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Ray A, Kumari S, Lal P. A Rare Case of Ectocervical Pregnancy and Its Successful Management: A Case Report and Review of the Literature. Cureus 2024; 16:e52388. [PMID: 38361710 PMCID: PMC10868712 DOI: 10.7759/cureus.52388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
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.
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Affiliation(s)
- Alokananda Ray
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
| | - Sarita Kumari
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
| | - Pooja Lal
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
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Valdés-Martínez OH, Sordia-Hernández LH, Sordia-Piñeyro MO, Guerra-Leal JD, García-Luna SM, Morales-Martínez FA. Intrasaccular methotrexate treatment of cervical pregnancies maintains fertility: a case series. J OBSTET GYNAECOL 2023; 43:2130207. [PMID: 36240120 DOI: 10.1080/01443615.2022.2130207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Otto Hugo Valdés-Martínez
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Luis Humberto Sordia-Hernández
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - María Ofelia Sordia-Piñeyro
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Jesús Dante Guerra-Leal
- Centro Universitario de Imagen Diagnostica, Departamento de Radiología e Imagen, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González". Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Selene M García-Luna
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Felipe Arturo Morales-Martínez
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
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Köninger A, Nguyen BP, Schwenk U, Vural M, Iannaccone A, Theysohn J, Kimmig R. Cervical ectopic pregnancy - the first case of live birth and uterus-conserving management. BMC Pregnancy Childbirth 2023; 23:664. [PMID: 37715117 PMCID: PMC10504772 DOI: 10.1186/s12884-023-05951-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/24/2023] [Indexed: 09/17/2023] Open
Abstract
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.
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Affiliation(s)
- Angela Köninger
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany.
- Department of Gynecology and Obstetrics, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Steinmetzstrasse 1-3, 93049, Regensburg, Germany.
| | - Buu-Phuc Nguyen
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Udo Schwenk
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Mehmet Vural
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
- Department of Gynecology and Obstetrics, Hospital St. Hedwig of the Order of St. John, University of Regensburg, Steinmetzstrasse 1-3, 93049, Regensburg, Germany
| | - Antonella Iannaccone
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Jens Theysohn
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany
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Ge I, Geißler C, Geffroy A, Juhasz-Böss I, Wiehle P, Asberger J. Treatment of Cesarean Scar and Cervical Pregnancies Using the Ovum Aspiration Set for Intrachorial Methotrexate Injection as a Conservative, Fertility-Preserving Procedure. Medicina (Kaunas) 2023; 59:medicina59040761. [PMID: 37109719 PMCID: PMC10143318 DOI: 10.3390/medicina59040761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Cesarean scar and cervical pregnancies are rare forms of ectopic pregnancies, occurring in 1 in 2000 and 1 in 9000 pregnancies, respectively. Both entities are medically challenging due to their high morbidity and mortality potential. Materials and Methods: In this retrospective study, we analyzed all cesarean scar and cervical pregnancies from 2010 to 2019 in the Department of Gynecology and Obstetrics of the University Hospital Freiburg, treated with both intrachorial (using the ovum aspiration set) and systemic methotrexate application. Results: We identified seven patients with a cesarean scar and four patients with cervical pregnancies. At diagnosis, the median gestational age was 7 + 1 (range: 5 + 5-9 + 5) weeks and the mean value of ß-hCG was 43,536 (range: 5132-87842) mlU/mL. On average, one dose of intrachorial and two doses of systemic methotrexate were administered per patient. The efficacy rate was 72.7% with three patients (27.3%) needing an additional surgical or interventional procedure. The uterus was preserved in 100% of the patients. Out of the eight patients with follow-up data, five reported subsequent pregnancies (62.5%) that resulted in six live births. None had recurrent cesarean scars or cervical pregnancies. In the subgroup analyses, when comparing cesarean scar pregnancies to cervical pregnancies, patient characteristics, treatment modality, and the outcome did not differ significantly, except for parity (2 versus 0, p = 0.02) and the duration since the last pregnancy (3 vs. 0.75 years, p = 0.048). When comparing cases with successful and failed methotrexate-only treatments, the maternal age was significantly higher in the successful group (34 vs. 27 years, p = 0.02). Localization of the gestation, gestational and maternal age, ß-hCG, and history of preceding pregnancies were non-predictive for the efficacy of the treatment. Conclusions: The combined application of intrachorial and systemic methotrexate for the treatment of cesarean scar and cervical pregnancies has been proven effective, well-tolerated, organ- and fertility-conserving with a low complication rate.
