Fertility Preservation in Heterotopic Cervical Pregnancy: What Is the Best Procedure?

Abstract

We describe a patient who underwent assisted reproduction techniques and was diagnosed with heterotopic cervical pregnancy, and then discuss the management of this entity, which is rare and has no standard protocols. Treatment consisted of intra-arterial methotrexate (50 mg/m² body surface area) and simultaneous selective embolization of uterine arteries. The literature is also reviewed to identify other approaches and outcomes.

Conservative management of cervical ectopic pregnancy: Single‐center experience

“…Treatment of cervical ectopic pregnancy is one of the most problematic issues in the area of early gestational complications. Because of historical narratives associating surgical treatment of CEP with maternal morbidity and mortality, non‐surgical approaches have been sought, and preferred where available . For this purpose, MTX, which is an anti‐metabolite drug known for its ability to kill trophoblastic cells, has been used in the treatment of CEP.…”

“…Because of historical narratives associating surgical treatment of CEP with maternal morbidity and mortality, non-surgical approaches have been sought, and preferred where available. [7][8][9]12 For this purpose, MTX, which is an anti-metabolite drug known for its ability to kill trophoblastic cells, has been used in the treatment of CEP. MTX was first used in the treatment of CEP by Farabow et al 10 Subsequent studies showed that that the drug was safe and efficient, [13][14][15][16][17] but dose, schedule and follow-up protocols are yet to be determined.…”

“…Formerly, cervical pregnancy has been treated surgically, usually by hysterectomy due to the high risk of severe hemorrhage. With the advent of rapid sensitive beta‐human chorionic gonadotrophin (β‐hCG) assay, improved transvaginal ultrasound, and the widespread use of early first trimester ultrasound, most cervical pregnancies have often been diagnosed earlier in gestation, thereby enabling clinicians to pursue more conservative treatment modalities that can prevent morbidity and loss of fertility . Most reports have demonstrated high efficacy and safety of conservative medical treatment of cervical pregnancy with systemic or local methotrexate (MTX), uterine artery embolization, or dilation and curettage (D&C) with Foley's balloon tamponade, but there is still no consensus among clinicians regarding the standard care for CEP.…”

Cervical pregnancy: A report of four cases

“…There are many protocols to administrate MTX for cervical pregnancy . We presented four cases successfully managed by transcatheter MTX injection into bilateral uterine arteries without embolization.…”

Cervical pregnancy with massive bleeding after treatment with methotrexate

“…In the past two decades with the advent of transvaginal sonography, which can facilitate an earlier diagnosis, conservative management is therefore more commonly practiced. A variety of approaches have been proposed,10 including dilation and evacuation combined with Foley balloon tamponade, methotrexate with/without KCL injection, uterine artery embolisation4 12 and ligation of cervical branches of uterine arteries. The most commonly reported medical treatments are methotrexate, either local injection (intra-amniotic or intrafetal)1 13 14 or systemic administration,2 3 7 9 15–17 commonly used in conjunction with fetal KCL injection 15 18.…”