A rare case of cervical ectopic pregnancy treated successfully with single-dose methotrexate Havaldar NA, Naik K, Krishna LG

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CASE REPORT

Year : 2012 | Volume : 1 | Issue : 3 | Page : 156-158

A rare case of cervical ectopic pregnancy treated successfully with single-dose methotrexate

Nusrat A Havaldar, Kusuma Naik, Linge Gowda Krishna
Department of Obstetrics and Gynecology, P.E.S. Institute of Medical Sciences and Research, Kuppam, India

Date of Web Publication

15-Jan-2013

Correspondence Address:
Nusrat A Havaldar
Assistant Professor, Department of Obstetrics and Gynecology, PESIMSR, Kuppam - 517 425
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2278-0521.106086

Abstract

Cervical pregnancy is the implantation of pregnancy in the endocervical canal; it is an infrequent form of ectopic gestation which accounts for 0.15% of all ectopic pregnancies. Diagnosis and treatment has changed dramatically in the last 20 years. Early detection by endovaginal ultrasound is desirable in order to plan management early and avoid serious and often life-threatening complications. A 24-year-old lady presented with 6 weeks of amenorrhoea with vaginal bleeding. She was diagnosed to have cervical ectopic pregnancy on ultrasound and was successfully treated with single-dose methotrexate.

Keywords: Cervical ectopic, methotrexate, β-human chorionic gonadotropin

How to cite this article:
Havaldar NA, Naik K, Krishna LG. A rare case of cervical ectopic pregnancy treated successfully with single-dose methotrexate. Saudi J Health Sci 2012;1:156-8

How to cite this URL:
Havaldar NA, Naik K, Krishna LG. A rare case of cervical ectopic pregnancy treated successfully with single-dose methotrexate. Saudi J Health Sci [serial online] 2012 [cited 2023 Jun 9];1:156-8. Available from: https://www.saudijhealthsci.org/text.asp?2012/1/3/156/106086

Introduction

Cervical ectopic pregnancy was first described in 1817. Cervical pregnancy is a rare form of ectopic pregnancy with an estimated incidence of 1 in 9000 deliveries. ^[1] The incidence is increasing because of assisted reproduction, especially after in vitro fertilization and embryo transfer. Prior dilatation and curettage also contributes significantly. In the past, hysterectomy was often the only choice available because of associated severe hemorrhage. Use of transvaginal sonography and β-human chorionic gonadotropin (β-hCG) allowed early diagnosis of cervical ectopic pregnancy and fertility-sparing treatment options. ^[2] Early nonsurgical diagnosis and timely treatment have resulted in a dramatic decline in mortality due to ectopic pregnancy. ^[3] Treatment with methotrexate (MTX), a folic acid antagonist highly toxic to rapidly replicating tissues, now reportedly achieves results comparable to surgery for the treatment of appropriately selected cervical ectopic pregnancies and is used commonly.

Case Report

A 24-year-old gravida 2, abortion 1 presented to our OPD with 6 weeks of amenorrhea and positive urine pregnancy test with spotting per vagina since 2 days. She was married since 4 years and had previous history of dilatation and curettage for induced abortion at 2 months of amenorrhea. On examination, the patient was hemodynamically stable. Pelvic scan showed no evidence of intrauterine pregnancy; transvaginal ultrasound showed gestational sac in cervical canal with regular yolk sac corresponding to 5 weeks of gestation, internal os was closed, and cervix was normal in length. Uterus was normal in shape and measured 7.6 × 3.6 × 5.3 cm, and endomyometrial echoes were normal [Figure 1].

Figure 1: Transvaginal ultrasound image shown in the sagittal view. The image demonstrates an empty uterus with a gestational sac in the cervical canal corresponding to 5 weeks of gestation

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All her routine investigations were normal. Since the patient desired future fertility, conservative management with single-dose methotrexate of 50 mg given intramuscularly was done. β-hCG before administration of methotrexate was 1940 mIU/ml. One day after starting chemotherapy, the patient had vaginal bleeding and passed out a clot. This was sent for histopathologic examination which showed features consistent with products of conception [Figure 2].