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Affiliation(s)
- Isabell Ge
- Department of Obstetrics and Gynaecology, University Hospital of Basel, 4056 Basel, Switzerland
- Breast Center, University Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Carmen Geißler
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Alexandra Geffroy
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Philipp Wiehle
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Jasmin Asberger
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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Kakinuma T, Kakinuma K, Matsuda Y, Yanagida K, Ohwada M, Kaijima H. Efficacy of transvaginal ultrasound-guided local injections of absolute ethanol for ectopic pregnancies with intrauterine implantation sites. World J Clin Cases 2023; 11:788-796. [PMID: 36818618 PMCID: PMC9928688 DOI: 10.12998/wjcc.v11.i4.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/27/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cervical pregnancies, interstitial tubal pregnancies, and cesarean scar pregnancies, which are ectopic pregnancies with intrauterine implantation sites exhibit increasing trends with the recent widespread use of assisted reproductive technologies and increased rate of cesarean deliveries. The development of high-sensitivity human chorionic gonadotropin testing reagents and the increased precision of transvaginal ultrasonic tomography have made early diagnosis possible and have enabled treatment. Removal of ectopic pregnancies using methotrexate therapy and/or uterine artery embolization has been reported. However, delayed resumption of infertility treatments after methotrexate therapy is indicated, and negative effects on the next pregnancy after uterine artery embolization have been reported.
AIM To examine the efficacy and safety of ultrasound-guided topical absolute ethanol injection in ectopic pregnancies with an intrauterine implantation site.
METHODS In this study, we retrospectively examined the medical records of 21 patients who were diagnosed with an ectopic pregnancy with an intrauterine implantation site at our hospital, between April 2010 and December 2018, and underwent transvaginal ultrasound-guided local injections of absolute ethanol to determine the treatment outcomes. We evaluated the treatment methods, treatment outcomes, presence of bleeding requiring hemostasis measures and blood transfusion, complications, and treatment periods. Successful treatment was defined as the completion of treatment using transvaginal ultrasound-guided local injections of absolute ethanol alone.
RESULTS There were 21 total cases comprising 10 cervical pregnancies, 10 interstitial tubal pregnancies, and 1 cesarean scar pregnancy. All patients completed treatment with this method. No massive hemorrhaging or serious adverse reactions were observed during treatment. The mean gestation ages at the time of diagnosis were 5.9 wk (SD, ± 0.9 wk) for cervical and 6.9 wk (SD, ± 2.1 wk) for interstitial tubal pregnancies. The total ethanol doses were 4.8 mL (SD, ± 2.2 mL) for cervical pregnancies and 3.3 mL (SD, ± 2.2 mL) for interstitial pregnancies. The treatment period was 28.5 days (SD, ± 11.7 d) for cervical pregnancies and 30.0 ± 8.1 d for interstitial pregnancies. Positive correlations were observed between the blood β- human chorionic gonadotropin level at the beginning of treatment and the total ethanol dose (r = 0.75; P = 0.00008), as well as between the total ethanol dose and treatment period (r = 0.48; P = 0.026).
CONCLUSION Transvaginal ultrasound-guided local injections of absolute ethanol could become a new option for intrauterine ectopic pregnancies when fertility preservation is desired.
