Human Reproduction, Vol. 14, No. 4, 1118-1121,
April 1999
© 1999 European Society of Human Reproduction and Embryology
Conservative treatment by angiographic uterine artery embolization of a 12 week cervical ectopic pregnancy: Case report
1 Department of Obstetrics and Gynaecology and 2 Department of Radiology, University of Naples `Federico II' via Pansini 5, 80131, Naples, Italy
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Abstract |
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A 32 year old woman, gravid 1, nulliparous, was admitted to our department at 11 weeks and 2 days of gestation after being diagnosed with cervical pregnancy. She was unsuccessfully treated with methotrexate for 5 days. On the fifth day after admission she underwent bilateral uterine artery angiographic embolization followed by vacuum evacuation and curettage of the cervical canal. A Foley catheter was also inserted in the cervical canal and left in place for 4 days. The patient was discharged in good condition on the seventh postoperative day.
Key words: cervical pregnancy/uterine artery embolization
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Introduction |
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Cervical pregnancy is a rare form of ectopic gestation. Its true incidence has never been accurately determined and estimates vary from 1 in 1000 (Shinagawa and Nagayama, 1969
) to 1/50 000 pregnancies (Breen, 1970). These represent ~0.15% of all ectopic pregnancies (Frates et al., 1994).
Since 1953 no maternal death has been reported in the literature as a consequence of cervical pregnancy. Nevertheless, patients with this pathology are at high risk of severe, potentially life-threatening haemorrhages, which may lead to hysterectomy with dramatic consequences on their reproductive future. In the last two decades the widespread use of ultrasound diagnosis has led to increasingly early diagnosis of cervical pregnancy, allowing the use of conservative treatments. These include curettage and packing, local excision and repair, cervical amputation, cervical cerclage after curettage and bilateral hypogastric ligation (Parente et al., 1983). A more innovative technique consists in combining curettage and local prostaglandin injection (Spitzer et al., 1997).
Successful systemic and local treatment with methotrexate has also been reported in recent years (Stovall et al., 1989, 1991; Balasch et al., 1994; Frates et al., 1994; Miyamura et al., 1994; Timor-Tritsch et al., 1994; Camli et al., 1995; Dotters et al., 1995; Hsu et al., 1995; Kung et al., 1995, 1997; Mantalenakis et al., 1995; Zohav et al., 1995; Kaminopetros et al., 1996; Marston et al., 1996; Cosin et al., 1997; Hung et al., 1997; Nomiyama et al., 1997; Sieck et al., 1997; Hajenius et al., 1998).
Finally, embolization of uterine arteries has also been proposed in order to reduce the risk of massive haemorrages (Lobel et al., 1990; Meyerovitz et al., 1991; Simon et al., 1991; Frates et al., 1994; Cosin et al., 1997), but has never been performed later than the seventh gestational week.
In this paper we report the case of a patient with cervical ectopic pregnancy diagnosed in the 12th gestational week, successfully treated with uterine artery embolization followed by vacuum evacuation and curettage, after failure of systemic methotrexate treatment.
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Case report |
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Our patient was 32 years old, gravid 1, nulliparous. She was admitted to our department at 11 weeks and 2 days gestation after being diagnosed with a cervical ectopic pregnancy at her first obstetric ultrasound scan performed on the same day at her doctor's office.
The first ultrasound scan had been delayed to this gestational age as the patient was travelling abroad. She had experienced two episodes of irregular bleeding in the previous two months which masked her pregnant status. The patient reported that she was a carrier of the ß-thalassaemia trait. Her medical history was otherwise unremarkable.
Physical examination of the patient, performed at admission, showed normal temperature, blood pressure and heart rate. Laboratory tests at admission revealed blood chemistry values in the normal range for the gestational status and hypochromic, microcytic, anaemia not due iron deficiency, compatible with a ß-thalassemia trait (haemoglobin: 9.4 g/dl; red blood cells: 4.95x106/mm3; mean corpuscular volume: 60.2 fl; mean corpuscular haemoglobin content (MCHC): 31.3 g/dl; mean corpuscular haemoglobin (MCH): 18.8 pg; serum iron: 81 µg/dl). Serum ß-human chorionic gonadotrophin (HCG) concentrations were 73.620 mUI/ml. An ultrasound scan was performed immediately after admission (Figure 1) and confirmed the previous diagnosis. A normal sized uterus was found with an empty cavity. The endometrium was thick and hyperechogenic. A gestational sac was evident below the closed internal cervical os, containing a live fetus with crown–rump length of 41 mm. The trophoblast was implanted on the left side of the cervical canal.
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On the same day of admission, treatment with methotrexate was started at the i.v. dose of 50 mg (1 mg/kg body weight) every other day, followed by calcium folinate rescue 24 h after each injection (50 mg i.v.), according to the protocol proposed by Stovall et al. (1989, 1991).
The effect of therapy was monitored by daily ß-HCG measurements and ultrasound scans (Table I). On day 4 of treatment, serum ß-HCG concentration was increased in comparison to day 0 and US scan revealed a living fetus (Table I).
