Embarazo ectópico cervical: diagnóstico preciso y enfoque de manejo médico. Reporte de caso
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feb 12, 2018
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Resumen
El embarazo ectópico cervical es una condición exótica. Su diagnóstico y manejo plantean un desafío importante, dada su asociación con desenlaces maternos graves. La sospecha clínica y la juiciosa aplicación de los criterios diagnósticos permiten establecer modalidades de terapia conservativa. Este artículo reporta un caso de embarazo ectópico cervical con diagnóstico de imágenes de ultrasonido y resonancia nuclear magnética en el que se administró tratamiento con metotrexato. El seguimiento clínico, de los exámenes paraclínicos y de ultrasonido mostraron la resolución completa de la condición. Se revisan aspectos relacionados con el diagnóstico y tratamiento.
Keywords
pregnancy ectopic, ultrasonography, magnetic resonance spectroscopy, Methotrexateembarazo ectópico, cuello del útero, ultrasonografía, espectroscopia de resonancia magnética, metotrexato
References
1. National Center for Biotechnology Information. Pregnancy, ectopic [internet]. Disponible en: http://www.ncbi.nlm.nih.gov/mesh/?term=ectopic+pregnancy.
2. Confidential Enquiry into Maternal and Child Health. Saving mothers’ lives: Reviewing manternals deaths to make motherhood safer: 2003-2005 [internet]. London: CEMACH; 2007. Disponible en: http://www.publichealth.hscni.net/sites/default/files/Saving %20Mothers %27 %20Lives %202003-05 %20.pdf
3. Centers for Disease Control and Prevention (CDC). Ectopic pregnancy—United States, 1990-1992. MMWR Morb Mortal Wkly Rep. 1995 Jan 27;44(3):46-8.
4. Goldner TE, Lawson HW, Xia Z, Atrash HK. Surveillance for ectopic pregnancy--United States, 1970-1989. MMWR CDC Surveill Summ. 1993 Dec 17;42(6):73-85.
5. Ruiz A. Embarazo ectópico. En: Ángel E, editor. Obstetricia integral: siglo 21. Bogotá: Universidad Nacional de Colombia; 2009.
6. Rodríguez DA, Acosta J. Panorama de la mortalidad materna en Colombia, 1995-2000: logros, fracasos, compromisos y retos. Inf Quinc Epidemiol Nac. 2001;6(23)-345-60.
7. Kirk E, Condous G, Haider Z, Syed A, Ojha K, Bourne T. The conservative management of cervical ectopic pregnancies. Ultrasound Obstet Gynecol. 2006;27:430-7.
8. Oliver R, Malik M, Coker A, Morris J. Management of extra-tubal and rare ectopic pregnancies: case series and review of current literature. Arch Gynecol Obstet. 2007;276:125-31.
8. Gómez JA. 95 casos de embarazo ectópico. Rev Colomb Obstetr Ginecol. 1954;4:17-89.
9. Timor-Tritsch IE, Monteagudo A, Mandeville EO, Peisner DB, Anaya GP, Pirrone EC. Successful management of viable cervical pregnancy by local injection of methotrexate guided by transvaginal ultrasonography. Am J Obstet Gynecol. 1994 Mar;170(3):737-9.
10. Herrera E, Otero E, Hincapié LC, Camacho R, Gómez G, Quintero CH, et al. Heterotopic pregnancy: Presentation of four cases. Colomb Med [internet]. 2011 [citado 2015 Feb 22];42(4):518-22. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S1657-95342011000400013&lng=en.
11. Verma U, Goharkhay N. Conservative management of cervical ectopic pregnancy. Fertil Steril. 2009 Mar;91(3):671-4. doi: 10,1016/j.fertnstert.2007,12,054.
12. Brinsden PR, Smith B, Craft IL. Cervical ectopic pregnancy following gamete intrafallopian transfer. J In Vitro Fert Embryo Transf. 1988 Dec;5(6):370-2.