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Affiliation(s)
- Toshiyuki Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Kaoru Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Yoshio Matsuda
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Kaoru Yanagida
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Michitaka Ohwada
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
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Aiob A, Shqara RA, Mikhail SM, Sharon A, Odeh M, Lowenstein L. The impact of the COVID-19 pandemic on ectopic pregnancy presentation and treatment: A retrospective cohort study. J Gynecol Obstet Hum Reprod 2023; 52:102508. [PMID: 36384217 DOI: 10.1016/j.jogoh.2022.102508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/17/2022] [Accepted: 11/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We examined ectopic pregnancy (EP) incidence, presentation and management, before and during the COVID-19 pandemic, and following initiation of vaccination against COVID-19. STUDY DESIGN In a single-center retrospective cohort study, we compared incidence, presentation and management of EP, between 98 women who presented during the pandemic (March 1 2020 to August 31, 2021), and 94 women diagnosed earlier (March 1 2018 to August 31, 2019). Sub-periods before and after introduction of the vaccination were compared. RESULTS Age and parity were similar between the periods. For the pandemic compared to the earlier period, the median gestational age at EP presentation was higher (6.24 ± 1.25 vs. 5.59 ± 1.24, P<0.001), and the proportions were higher of symptomatic women (42.9% vs. 27.7%, p = 0.035) and urgent laparoscopies (42.9% vs. 24.5%, p = 0.038). In a multivariable linear model, women who presented during the pandemic were more likely to undergo an urgent laparoscopy [OR 2.30, 95%CI (1.20-4.41)], P = 0.012. In urgent surgeries performed during the pandemic compared to the earlier period, the proportion of women with a hemoglobin drop >2 gr/dL was greater (60% vs. 30%, p = 0.024). Statistically significant differences were not found in sonographic or laboratory findings, in rupture or massive hemoperitoneum rates, or in the need for blood transfusion in urgent laparoscopy. Outcomes were similar before and after introduction of vaccinations. CONCLUSION During the pandemic, and even after the introduction of vaccination, women with EP were more likely to undergo urgent surgery, and blood loss was greater. This is likely due to delayed diagnosis.
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Zhu Q, Tang Y, Tian Q, Cheng H, Yang J, Xiong L, Li W, Zou L, Cheng W, Luo X. Clinical efficacy and safety analysis of different treatment options for Cervical pregnancy. Int J Hyperthermia 2023; 40:2255757. [PMID: 37699591 DOI: 10.1080/02656736.2023.2255757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVE To compare the efficacy and safety of different treatment options for cervical pregnancy (CP). MATERIALS AND METHODS A total of 74 patients diagnosed with CP at Hunan Provincial Maternal and Child Health Care Hospital between January 2016 and September 2022 were retrospectively analyzed. Among them, 31 were treated with uterine artery embolization (UAE) followed by hysteroscopic curettage, 34 were treated with hysteroscopic curettage alone, and nine were treated with high-intensity focused ultrasound (HIFU) followed by hysteroscopic curettage. Medical records and pregnancy outcomes were analyzed. RESULTS There were no significant differences in age, gravidity, parity, abortion, or preoperative hemoglobin levels among the patients in the three groups; however, significant differences in gestational age, gestational sac diameter, preoperative β-hCG, and presence of cardiac pulsation were observed (p < 0.05). After treatment, there was no conversion to laparotomy, and the uterus was preserved in all patients. Significant differences in blood loss during curettage, hospitalization costs, hospital days, menstrual recovery interval, β-hCG decline rates, retained products of conception, and intrauterine adhesions rate among the three groups were observed (p < 0.05). There were no significant differences in the placement of the uterine Foley balloon, effective curettage rate, pre-and postoperative hemoglobin decline, live birth rate, or proportion of subsequent pregnancies among the three groups. CONCLUSION Our results showed that hysteroscopic curettage, HIFU, and UAE followed by hysteroscopic curettage are safe and effective for treating patients with CP. Compared with the UAE, HIFU has the advantages of lower hospitalization costs, shorter hospital stays, and shorter menstrual recovery intervals.