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The decision was then taken to perform a vacuum evacuation and curettage of the cervical canal after embolization of the uterine arteries. Angiographic embolization was successfully performed under general sedation (Figure 2
). The procedure was performed through percutaneous transbrachial catheterization of the left humeral artery with an hydrophilic 4F head hunter-shaped catheter. The left uterine artery was then deeply catheterized down to the bifurcation. After selective arteriography, the artery was totally embolized with small particles of sterile fibrin (Zymospuma; Baldacci, Pisa, Italy) mixed with collagen sponge of bovine origin (Lyostypt; B/Braun, Melsungen, Germany), suspended in a non-ionic contrast medium (Lomeron 300; Bracco, Milano, Italy). Embolization was stopped just before the contrast medium could flow back from the uterine artery. The procedure was repeated on the right uterine artery and its total duration was about 25 min. The total fluoroscopy time was 7 min.
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Vacuum evacuation and curettage of the cervical canal was performed 3 h after embolization, under ultrasonographic guidance and general anaesthesia. Despite the absence of significant bleeding, a 24 ml Foley balloon catheter was placed into the canal and vaginal tamponade was left in place. On the first postoperative day haemoglobin was 8.1 g/dl and on the fifth day 8.0 g/dl.
The vaginal tamponade was removed on the third postoperative day and the Foley catheter on the fourth. On the first and fifth postoperative days ß-HCG values had fallen to 16000 and 1400 mIU/l respectively. On the fourth postoperative day an ultrasound scan showed a normal uterine cervix.
The patient was discharged in good condition on the seventh postoperative day. Three months after dismissal, the patient underwent colour Doppler examination of the uterine arteries, which showed normal flow. Six months after the procedure the patient resumed regular menstrual cycles.
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Discussion |
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The widespread use of ultrasound diagnosis and especially of transvaginal ultrasound has dramatically improved the ability to detect cervical pregnancies at an early gestational age, thus allowing conservative treatments. Recently Jurkovic et al. have reviewed current ultrasound criteria for the detection of cervical pregnancy and suggested modifications necessary for use with transvaginal and colour Doppler imaging (Jurkovic et al., 1996
). Unfortunately in our case, as the patient was unaware of being pregnant, the diagnosis of cervical pregnancy was made only in the 12th week, when, according to most authors, the majority of conservative treatments is going to fail.
Indeed, successful therapy of cervical pregnancy with systemic methotrexate is very rare when HCG concentration is >10 000 mIU/ml at the beginning of therapy (Van de Meerssche et al., 1995). Moreover, in their accurate review of this topic, Kung et al. report that among 18 cases successfully treated with methotrexate, 12 required the use of adjuvant therapies (Kung et al., 1997).
According to Stovall et al. methotrexate therapy in ectopic pregnancies should be continued until there is a decrease of 
15% in two consecutive daily ß-HCG titres (Stovall et al., 1989, 1991) and the large majority of patients require no more than four doses of the drug.
In our case, systemic administration of methotrexate failed to induce a decrease of ß-HCG serum concentration after 5 days of therapy. Indeed, serum ß-HCG concentration in our patient at admission was 73.620 mUI/ml and fetal heart beat was evident. In such a case, intra-amniotic injection of methotrexate could have been more effective than systemic administration. However, Timor-Tritsch et al., who were among the first to use this modality of treatment, suggest that it should be reserved for cervical pregnancies of <12 weeks gestation (Timor-Tritsch et al., 1994).
After failure of medical treatment, in order to reduce the risk of massive blood loss inherent to surgical treatment, we decided to employ angiographic embolization of the uterine arteries, followed by vacuum evacuation and curettage of the cervical canal. In consideration of the low haemoglobin concentration of our patient we also inserted a Foley catheter in the cervical canal after curettage as an adjunctive safety measure.
During surgical treatment of cervical pregnancy the main problem is to achieve an adequate haemostasis. Jurkovic et al. (Jurkovic et al., 1996) concluded that preoperative embolization of the uterine arteries appears to be the best method to prevent major bleeding, even if other methods, such as local prostaglandin injection, cervical cerclage and/or intracervical insertion of a Foley or Dufour catheter are probably more familiar to the gynaecologist.
Selective angiographic arterial embolization was initially developed for use in the gastrointestinal tract. Today this method has extensive application for the control of haemorrhage in many parts of the body and has been initially used in gynaecology in controlling massive bleeding in patients with advanced carcinoma of the cervix (Thompson et al., 1992). The use of this technique as an adjunct to curettage to reduce the risk of haemorrhage in cervical pregnancy has been repeatedly reported at early gestational ages, but never later than the seventh week of gestation (Lobel et al., 1990; Meyerovitz et al., 1991; Simon et al., 1991; Frates et al., 1994; Cosin et al., 1997). The favourable resolution of our case shows that this treatment option is feasible in cervical pregnancy even at a later gestational age.
We can conclude that cervical pregnancies diagnosed at an early gestational age can be safely treated with systemic methotrexate as has been repeatedly reported. However, at later gestational ages, as in this case, after a cautious attempt with medical therapy, surgical treatment becomes mandatory. In these circumstances angiographic embolization of the uterine arteries may greatly reduce the risks inherent to the surgical procedure.
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Notes |
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3 To whom correspondence should be addressed at: Università di Napoli `Federico II', Istituto di Ginecologia, Ostetricia, e Fisiopatologia della Riproduzione Umana, Via Pansini, 5, 80131 Napoli, Italy
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Submitted on May 20, 1998; accepted on December 4, 1998.
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