Viable invasive cervical pregnancy treated with minimally invasive procedures

Overview

With an incidence of 1% of all ectopic pregnancies, cervical ectopic pregnancy (CEP) is due to possible early misdiagnosis or bleeding and rupture can become a life-threatening condition with the need for urgent hysterectomy, which has been seen in clinical practice recently. We present a case of early diagnosed invasive CEP treated with combined minimally invasive procedure (MIP) due to acute pelvic pain and bleeding. In our case, we applied several of these methods to a primigravida with early invasive CEP with fertility preservation. By combining the self-described local medications with uterotonics and cervical anaemia treatment, intravenous tranexamic acid and MIP, we were able to preserve the uterus with minimal blood loss and the possibility of future conception.

Keywords:

suction curettage – cervical pregnancy – cervical cerclage – haemostatic sponge – balloon tamponade

Introduction

With an incidence of 1% of all ectopic pregnancies, cervical ectopic pregnancy (CEP) is due to possible early misdiag-nosis or bleeding and rupture can become a life-threatening condition with the need for urgent hysterectomy, which has been seen in clinical practice. Early diagnosis indicates early medical therapy with methotrexate with/without uterotonics and minimally invasive procedures (MIP) such as cervical cerclage, suction curettage, balloon or gauze tamponade, hysteroscopic resection or combinations thereof [1–4]. We present a case of early diagnosed invasive CEP treated with combined MIP because of acute pelvic pain and bleeding.

Case report

A 38-year-old primigravida was admitted to the emergency unit in a gynaecological clinic because of ultrasound-verified viable CEP at 7+3 weeks of gestation after an assisted reproduction procedure (ARP) with bleeding and pelvic pain (Fig. 1). bHCG value was 4,480 mIU/mL. Doppler sonography detected early trophoblastic invasion through the entire anterior cervical wall. Because of clinical, ultrasound and laboratory findings, methotrexate 1 mg/kg and leucovorin 0.1 mg/kg were administered intramuscularly, followed by mifepristone (600 mg) and misoprostol (400 mcg) orally on the second day. After therapy, severe acute pelvic pain occurred with bleeding and a tense, livid ballooned cervix with a viable embryo with embryocardia. Doppler sonography detected early invasive malplacentation with a threatening cervical rupture. Given the above and nulliparity conditions, Shirodkar’s cerclage and bilateral cervical artery ligature were performed under general anaesthesia. Cervical anaemia treatment was done with 10 mL noradrenaline at a 1: 200 ratio, while suction cervical curettage, haemostatic sponge insertion and Foley 26 Ch balloon tamponade due to haemorrhage from the invaded thin cervical walls with tranexamic acid (1.0 g) and carboprost tromethamine before and after procedure were performed. Blood loss was less than 300 mL. After 24 h, the balloon tamponade was removed, and the cerclage suture was removed after eight days. bHCG was in significant decline (211 mIU/mL) with complete recovery of the patient. Unfortunately, one year after CEP, after a repeated ARP, a right tubal pregnancy developed, for which a salpingectomy was performed.

Discussion

In our case, we applied several of these methods to a primigravida with early invasive CEP with fertility preservation. ARP, previous caesarean section and cervical operative procedures are risk factors for CEP [5]. Early diagnosis of low cervicoistmic implantation with strong Doppler signals in the cervical wall are signs of early trophoblastic invasion and invasive malplacentation. Due to inadequate implantation in cervical tissue because of a low percentage of myofibrils, the possibility of invasive, early morbid placentation is high with a higher percentage of complications (cervical rupture, severe haemorrhage, obstetrics shock development, need for hysterectomy) [5].

There are individual case reports or small case series on MIP in CEP treatment, so any contribution to addressing this emerging and potentially life-threatening condition is worthwhile. The use of local vasoconstrictors with or without uterotonics significantly reduces bleeding and allows for evacuation. Thus, Ishikawa et al [6] in 11 CEP-verified women for bleeding prevention administered ultrasound-guided injection of diluted vasopressin prior to suction curettage and achieved success in all cases with this MIP, and we used 1: 200 diluted noradrenaline with excellent cervical anaemia treatment effect. Timor Tritsch et al [7] presented a study of 18 women with CEP from 5–12 weeks of pregnancy, in addition to systemic therapy with metrotrexate ultrasound-guided placement and inflation of a Foley balloon catheter, where this was recommended as a safe method of bleeding control in CEP as a combination of drug treatment and MIP. Fylstra [8] presented MIP in the treatment of 13 patients with CEP in whom he used suction curettage and balloon tamponade. In our practice, we presented a case of unrecognized CEP with severe bleeding treated with suction curettage and cervicovaginal gauze tamponade with uterine preservation [9], with a remark on this problem 13 years later [3].

Pereira et al [1] presented use of curettage, tamponade, and cerclage due to heavy bleeding after residual CEP in a 33-year old patient three months after intra-amniotic injection of potassium chloride, methotrexate, and uterine artery embolization due to CEP. Matteo et al [2] described a case of a CEP successfully treated with methotrexate combined with hysteroscopic local endocervical resection of the heterotopic gestational sac. In addition to the described MIP, due to the invasion of the destroyed cervical wall, we successfully installed a haemostatic sponge in the bed of CEP before applying the balloon tamponade.

Conclusion

By combining our described local medications with uterotonics and cervical anaemia treatment, including intravenous tranexamic acid and MIP, we were able to preserve the uterus with minimal blood loss and the possibility of future conception.

Submitted/Doručeno: 15. 1. 2023
Accepted/Přijato: 11. 5. 2023

Anis Cerovac, MD, PhD
Department of Gynaecology and Obstetrics
General Hospital Tešanj
Braće Pobrić 17
74260 Tešanj
Bosnia and Herzegovina
cerovac.anis@gmail.com