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Affiliation(s)
- Qiaoling Zhu
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Yi Tang
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Qi Tian
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Hui Cheng
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Jing Yang
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Li Xiong
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Wei Li
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Lingzhi Zou
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Wei Cheng
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
| | - Xiaomei Luo
- Department of Obstetrics and Gynecology, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, P.R. China
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Yeh CY, Su JW, Yin-Yi Chang C, Yang CY, Lin WC, Huang CC. Cervical pregnancy: a case report of hysteroscopic resection and balloon compression combined with systematic methotrexate treatment. Taiwan J Obstet Gynecol 2022; 61:1061-1064. [DOI: 10.1016/j.tjog.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/24/2022] Open
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Li W, Gan X, Kashyap N, Zou L, Zhang A, Xu D. Comparison of high-intensity focused ultrasound ablation and uterine artery embolization in the management of cervical pregnancy. Front Med (Lausanne) 2022; 9:990066. [PMID: 36186779 PMCID: PMC9522970 DOI: 10.3389/fmed.2022.990066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCervical pregnancy (CP) is an uncommon type of ectopic pregnancy with a rising risk to life. Currently, there is no universal protocol for the safe and effective management of CP. This study aimed to investigate the clinical efficacy of high-intensity focused ultrasound ablation (HIFU) vs. uterine artery embolization (UAE) in the management of CP to develop a standard for the treatment of CP.MethodsFrom January 2015 to October 2021, 36 patients with CP were diagnosed, treated, and followed up at the Department of Gynecology of Third Xiangya Hospital of Central South University. A total of 11 patients were treated with HIFU followed by suction curettage under hysteroscopic guidance, and 25 patients were treated with UAE followed by suction curettage under hysteroscopic guidance. Medical records and pregnancy outcomes were retrospectively analyzed.ResultsCompared to the UAE group, the HIFU group had a shorter interval time (1.5 ± 0.21 days vs. 2.6 ± 0.26 days), shorter duration of hospitalization (5.5 ± 0.31 days vs. 6.6 ± 0.21 days), shorter recovery time of menstruation (30.6 ± 7.09 days vs. 36.9 ± 5.54 days), fewer adverse reactions (0/11 vs. 9/25), and fewer postoperative complications (1/11 vs. 8/25). There were no significant differences in age, gravidity, parity, abortion, gestational age, cardiac pulsation, admission symptoms, hemoglobin level, largest diameter of the sac/mass, serum human chorionic gonadotropin (hCG) level at admission, hospitalization expenses, hospitalization days, blood loss during curettage, degree of hCG decline, residue after curettage, fertility requirement, and pregnancy outcomes.ConclusionBoth HIFU and UAE are safe and effective in the treatment of patients with CP. Compared to UAE, HIFU treatment for CP is a safer and more effective therapeutic schedule owing to the advantages of being more minimally invasive, shorter interval time, shorter hospitalization days and recovery time of menstruation, fewer adverse reactions, and fewer postoperative complications.
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Affiliation(s)
- Waixing Li
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoli Gan
- Department of Obstetrics and Gynecology, Pingxiang Maternal and Child Health Care Hospital, Pingxiang, China
| | - Nidhi Kashyap
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lingxiao Zou
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Aiqian Zhang
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
- Aiqian Zhang
| | - Dabao Xu
- Department of Obstetrics and Gynecology, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Dabao Xu
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Fouda A, Enayat A, Ahmed WE. Conservative management of a viable cervical ectopic pregnancy with systemic and multiple local methotrexate injections. A case report. EUR J CONTRACEP REPR 2022; 27:265-268. [PMID: 35129019 DOI: 10.1080/13625187.2022.2026325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Cervical ectopic pregnancy is rare and has serious haemodynamic implications, usually requiring a hysterectomy. However, the patient's haemodynamic profile and reproductive history may warrant medical management with methotrexate. We present a case report of a 33-year-old primigravida managed conservatively (patient insisted) for cervical ectopic pregnancy. MATERIALS AND METHODS A 10-weeks pregnant lady suffered from cervical pregnancy as confirmed by ultrasonography with initial β-HCG titre = 65,928 mIU/mL. She received a methotrexate IM-injection followed by multiple transabdominal-ultrasound-guided local doses. Serial sonography to monitor gestational sac size and β-HCG levels were done weekly. RESULTS β-HCG levels declined satisfactorily over 4 weeks: 19,166 mIU/mL, 6900 mIU/mL and 1104 mIU/mL on days 14, 21 and 28, respectively. She remained haemodynamically stable throughout admission. On day-35, β-hCG titre reached 400 mIU/mL, and products of conception seen on ultrasound (20 × 25 mm), that were later complicated by secondary infection, necessitated evacuation curettage. β-HCG titre was 2 mIU/mL by 48th day. CONCLUSIONS Live cervical ectopic pregnancy with high β-hCG titres can be conservatively managed with multidose methotrexate injection administered systemically and locally. However, the efficacy of the applied dose of 25 mg or using higher doses should be evaluated to avoid occurrence of residual lesion.
