Sonographic evolution of a living cervical pregnancy treated with intraamniotic instillation of methotrexate

Successful management of a consecutive cervical pregnancy by sonographically guided transvaginal local injection: case report and review of the literature

OBJECTIVE

The purpose of this study was to describe the successful management of a recurrent cervical pregnancy with local injection and to review similarly treated cases to determine adverse outcomes.

METHODS

A case of a recurrent cervical pregnancy treated with transvaginal local injection was reported. A MEDLINE English language search identified 90 cases of cervical pregnancy treated with local therapy. This literature was analyzed with regard to the various demographic and outcome variables described.

RESULTS

Successful use of the transvaginal local approach is described. A review of cases identified a mean maternal age of 33.6 years with a mean gestational age at diagnosis of 7.5 weeks. Bleeding was the most common presenting sign (79%). The mean beta-human chorionic gonadotropin level at the time of diagnosis was 27,798 IU with an average time to resolution of 7.5 weeks. The most common risk factor was a history of curettage (69%), followed by previous cesarean delivery (35%). An additional dose of methotrexate was needed in 6% of cases. Bleeding requiring alternate procedures was present in 5% of cases. There were no complications in 81% of cases. The need for transfusion and development of infection were seen in 3% of cases each. There was 1 case (1.1%) requiring hysterectomy, and no maternal deaths were reported.

CONCLUSIONS

Conservative management of cervical pregnancy using local injection has been reported to have a low complication rate and a high efficacy for cure.

Transvaginal ultrasound-guided treatment of cervical pregnancy

OBJECTIVE

To describe our experience with sonographically guided injection of methotrexate and potassium chloride (KCl) to treat early cervical pregnancy.

METHODS

We prospectively reviewed all cases of cervical pregnancies treated conservatively through transvaginal ultrasound-guided therapy at our institutions. Thirty-eight cases were identified, from 1993 through 2004. All cases were managed with transvaginal intra-amniotic and intrachorionic injection of 50 mg of methotrexate under ultrasound guidance. An additional intracardiac fetal injection of 2 mL KCl was given for those cervical pregnancies with documented cardiac activity. Follow-up sonographic examinations and serum beta-hCG measurements were performed twice weekly for 2 weeks after the procedure, then weekly.

RESULTS

The mean initial beta-hCG level was 38,948 milli-International Units/mL and ranged from 5,608 to 103,256 milli-International Units/mL for 22 cases with fetal heart activity and from 2,765 to 18,648 milli-International Units/mL for 16 cases without. Gestational age ranged from 5.4 to 14 weeks (mean 8.8 weeks). All cervical pregnancies were successfully aborted, with an average resolution of the cervical mass in 49 days. Postoperative beta-hCG declined to less than 5 milli-International Units/mL within a mean of 38 days. A mean 4.5-year follow-up showed that, of 21 patients who desired pregnancy, 18 had achieved subsequent successful pregnancies.

CONCLUSION

Cervical pregnancies can be successfully managed without surgical intervention through local injection of methotrexate and KCl. This treatment not only ablates the ectopic pregnancy but also preserves the uterus for subsequent pregnancies.

Cervical pregnancy treated with transvaginal ultrasound-guided intra-amniotic instillation of methotrexate

AIM

Aim of the study was to investigate the efficacy of single transvaginal ultrasound-guided intraamniotic installation of methotrexate in the management of cervical pregnancy with concurrent review of the literature.

MATERIALS AND METHODS

Six patients with cervical pregnancy are included in the study. All patients were treated with single transvaginal ultrasound-guided intraamniotic installation of 70 mg of methotrexate plus folic acid p.o. The main presenting symptoms were mild to moderate vaginal bleeding and lower abdominal cramp-like pain, resembling the clinical presentation of a threatened abortion. The typical ultrasound findings were the absence of intrauterine gestational sac and the detection of a gestational sac within the cervical canal, invading the anterior or the posterior wall of the cervix and normal appearance of the adnexa, bilaterally. The hourglass-shaped cervix was not characteristic at 5 weeks of gestation but it was at 8 weeks of gestation.

DISCUSSION

Ultrasound-guided intraamniotic installation of methotrexate in the management of cervical pregnancy appears to be an effective and safe method but the choice of the method should be depended on the gestational age of cervical pregnancy, the presence of active bleeding or not and its severity, the desire for preservation of future fertility, the presence of coexisting valuable intrauterine pregnancy and the experience of the physician in charge.

Sonographic Evaluation of an Anembryonic Cervical Pregnancy Treated with Methotrexate

Cervical ectopic pregnancies are rare, but they can pose a serious threat to the future fertility of a patient. Previously, the only available mode of treatment was dilatation and curettage, which often led to uncontrolled bleeding and hysterectomy. In the last decade, the treatment of ectopic pregnancy with methotrexate has proven to be an effective therapy and enables the preservation of future fertility. We describe the sonographic features and evolution of an anembryonic cervical pregnancy treated with an intramuscular methotrexate injection.

Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies

OBJECTIVES

This retrospective study examined the overall efficacy of methotrexate chemotherapy in the treatment of cervical pregnancy and attempted to determine whether differences in the response to methotrexate therapy exist between patients with viable and nonviable cervical pregnancies.

STUDY DESIGN

A MEDLINE database search and a bibliographic review of the relevant literature were conducted to find reported cases of cervical pregnancy treated with methotrexate administration during the period from 1983 to 1997. Clinical and demographic characteristics, methotrexate regimen, concomitant invasive procedures, complications, and outcomes in viable and nonviable pregnancy groups were analyzed and compared.

RESULTS

A total of 62 reported cases of cervical pregnancy were assessed. There were no statistically significant differences in demographic data, transfusion rate, and human chorionic gonadotropin remission time between viable and nonviable cervical pregnancy groups. Among the 35 cases of viable pregnancy 63% of women received systemic injection alone or a combination of systemic and local (intra-amniotic or intracervical) injection with methotrexate or potassium chloride and 37% had local injection of methotrexate (with or without potassium chloride) alone. Among the 23 cases of nonviable cervical pregnancy 96% of women received systemic methotrexate injection only. The need for >/=1 concomitant surgical procedure (such as simple curettage, dilation and curettage, cervical blocking, or uterine artery embolization) in conjunction with methotrexate therapy was significantly higher (P =.021) in the viable pregnancy group (43%) than in the nonviable pregnancy group (13%). The 94% success rate of preservation of the uterus in the viable pregnancy group was not significantly different from the 91% preservation rate in the nonviable pregnancy group. All patients who had successful uterine preservation returned to normal menstrual patterns.

CONCLUSION

This retrospective study found that conservative treatment with methotrexate chemotherapy of patients with either viable or nonviable cervical pregnancies at <12 weeks' gestation carries a 91% success rate for preservation of the uterus. The structure of the cervix was restored and menstruation returned for all patients in whom the uterus was preserved after treatment. There was no evidence to suggest that the reproductive performance of these patients was affected by the treatment.