13. Balasch J, Peñarrubia J, Ballescá JL, Creus M, Casamitjana R, Vanrell JA. Intra-uterine insemination, cervical pregnancy and successful treatment with methotrexate. Hum Reprod. 1994 Aug;9(8):1580-3.
14. Giarenis I, Shenoy J, Morris E. Cervical ectopic pregnancy after endometrial ablation: A case report. Arch Gynecol Obstet. 2008 Jun;277(6):567-9.
15. Ahmadi F, Irani S. Cervical ectopic pregnancy following assisted reproductive technology: A case report. Int J Fertil Steril. 2012 Oct;6(3):201-4.
16. Pantelis A, Daniilidis A, Dinas K. Conservative treatment of a 7 weeks cervical ectopic pregnancy after intra-uterine insemination. Hippokratia. 2013 Jan;17(1):95.
17. Anev I, Wang J, Palep-Singh M, Seif MW. Monochorionic diamniotic twin cervicalectopic pregnancy following assisted conception: a case report. J Reprod Med. 2013 Sep-Oct;58(9-10):445-7.
18. Giorgio B, Ball KG, Ogden S, Verco PW, Finikiotis G. Cervical ectopic pregnancy--case report. Aust N Z J Obstet Gynaecol. 1980 Aug;20(3):164-7.
19. Hingorani SR, Parulekar SV, Ratnam KL. Isthmico-cervical ectopic pregnancy following caesarean section. J Postgrad Med. 1994 Jan-Mar;40(1):33-5.
20. Gun M, Mavrogiorgis M. Cervical ectopic pregnancy: a case report and literature review. Ultrasound Obstet Gynecol. 2002 Mar;19(3):297-301.
21. Cerveira I, Costa C, Santos F, Santos L, Cabral F. Cervical ectopic pregnancy successfully treated with local methotrexate injection. Fertil Steril. 2008 Nov;90(5):2005.e7-2005.e10. doi: 10,1016/j.fertnstert.2008,01,017.
22. Yu B, Douglas NC, Guarnaccia MM, Sauer MV. Uterine artery embolization as an adjunctive measure to decrease blood loss prior to evacuating a cervical pregnancy. Arch Gynecol Obstet. 2009 May;279(5):721-4. doi: 10,1007/s00404-008-0775-4.
23. Raskin MM. Diagnosis of cervical pregnancy by ultrasound: a case report. Am J Obstet Gynecol. 1978 Jan 15;130(2):234-5.
24. Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol. 1996 Dec;8(6):373-80.
25. Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y. Fast MR imaging in obstetrics. Radiographics. 2002 May-Jun;22(3):563-80.
26. Tamai K, Koyama T, Togashi K. MR features of ectopic pregnancy. Eur Radiol. 2007 Dec;17(12):3236-46.
27. Jung SE, Byun JY, Lee JM, Choi BG, Hahn ST. Characteristic MR findings of cervical pregnancy. J Magn Reson Imaging. 2001;13(6):918-22.
28. Yoshigi J, Yashiro N, Kinoshita T, O'uchi T, Kitagaki H. Diagnosis of ectopic pregnancy with MRI: efficacy of T2*-weighted imaging. Magn Reson Med Sci. 2006 Apr;5(1):25-32.
29. Kataoka ML, Togashi K, Kobayashi H, Inoue T, Fujii S, Konishi J. Evaluation of ectopic pregnancy by magnetic resonance imaging. Hum Reprod. 1999 Oct;14(10):2644-50.
30. Takashima M, Yamasaki M, Fujita I, Ohashi M, Matsuo H, Mochizuki M, Kitagaki H, Kono M. Enhanced magnetic resonance imaging in monitoring of conservative treatment of cervical pregnancy. J Obstet Gynaecol. 1995 Dec;21(6):545-50.
31. Studdiford WE. Cervical pregnancy: A partial review of the literature and a report of two probable cases. Am J Obstet Gynecol. 1945;49(2):169-85.
32. Morton DG. Cervical pregnancy; a report of two cases and a discussion of the treatment. Am J Obstet Gynecol. 1949 May;57(5):910-7.