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Affiliation(s)
- Aya Fouda
- Department of Obstetrics and Gynecology, Nasr City Insurance Hospital, Cairo, Egypt
| | - Ashraf Enayat
- Department of Radiology, Al-Azhar University, Cairo, Egypt
| | - Walaa Elsayed Ahmed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Helwan University, Cairo, Egypt
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Abstract
Cervical ectopic pregnancy is a rare but life-threatening condition in which early diagnosis and treatment are key to a successful outcome. In the past, this diagnosis led inevitably to a hysterectomy due to the risk of massive bleeding. Currently, the most effective method of treatment is yet to be found. We report a case of a 31-year-old nulliparous female with six weeks of amenorrhea and vaginal bleeding. The first approach missed the diagnosis, but an ultrasound performed by an expert revealed a gestational sac with an embryo in the cervical canal. The fertility-sparing therapeutic strategy involved performing treatment with systemic and local methotrexate, followed by embolization of the uterine artery and cervical curettage to remove the trophoblast. Our aim is to strengthen the importance of an early diagnosis and multidisciplinary perspective. Uterine artery embolization was the key to minimizing bleeding, enabling a treatment that preserved fertility.
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Affiliation(s)
- Francisco Évora
- Obstetrics and Gynecology, Coimbra Hospital and University Center, Coimbra, PRT
| | - Kristina Hundarova
- Obstetrics and Gynecology, Coimbra Hospital and University Center, Coimbra, PRT
| | - Fernanda Águas
- Obstetrics and Gynecology, Coimbra Hospital and University Center, Coimbra, PRT
| | - Giselda Carvalho
- Obstetrics and Gynecology, Coimbra Hospital and University Center, Coimbra, PRT
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Yamaguchi M, Ohba T, Katabuchi H. Safety and efficacy of a single local methotrexate injection for cesarean scar pregnancy. J Minim Invasive Gynecol 2021; 29:416-423. [PMID: 34808380 DOI: 10.1016/j.jmig.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/20/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the safety and efficacy of a single local methotrexate (MTX) injection for the treatment of cesarean scar pregnancy (CSP), assess reproductive outcomes after treatment, and confirm clinical outcomes after the treatment of CSP patients according to the presence of fetal cardiac activity or serum human chorionic gonadotropin (hCG) levels. DESIGN Retrospective cohort study SETTING: University hospital PATIENTS: Women with CSP INTERVENTIONS: Single local MTX injection under transvaginal ultrasound guidance MEASUREMENTS AND MAIN RESULTS: Forty-five CSP cases were identified; the mean (SD, range) estimated gestational age was 7.7 (1.7, 5.4-12.5) weeks and the mean serum hCG level was 51,801 (40,761, 2,307-187,898) mIU/mL. Three cases required additional treatment with MTX, and none of the cases needed uterine artery embolization or hysterectomy. The success rate for a single dose was 93.3%, and it was 100% if additional treatments with MTX were included. The mean time required for hCG normalization in those with fetal cardiac activity or with an initial level of hCG greater than 100,000 mIU/mL was not significantly longer than that in the controls (93.4 vs. 77.1 days, p=0.12; 113.7 days vs. 83.6 days, p=0.10). Of the 23 women who desired a subsequent pregnancy, 13 delivered 14 healthy newborns after treatment, three had an ongoing pregnancy, and three experienced recurrent CSP. CONCLUSIONS A single local MTX injection is safe and effective for the treatment of CSP despite the presence of fetal cardiac activity or any initial level of hCG and may allow the possibility of a subsequent uneventful pregnancy.
