Alanis-Fuentes J. H. Dr. Manuel Gea González. Mexico
Ectopic pregnancy has become a worldwide “epidemic”. From 1970 to 1992, its incidence has increased by 9 times. The prevalence is estimated at 1.6 ectopic pregnancies per 100 births with a maternal mortality rate up to 9% when of interstitial type. In Mexico, investigators reported a rate of 6.1 per 1000 live births, with immediate and late complications that resulted in infertility or maternal mortality. (1)
CERVICAL ECTOPIC PREGNANCY:
Cervical ectopic pregnancies are extremely rare, representing approximately 0.1% of all ectopic pregnancies. The incidence is estimated at 1:2,500 to 1:98,000 pregnancies. Before the decade of the 1980s, the diagnosis was only made retrospectively, when after performing the dilation and curettage for incomplete abortion there was uncontrollable bleeding resulting in hysterectomy. (2) Recognized risk factors for cervical ectopic pregnancy are, lesions or previous scars on the cervix, uterine curettage, chronic pelvic infections, and use of IUD. Also, pregnancies achieved through in vitro fertilization and embryo transfer. (2)
There are case reports describing full term cervical ectopic pregnancies as the one described by Dr. Rokitansy in 1860. The contemporary accepted diagnostic criteria of cervical ectopic pregnancy are based on the contribution of Dr. Studdiford referring to it as the “kind of abnormal pregnancy with cervical implantation”. There are 28 cases reported in the literature before 1945, half of which were made as retrospective diagnosis based on pathology results. Of these, 6 patients died and some required blood transfusion of up to 11 liters of blood. Dr Studdiford himself treated two cases. (3)
The traditional treatment this pathology is hysterectomy as a result of uncontrollable bleeding or planned in up to 70% of cases. (4. 5) There have been multiple treatment modalities described, from evacuation by instrumented curettage that in most cases results in uncontrollable bleeding requiring subsequent hysterectomy. Also, selective uterine and/or hypogastric artery embolization has been described prior to attempting endocervical tissue removal. (7) A recent approach has been the use on methotrexate (MTX) 1 mg/kg, administered IV, IM or as an intra-amniotic injection under sonographic or hysteroscopic guidance, in some cases with intraamniotic KCL injection, followed by serum HGC weekly level monitoring. (8.9)
If the diagnosis is made before bleeding, there is an option to decrease the trophoblastic invasion by establishing conservative medical treatment with methotrexate or etoposide. (10)
The patient is a 28 years old primigravida, who presented complaining of slight vaginal bleeding and a positive home pregnancy test. She was 3.5 weeks dated by last menstrual period. Transvaginal ultrasound revealed no evidence of gestational sac; in the left ovary there was an anechoic image of 2 x 1 cm, suggestive of corpus luteum. Beta HGC was 1410 mIU/ml. Patient was stable and plan to repeat US in 1 week and serial HCG level was made. At 4.5 weeks the repeat HCG level was 4878 mIU/ml. The ultrasound examination revealed uterine cavity with an empty 10 mm gestational sac without fetal pole, there was an evident yolk sac at the endocervical region (Image 1). Medical management with methotrexate 1 mg/kg/day on days 1,3,5 and 7, with rescue therapy of folic acid on days 2,4,6 and 8 with intended maximum 4 doses was started.
After one week the repeat HGC: 7,344 mIU/ml. At that point an additional 50 mg of methotrexate were administered IM and decision was made to proceed with operative hysteroscopy with a Bettocchi hysteroscope. The cervix was located by vaginoscopic approach which revealed a protruding red mass with a diameter of approximately 3 cm, and the presence of a gestational sac implanted in the endocervix was confirmed. (Image 2) Coagulation and subsequent cut with bipolar spring electrode (screw) using VersaPoint generator (Gynecare) starting from lateral to medial until complete coagulation of implantation site was achieved with consequent excision. (Image 3) To complete the excision of the surgical specimen, a speculum was placed in the vagina and the gestational sac was removed using ring forceps. (Image 4)
Pathology confirmed the presence o endocervical epithelium and chorionic villi. Hysteoslpingogram performed 3 months postoperatively showed endocervical canal, uterus and bilateral patent normal fallopian tubes. (Image 5)
Although mortality rates have declined from 45% to almost 0%, conservative management of this condition is not always without complications. There is no consensus on the best medical or surgical treatment of cervical ectopic pregnancy. The management of this pathology is based on anecdotic information. Many questions remain only answered with no solid medical evidence. What is the best gestational age to treat this pathology? What is the proper use of methotrexate and KCL? What are risk factors for poor outcome? Are there contraindications for a conservative approach?
We believe that operative hysteroscopy, in expert hands, is a safe alternative for the treatment of cervical ectopic pregnancy in patients who desire future fertility.
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