33. Chetty M, Elson J. Treating non-tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol. 2009;23(4):529-38. doi: 10,1016/j.bpobgyn.2008,12,011
34. Hosni MM, Herath RP, Mumtaz R. Diagnostic and therapeutic dilemmas of cervical ectopic pregnancy. Obstet Gynecol Surv. 2014 May;69(5):261-76. doi: 10,1097/OGX.0000000000000062.
35. Aboulghar MA, Mansour RT, Serour GI. Transvaginal injection of potassium chloride and methotrexate for the treatment of tubal pregnancy with a live fetus. Hum Reprod. 1990;5:887-8.
36. Altaras M, Cohen I, Cordoba M, Ben-Nun I, Ben-Aderet N. Treatment of an interstitial pregnancy with actinomycin D: case report. Br J Obstet Gynaecol. 1988;95:1321-3.
37. Gazvani MR, Emery SJ. Mifepristone and methotrexate: the combination for medical treatment of ectopic pregnancy. Am J Obstet Gynecol. 1999;180:1599-1600.
38. Kenigsberg D, Porte J, Hull M, Spitz IM. Medical treatment of residual ectopic pregnancy: RU 486 and methotrexate. Fertil Steril. 1987;47:702-3.
39. Lindblom B, Hahlin M, Lundorff P, Thorburn J. Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2 alpha. Fertil Steril. 1990;54:404-8.
40. Lang PF, Weiss PA, Mayer HO, Haas JG, Honigl W. Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2 alpha: A prospective randomised study. Lancet. 1990;336:78-81.
41 Marret H, Fauconnier A, Dubernard G, Misme H, Lagarce L, Lesavre M, et al.. Overview and guidelines of off-label use of methotrexate in ectopic pregnancy: Report by CNGOF. Eur J Obstet Gynecol Reprod Biol. 2016;205:105-9.
42. Stika CS. Methotrexate: the pharmacology behind medical treatment for ectopic pregnancy. Clin Obstet Gynecol. 2012 Jun;55(2):433-9. doi: 10,1097/GRF.0b013e3182510a35.
43. Hertz R, Li MC, Spencer DB. Effect of methotrexate therapy upon choriocarcinoma and chorioadenoma. Proc Soc Exp Biol Med. 1956 Nov;93(2):361-6.
44. Tanaka T, Hayashi H, Kutsuzawa T, Fujimoto S, Ichinoe K. Treatment of interstitial ectopic pregnancy with methotrexate: report of a successful case. Fertil Steril. 1982 Jun;37(6):851-2.
45. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008 Jun;111(6):1479-85.
46. Varma R, Mascarenhas L. Evidence-based management of ectopic pregnancy. Reprod Med Rev. 2001;9(1):49-75.
47. Mitra AG, Harris-Owens M. Conservative medical management of advanced cervical ectopic pregnancies. Obstet Gynecol Surv. 2000 Jun; 55(6):385-9.
48. Chrestiana D, Cheng AB, Panebianco NL, Dean AJ. Pitfalls in cervical ectopic pregnancy diagnosis by emergency physicians using bedside ultrasonography. Am J Emerg Med. 2014 Apr;32(4):397.e1-3. doi: 10,1016/j.ajem.2013,10,055.
49. Vela G, Tulandi T. Cervical pregnancy: the importance of early diagnosis and treatment. J Minim Invasive Gynecol. 2007 Jul-Aug;14(4):481-4.
2. Confidential Enquiry into Maternal and Child Health. Saving mothers’ lives: Reviewing manternals deaths to make motherhood safer: 2003-2005 [internet]. London: CEMACH; 2007. Disponible en: http://www.publichealth.hscni.net/sites/default/files/Saving %20Mothers %27 %20Lives %202003-05 %20.pdf
3. Centers for Disease Control and Prevention (CDC). Ectopic pregnancy—United States, 1990-1992. MMWR Morb Mortal Wkly Rep. 1995 Jan 27;44(3):46-8.
4. Goldner TE, Lawson HW, Xia Z, Atrash HK. Surveillance for ectopic pregnancy--United States, 1970-1989. MMWR CDC Surveill Summ. 1993 Dec 17;42(6):73-85.
