Management of Cervical Ectopic Pregnancies: A Scoping Review

Abstract

Cervical ectopic pregnancies represent fewer than 0.1% of all ectopic pregnancies but carry increased risk of significant hemorrhage and long-term reproductive consequences if not managed properly. In part due to the rarity of their occurrence, a standard-of-care protocol for management of cervical ectopic pregnancy (EP) other than hysterectomy does not exist. A trend toward more conservative management has broadened the literature; however, it is unclear what clinical characteristics can be used to guide choice of treatment.This retrospective study aimed to investigate published cases of cervical EP to determine how initial patient characteristics may be used to guide management strategies based on treatment success rate. PubMed, EMBASE, and Web of Science were searched for peer-reviewed citations published between 2000 and 2018. Included cases reported one of the following: initial β-human chorionic gonadotropin (β-hCG), crown-rump length (CRL), or gestational sac diameter. Cases were excluded that reported heterotopic pregnancy, were a result of in vitro fertilization, or included cervicoisthmic pregnancy. Patient characteristics abstracted from studies included age, gravidity, parity, initial β-hCG, CRL, gestational sac diameter, presence of fetal cardiac activity, and hemodynamic stability at initial presentation. Also abstracted were outcomes including initial treatment success and failure defined as resolution of cervical EP with the predefined treatment plan and requirement of additional and unplanned interventions due to predefined treatment plan failure, respectively. The primary exposure variable was the treatment, which was divided into systemic methotrexate (MTX), uterine artery embolization (UAE), dilatation and curettage (D&C), potassium chloride, MTX + UAE, D&C + UAE, and other. The primary study outcome was the initial success of planned treatments provided to the patient.A total of 204 articles from 44 countries including 454 cases were reviewed. Median β-hCG was 14,733 mIU/mL and median gestational age 7 weeks 4 days. Compared with MTX alone, other treatment methods had an increased likelihood of initial treatment success including UAE (

Cervical Ectopic and Cesarean Scar Pregnancies: Navigating the Differential of an Abnormal Lower Uterine Pregnancy

“…Similar to treatment of tubal ectopic pregnancy, methotrexate is more effective in treating cervical and cesarean scar pregnancies at lower βhCG levels, earlier gestational ages, and with no evidence of embryonic cardiac activity. 5,23,25 Absolute contraindications to methotrexate therapy include immunodeficiency, significant cytopenia, allergy, active pulmonary or peptic ulcer disease, clinically important hepatic or renal dysfunction, breastfeeding, evidence of pregnancy rupture or hemodynamic instability, and inability to participate in follow-up. Before administration, it is important to check a CBC with differential, a βhCG level, liver function tests, creatinine, and a type and screen.…”

“…The largest complication rate associated with treatments was hemorrhage requiring transfusion, which was indicated in 2% of patients undergoing UAE and 29.4% of those undergoing dilation and curettage. 5 It is important to explore the patient's desire for future fertility when considering UAE, given the theoretical concern for subsequent ischemia resulting in endometrial and/or ovarian damage. Both the American College of Obstetricians and Gynecologists and the Society of Interventional Radiology identify future fertility as a relative contraindication to this procedure.…”

“…That said, successful pregnancies have been documented after UAE, with a subsequent pregnancy rate as high as 44%. 5,30 Other case reports have described the other aforementioned surgical treatments. Hysteroscopic resection has shown promising results in small case series.…”

“…There are currently no studies explicitly examining the rates and risks of subsequent pregnancy after conservative treatment of a cervical ectopic pregnancy, though successful subsequent pregnancies have been documented. In the aforementioned review of management of 454 cervical pregnancies by Fowler et al, 5 there were 33 cases of future pregnancy recorded. These data are somewhat difficult to interpret, given that 344 of the cases included in the study did not comment on future pregnancy.…”

“…They account for fewer than 1% of all ectopic pregnancies with a reported incidence of anywhere from 1 in 2000 to 1 in 18,000. 4,5 Pregnancies can also implant abnormally into a previous cesarean delivery scar. Some experts do not consider this an ectopic pregnancy, as the pregnancy can grow into the uterine cavity, though these pregnancies are dangerous and abnormal.…”