Management of Cervical Ectopic Pregnancies

Abstract

OBJECTIVE: To investigate published cases of cervical ectopic pregnancy between 2000 and 2018 and compare management strategies and treatment success rates based on initial patient characteristics. METHODS: PubMed, EMBASE, and Web of Science were searched to capture peer-reviewed citations published between 2000 and 2018. Cases reporting either β-hCG level, crown–rump length, or gestational sac diameter for each individual patient were included. Data regarding the article information, patient characteristics, treatment used, and outcomes were collected. Initial success was defined as resolution of the cervical ectopic pregnancy with the predefined treatment plan. Initial failure was defined as the requirement of additional unplanned interventions due to the predefined treatment plan not being successful. End success was defined as resolution of the cervical ectopic pregnancy without hysterectomy. RESULTS: A total of 204 articles from 44 countries comprising 454 cases were reviewed. The initial β-hCG level ranged from 9 to 286,500, with a median of 14,773, and gestational age ranged from 4 to 18 weeks, with an average of 7 4/7 weeks (±2 0/7 weeks). In looking at initial success, compared with methotrexate alone, dilation, and curettage (odds ratio [OR] 2.26; 95% CI 2.64–10.45), dilation and curettage combined with uterine artery embolization (OR 4.85; 95% CI 2.06–11.44) and uterine artery embolization (OR 5.17; 95% CI 1.14–23.53) were more effective options. More than half of patients (50.2%) required multiple interventions, and 41 (9%) resulted in hysterectomy. CONCLUSIONS: Management of cervical ectopic pregnancies should be guided by patient stability, β-hCG level, size of pregnancy, and fetal cardiac activity but may benefit from a planned multimodal approach.

Embarazo ectópico cervical. Presentación de caso clínico

“…Existen dos vías de tratamiento; el conservador que se puede aplicar a pacientes hemo dinámicamen-te estables y que consiste en el uso de metrotexato local y sistémico, embolización de arteria uterina, aspiración y legrado uterino. Otra alternativa es el manejo quirúrgico mediante histerectomía que se debe aplicar, en paciente que se encuentra con sangrado masivo, en estado inestable, con riesgo de muerte o en pacientes que ya no tienen deseos de preservar la fertilidad (14).…”

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

“…Cervical and cesarean scar pregnancies can both additionally be treated with ultrasound-guided intrasac injection of methotrexate. 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.…”

“…Dilation and curettage was associated with a 75.3% success rate. 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…”

A diagnostic dilemma of an 18-week cervical ectopic pregnancy: A case report

“…Risk factors for CEP include in vitro fertilisation, cigarette smoke and previous uterine surgery, such as cervical dilation, uterine curettage or caesarean section [ 4 , 5 ]. An accurate diagnosis at early gestation allows appropriate planning and management of CEP using a combination of systemic or intra-sac methotrexate, uterine artery embolization and ultrasound guided endocervical curettage, with the aim to preserve fertility [ 6 , 7 ].…”