Figure 2: Histopathology section showing placental tissue with the villi and anchoring trophoblastic tissue

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Thereafter, the patient had vaginal spotting and a repeat transvaginal scan done 4 days after initiating chemotherapy showed collapsed sac in the cervical canal. The patient was discharged 6 days after admission and remained well during her outpatient follow-up visits. The patient's serum β-hCG levels on day 4, day 7, day 14, and day 21 were 200, 50, 5, and 1 mIU/ ml, respectively. She was followed with serum β-hCG levels till three consecutive samples were negative. Ultrasonography after 4 weeks of methotrexate therapy showed no evidence of retained products of conception [Figure 3].

Figure 3: Transabdominal ultrasound image of post-methotrexate therapy shows no evidence of products of conception

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Discussion

Cervical pregnancy is a rare form of ectopic pregnancy associated with increased morbidity and mortality. Cervical pregnancy is defined as the implantation of the conceptus below the level of the internal os. Although the exact etiology of cervical pregnancy is still uncertain and may be multifactorial, intrauterine adhesions, cesarean sections, fibroids, previous therapeutic abortions, and in vitro fertilization (IVF) have all been associated with cervical implantation. Cervical pregnancy occurs in 0.1% of IVF pregnancies and accounts for 3.7% of IVF ectopic gestations.

Vaginal bleeding, which is often profuse, is the most common presenting symptom of cervical pregnancy. ^[4] Lower abdominal pain or cramps occur in less than one-third of women. In one series, with an average gestational age of 9 weeks, the cervix was enlarged, globular, or distended in 86% of cases, whereas the uterus was enlarged in 54%. ^[4] Speculum examination is found to be more informative and less likely to result in bleeding than bimanual examination. The external os is often open, showing membranes or pregnancy tissue. Cervical pregnancy carries a significant risk of hemorrhage with the possible need for a hysterectomy to control the bleeding. Improved access to transvaginal ultrasound scanning facilities and the rapid assay of β-hCG means that most ectopic pregnancies, including cervical pregnancies, are now detected earlier. As a result of diagnosis earlier in gestation, women have lower serum β-hCG levels, are clinically more stable, and can therefore be offered conservative management. ^[5]

The traditional treatment of cervical pregnancy is dilatation and curettage. However, due to the poor hemostatic properties of cervical tissue, the procedure is often associated with massive bleeding. Options for medical treatment include local or systemic injection of methotrexate and local injection of potassium chloride in the presence of fetal cardiac activity. Conservative surgical treatment includes dilatation and curettage, cervical cerclage, intracervical balloon tamponade, local hemostatic sutures, local injection of prostaglandin, ligation of the descending branches of the uterine arteries, uterine artery embolization, and bilateral hypogastric artery ligation. ^{[6],[7],[8],[9],[10]}

Medical management of a cervical pregnancy is preferred, and surgical techniques are generally used only when chemotherapy fails or in emergency situations when a woman, usually undiagnosed, presents with life-threatening acute hemorrhage. Medical treatment protocols for methotrexate were established in the late 1980s and have become a widely accepted primary treatment for ectopic pregnancy. The two commonly used methotrexate treatment regimens are multiple dose and single dose. Methotrexate can be administered intramuscularly, orally, and directly injected into the ectopic mass.

Predictors of methotrexate treatment failure: ^[11],[12]

Adnexal fetal cardiac activity
Size and volume of the gestational mass (>4 cm)
High initial hCG concentration (>5000 mIU/ml)
Presence of free peritoneal blood
Rapidly increasing hCG concentrations (>50%/48 h) before methotrexate
Continued rapid rise in hCG concentrations during methotrexate.

The mean time interval between elimination of the cervical pregnancy by methotrexate and the awareness of subsequent conception was 8 months, as averaged from the sum of five available data sources. ^{[13],[14],[15],[16],[17]}

Conclusion

The diagnosis of ectopic pregnancy in patients who present with first trimester bleeding and pelvic pain is an important and often difficult diagnosis to make. It is important to be aware of the different variants of ectopic pregnancy and their appearance on sonogram. A cervical pregnancy is an important variant that is confusing in its ultrasound appearance. Correct identification may enable conservative and safe medical management.

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