conventional surgical treatment. We review current literature regarding the role of interventional radiology in postpartum hemorrhage, abnormal placentation, abortion, and cervical ectopic pregnancy. We discuss techniques, success rates, and complications.