Manejo conservador en una paciente con embarazo ectópico cervical en Nariño, Colombia: reporte de caso y revisión de la literatura

Abstract

RESUMENObjetivos: reportar el caso de un embarazo cervical (EC) que recibió manejo conservador exitoso y realizar una revisión de la literatura sobre el tratamiento médico y quirúrgico conservador. Materiales y métodos: se presenta el caso de una paciente con embarazo cervical, quien recibió manejo farmacológico con metotrexate (MTX) y posterior legrado con evolución clínica satisfactoria. Se realizó una búsqueda de artículos en Medline vía PubMed, LILACS, SciElo y Google académico con los términos: "cervical ectopic pregnancy", "conservative treatment", "curettage", "methotrexate", ABSTRACT Objectives: To report a case of cervical pregnancy (CP) treated successfully with a conservative approach, and to conduct a review of the literature regarding conservative medical and surgical treatment. Materials and Methods: Patient with cervical pregnancy treated pharmacologically with methotrexate (MTX) followed by dilation and curettage, with a satisfactory clinical course. A search of articles was conducted in Medline via PubMed, LILACS, SciElo and Google Scholar using the terms "cervical ectopic pregnancy," "conservative treatment," "curettage,» "methotrexate," "uterine artery embolization," "hysteroscopy." Reports and case series were selected of patients with cervical pregnancy diagnosed on ultrasound at any gestational age, subjected to conservative medical or surgical treatment. Results: A total of 22 studies were included; 95 patients with CP treated with MTX were identified, 93 of them successfully treated. The most frequent complication was bleeding in 12%; 26% required complementary surgical treatment. Increasingly, uterine artery embolization (UAE) is carried out preventatively (7 cases) before curettage or treatment with MTX. The hysteroscopy is another recent alternative (20 cases). Abdominal hysterectomy was required in two cases, one of which was a cervico-isthmic pregnancy. Conclusions:Treatment with MTX continues to be the most frequent strategy. Dilation and curettage with endocervical plugging may be an option to consider in the emergency management of EP in primary care institutions. In institutions equipped with high complexity technology, uterine artery embolization before the surgical procedure and histeroscopy are options to be considered. Considering that early diagnosis of EP is now possible, multi-center studies comparing different management options are needed for better assessment of their safety and effectiveness.

A Systematic Review about Cervical Pregnancy and our Experience

“…Persadie et al reported the administration of multiple doses of methotrexate followed by removal with forceps and curettage, a therapeutic method that resulted in septicemia caused by E. Coli [ 24 ]. Bolaños-Bravo et al mentioned a more sophisticated approach in which they combined the systematic administration of methotrexate followed by dilation and curettage, and subsequently the placement of a Foley catheter, to prevent any potential urgent hemorrhage [ 16 ].…”

Cervical Ectopic Pregnancy: A Multidisciplinary Approach

“…The ultrasound criteria to establish the diagnosis consists of the 1) absence of an intrauterine pregnancy, 2) presence of a gestational sac below the level of the internal cervical os, 3) absence of a sliding sign, and 4) presence of flowing blood around the gestational sac detected by Doppler [6]. Other additional signs include closed internal cervical os, an "8" or hourglass uterine shape (because of the ballooned cervical canal), endometrial decidualization, and the presence of embryonic structures in the ectopic gestational sac [7]. Regarding ultrasound features, cervical pregnancy can easily be misdiagnosed as scar pregnancy.…”

“…In these cases, combined therapy with intra-amniotic methotrexate may increase the effectiveness of the treatment. In the presence of a heartbeat, an intraamniotic administration of potassium chloride for embryocide or feticide is also recommended [7]. Some authors describe beneficial effects in aspiration and injection of approximately equal amounts of volume into the cavity when performing the intra-amniotic injection, so the internal pressure does not vary.…”

“…However, due to the lack of smooth muscle tissue in the cervical region, there is a predisposition to massive bleeding during conservative surgery, which often requires an emergent hysterectomy to control hemorrhage [5]. Therefore, adjuvant measures to reduce blood loss post-or pre-procedure are recommended and include tamponade with a Foley balloon catheter or reduction of blood supply by vasopressor/prostaglandin cervical injections, cervical cerclage, surgical ligation of cervical/uterine/internal iliac arteries, and arterial embolization [2,7,8]. According to updated references, the use of uterine artery embolization in obstetric and gynecological emergencies has high efficacy and few complications [3,10].…”