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Affiliation(s)
- Munekage Yamaguchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan.
| | - Takashi Ohba
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
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Imai K, Fukushi Y, Nishimura M, Ohara Y, Suzuki Y, Ota H, Nakajima A, Wada S, Fujino T. Combination of conservative treatment and temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection for cervical pregnancy: A retrospective study. J Gynecol Obstet Hum Reprod 2021; 50:101735. [PMID: 32251739 DOI: 10.1016/j.jogoh.2020.101735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/28/2020] [Accepted: 03/21/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION We investigated whether temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection (LUA clipping-TCR) is an effective minimally invasive treatment for the management of cervical pregnancy. MATERIALS AND METHODS This study is a retrospective clinical case series conducted at Teine Keijinkai Hospital from January 2014 to June 2019. Nine cervical pregnancies among 164 ectopic pregnancies were retrospectively examined. The intervention involved performing LUA clipping-TCR on villous tissue. Information on patient characteristics, clinical data, and surgical details was collected from medical records and surgical videos. RESULTS The mean (range) age of the patients was 33 years (29-41 years); and mean gestational sac diameter, 12.8 mm (5-24 mm). Five patients had a history of intrauterine procedures. Three patients had a positive fetal heartbeat. The mean (range) preoperative serum hCG level (mIU/mL), surgical time (min), uterine artery blocking time (min), and amount of surgical blood loss (ml) were 14,040 (2880-41,367), 82 (62-120), 42 (21-68), and 57 (10-200), respectively. The mean decrease in serum hCG level (second postoperative day) and duration until resumption of menstruation were 79.7 % (70-86.7 %) and 46 days (35-80 days), respectively. The hospitalization period was 2-3 days, with no evidence of persistent ectopic pregnancy. Live birth was achieved in four cases. DISCUSSION Our results confirm previous findings and provide new evidence that LUA clipping-TCR is effective for cervical pregnancy management and fertility preservation, respectively. Future large-scale prospective studies to compare different cervical pregnancy management methods are required.
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Ozcivit IB, Cepni I, Hamzaoglu K, Erenel H, Madazlı R. Response to “Letter to the editor RE: “Conservative management of 11 weeks old cervical ectopic pregnancy with transvaginal ultrasound-guided combined methotrexate injection: Case report and literature review””. Int J Surg Case Rep 2020; 75:458-459. [PMID: 33076194 PMCID: PMC7527616 DOI: 10.1016/j.ijscr.2020.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022] Open
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Jiang J, Xue M. The treatment of cervical pregnancy with high-intensity focused ultrasound followed by suction curettage: report of three cases. Int J Hyperthermia 2019; 36:273-276. [PMID: 30676110 DOI: 10.1080/02656736.2018.1563914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Cervical pregnancy (CP) is a rare type of ectopic pregnancy and is considered to be a life-threatening condition due to the risk of severe hemorrhage. Unfortunately, no consensus on standard conservative treatment for CP has been established. The study objective was to evaluate the efficacy and safety of high-intensity focused ultrasound (HIFU) followed by suction curettage for cervical pregnancy. METHOD Three patients with cervical pregnancy undergoing high-intensity focused ultrasound followed by suction curettage were analyzed. Patient age, gestational age, endocervical mass, serum human chorionic gonadotrophin (HCG) level, blood loss, and time for normal menstruation recovery were recorded. RESULTS Three patients with cervical pregnancy were successfully treated with HIFU followed by suction curettage. After HIFU treatment, the fetal cardiac activity disappeared or the blood flow in the pregnancy tissue significantly decreased. The termination of the cervical pregnancy of all three patients was performed successfully without heavy bleeding. The estimated blood loss was 10-20 ml. The time for menstruation recovery was 30-45 days. No obvious complications of HIFU were observed in these cases. CONCLUSION High-intensity focused ultrasound followed by suction curettage seems to be considered as conservative management for patients who desire to preserve their uterus.
