Cervical pregnancy: transvaginal sonographic diagnosis and conservative surgical management after failure of systemic methotrexate

We present a case of cervical pregnancy diagnosed with endovaginal sonography and managed successfully with conservative surgical instrumentation after failure of systemic treatment with methotrexate. The patient was a 28-year-old nullipara who was referred to our Prenatal Care Sonographic Unit with a diagnosis of ectopic pregnancy. On initial transvaginal sonographic (TVS) examination the patient was found to have a viable 7-week gestation (crown–rump length (CRL) 9.9 mm) located in the endocervical canal 2 cm from the external cervical os (Figure 1). She was admitted to the High Risk Pregnancy Unit for management. Neither examination in conjunction with a sterile speculum nor digital examination revealed relevant information. Her initial beta-human chorionic gonadotropin (β-hCG) level was 12 700 mIU/mL. We decided to manage the patient with systemic methotrexate given as a single dose of 50 mg/m2 with folinic acid rescue. Prior to methotrexate administration a follow-up sonographic examination was performed which confirmed cardiac activity (Figure 2). A total dose of 80 mg methotrexate (diluted in 200 cc 5% dextrose) was then infused intravenously at a rate of 0.67 mg/h. Rescue with folinic acid was performed 24 h later. TVS evaluation performed 48 h after methotrexate administration revealed no embryonic cardiac activity. Sonographic evaluation performed on day 9 revealed a slight reduction in the size of the embryo (CRL 8.5 mm). The β-hCG level on day 10 had fallen to 200 mIU/mL. On the same day the patient presented with moderate transvaginal bleeding necessitating surgical intervention. Dilation and curettage was performed and complete evacuation of the products of conception was successfully carried out. A No. 24 Foley catheter was inflated with 45 cc distilled water at the implantation site in the endocervix to control further bleeding. Gradual release of the inflated Foley catheter was performed over the next 3 days until no bleeding was evident, when the patient was discharged without complications. TVS follow-up examination 10 days after discharge demonstrated a normal appearance of the endocervical canal where the embryo had been implanted (Figure 3). (a) Cervical pregnancy located 2 cm from the external cervical os. (b) The diameter of the embryonic sac was 12 mm. (c) The crown–rump length at initial examination was 9.9 mm. Prior to systemic methotrexate, peritrophoblastic blood flow and embryonic cardiac activity was confirmed with transvaginal sonography and color Doppler examination. Endovaginal sonographic view 10 days after discharge. Note the normal appearance of the endocervical canal where the embryo had been implanted. Cervical pregnancy is a rare complication occurring in 1 in 1000–95 000 pregnancies1. Adverse outcomes have been reported when early and appropriate management has not been performed2-4. Etiological risk factors include prior cervicouterine instrumentation, surgical trauma, uterine anomalies, multifetal pregnancy, embryonic chromosomal abnormalities, multiparity, tumors of the reproductive organs and decidual proliferation of the endocervical epithelium due to hyperestrogenemia5. The frequency of diagnosis and mode of treatment of cervical pregnancy have changed dramatically in the last 15 years and TVS has enabled early diagnosis6. Successful outcomes of cervical pregnancy managed conservatively with systemic7-11 or local instillation of methotrexate12 have been demonstrated. Some researchers have performed angiographic embolization as a complementary measure to systemic chemotherapy13, 14. Prognostic factors for unsuccessful conservative management have been identified. Bai et al.15 found no relation between women's parity, size of the conceptus or presence of fluid in the peritoneal cavity and the efficacy of the treatment. However, those cervical pregnancies that presented with a serum β-hCG concentration of ≥ 10 000 mIU/mL and cardiac activity were associated with a higher failure rate of primary methotrexate treatment. Hung et al.16 have added two more prognostic factors: ≥ 9 weeks' gestation and CRL > 10 mm. Our patient had two out of four of these prognostic factors (β-hCG level of 12 700 mIU/mL and the presence of cardiac activity). Owing to the fact that our patient was nulliparous, conservative management was strongly encouraged. TVS confirmation of cessation of cardiac activity at 48 h after administration confirmed the methotrexate's fetocidal efficacy. We had planned to manage the case expectantly, with serial determinations of β-hCG and TVS examinations until there was complete disappearance of the products of conception thus obviating the need for major surgical intervention. There was a dramatic decrease in the last β-hCG value and the last sonographic evaluation showed a slight decrease in embryonic size. Unfortunately the patient presented with moderate vaginal bleeding that required surgical intervention. Complete evacuation of the products of conception was successfully carried out and an inflated Foley catheter was required for cervical tamponade. As the gestational age increases so the need for radical surgery increases and therefore the risk of complications2-4, 17. The inevitable need for hysterectomy despite initial conservative surgical management in an advanced cervical pregnancy (i.e. 10.2 weeks) has been reported by Tuncer et al.3. In that case, methotrexate administration was not chosen due to the presence of active tuberculosis. Dilation and curettage did not control the hemorrhage. At laparotomy, despite bilateral uterine artery ligation, profuse bleeding continued necessitating hysterectomy. In another report, misdiagnosis allowed a pregnancy to proceed until the 22nd week of gestation and made its management more complicated. An abdominal hysterectomy with preservation of the adnexa was performed4. In the present case, systemic use of methotrexate may have permitted successful conservative surgical management thus preserving the patient's reproductive capacity. In conclusion, although conservative management with methotrexate has been reported to be successful, each case should be managed individually and the need for surgical intervention should always be considered. G. León*, L. Hidalgo , P. Chedraui , * Prenatal Care Outpatient Sonography Unit, Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, High Risk Pregnancy Unit, Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, Institute of Biomedicine, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, PO Box 09-01-4671, Guayaquil, Ecuador