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Affiliation(s)
- Jianfa Jiang
- a Department of Obstetrics and Gynecology , The Third Xiangya Hospital of Central South University , Changsha , Hunan Province , China
| | - Min Xue
- a Department of Obstetrics and Gynecology , The Third Xiangya Hospital of Central South University , Changsha , Hunan Province , China
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Conti V, Luciano G, Pecoraro G, Iovieno R, Filippelli A, Guida M. Multidosing Intramuscular Administration of Methotrexate in Interstitial Pregnancy With Very High Levels of β-hCG: A Case Report and Review of the Literature. Front Endocrinol (Lausanne) 2018; 9:363. [PMID: 30042729 PMCID: PMC6048239 DOI: 10.3389/fendo.2018.00363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/18/2018] [Indexed: 01/17/2023] Open
Abstract
Ectopic pregnancy (EP) is the implantation of an embryo outside the endometrial cavity of the uterus. Signs and symptoms of EP may arise between the 6th and the 8th week of gestation and include vaginal bleeding, lower abdominal and pelvic pain. Frequently EPs implant in the fallopian tubes. A rare EP is the interstitial pregnancy, a life-threatening condition being responsible for nearly 20% of all deaths caused by EPs. Because of its unique location, the diagnosis is difficult and based on signs and specific criteria together with measuring of serum β-hCG. Usually, EP is treated by surgical approach, which is associated with increased morbidity, decreased fertility and increased likelihood of hysterectomy and uterine rupture in a subsequent pregnancy. Early diagnosis is crucial to life saving and allowing alternative therapeutic interventions such as pharmacological treatments. Methotrexate (MTX) represents the mainstay therapy. There is no standard care for the interstitial pregnancy for what concerns either surgical or pharmacological approaches. We reported a case of a 36-year-old woman admitted to the Hospital of Salerno-Italy with a value of serum β-hCG of 35,993 IU/L. Transvaginal ultrasonography revealed an empty uterine cavity and a mass of 35.7 mm in diameter characterized by a hypoechoic central area. The patient was in stable haemodynamic condition and no haematologic, renal and hepatic impairments were recorded. Despite the high serum β-hCG levels, a pharmacological approach was preferred to a surgical one. The patient was treated with intramuscular administration of MTX in daily dose of 1 mg/Kg alternated with 0.1 mg/kg folinic acid for 5 days. The patient remained hospitalized for 20 days and no side effects were reported. The decrease of the serum β-hCG was monitored and more than 15% reduction was detected between the 4th and the 7th day after the beginning of the treatment. The serum β-hCG became undetectable 35 days after. A multidosing intramuscular administration of MTX was effective and safe even in the presence of very high serum β-hCG levels. Together with similar cases reported in literature, the present results can contribute to improve the decision making in the treatment of the interstitial pregnancy.
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Affiliation(s)
- Valeria Conti
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Giovanni Luciano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Giovanni Pecoraro
- Unit of Gynecology and Obstetrics of “San Giovanni di Dio e Ruggi d'Aragona”, University Hospital, Salerno, Italy
| | - Roberto Iovieno
- Unit of Gynecology and Obstetrics of “San Giovanni di Dio e Ruggi d'Aragona”, University Hospital, Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Maurizio Guida
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
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Juusela AL, Gimovsky ML. Intraoperative Hemorrhage Requiring Emergent Hysterectomy: Failed Conservative Management of a Cervical Placenta Accreta. J Gynecol Surg 2017. [DOI: 10.1089/gyn.2017.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kwon JH, Kim GM, Han K, Kim MD, Won JY, Lee DY. Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study. Cardiovasc Intervent Radiol 2017; 40:1351-7. [PMID: 28462440 DOI: 10.1007/s00270-017-1664-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
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.
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