5. Ruiz A. Embarazo ectópico. En: Ángel E, editor. Obstetricia integral: siglo 21. Bogotá: Universidad Nacional de Colombia; 2009.
6. Rodríguez DA, Acosta J. Panorama de la mortalidad materna en Colombia, 1995-2000: logros, fracasos, compromisos y retos. Inf Quinc Epidemiol Nac. 2001;6(23)-345-60.
7. Kirk E, Condous G, Haider Z, Syed A, Ojha K, Bourne T. The conservative management of cervical ectopic pregnancies. Ultrasound Obstet Gynecol. 2006;27:430-7.
8. Oliver R, Malik M, Coker A, Morris J. Management of extra-tubal and rare ectopic pregnancies: case series and review of current literature. Arch Gynecol Obstet. 2007;276:125-31.
8. Gómez JA. 95 casos de embarazo ectópico. Rev Colomb Obstetr Ginecol. 1954;4:17-89.
9. Timor-Tritsch IE, Monteagudo A, Mandeville EO, Peisner DB, Anaya GP, Pirrone EC. Successful management of viable cervical pregnancy by local injection of methotrexate guided by transvaginal ultrasonography. Am J Obstet Gynecol. 1994 Mar;170(3):737-9.
10. Herrera E, Otero E, Hincapié LC, Camacho R, Gómez G, Quintero CH, et al. Heterotopic pregnancy: Presentation of four cases. Colomb Med [internet]. 2011 [citado 2015 Feb 22];42(4):518-22. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S1657-95342011000400013&lng=en.
11. Verma U, Goharkhay N. Conservative management of cervical ectopic pregnancy. Fertil Steril. 2009 Mar;91(3):671-4. doi: 10,1016/j.fertnstert.2007,12,054.
12. Brinsden PR, Smith B, Craft IL. Cervical ectopic pregnancy following gamete intrafallopian transfer. J In Vitro Fert Embryo Transf. 1988 Dec;5(6):370-2.
13. Balasch J, Peñarrubia J, Ballescá JL, Creus M, Casamitjana R, Vanrell JA. Intra-uterine insemination, cervical pregnancy and successful treatment with methotrexate. Hum Reprod. 1994 Aug;9(8):1580-3.
14. Giarenis I, Shenoy J, Morris E. Cervical ectopic pregnancy after endometrial ablation: A case report. Arch Gynecol Obstet. 2008 Jun;277(6):567-9.
15. Ahmadi F, Irani S. Cervical ectopic pregnancy following assisted reproductive technology: A case report. Int J Fertil Steril. 2012 Oct;6(3):201-4.
16. Pantelis A, Daniilidis A, Dinas K. Conservative treatment of a 7 weeks cervical ectopic pregnancy after intra-uterine insemination. Hippokratia. 2013 Jan;17(1):95.
17. Anev I, Wang J, Palep-Singh M, Seif MW. Monochorionic diamniotic twin cervicalectopic pregnancy following assisted conception: a case report. J Reprod Med. 2013 Sep-Oct;58(9-10):445-7.
18. Giorgio B, Ball KG, Ogden S, Verco PW, Finikiotis G. Cervical ectopic pregnancy--case report. Aust N Z J Obstet Gynaecol. 1980 Aug;20(3):164-7.
19. Hingorani SR, Parulekar SV, Ratnam KL. Isthmico-cervical ectopic pregnancy following caesarean section. J Postgrad Med. 1994 Jan-Mar;40(1):33-5.
20. Gun M, Mavrogiorgis M. Cervical ectopic pregnancy: a case report and literature review. Ultrasound Obstet Gynecol. 2002 Mar;19(3):297-301.
21. Cerveira I, Costa C, Santos F, Santos L, Cabral F. Cervical ectopic pregnancy successfully treated with local methotrexate injection. Fertil Steril. 2008 Nov;90(5):2005.e7-2005.e10. doi: 10,1016/j.fertnstert.2008,01,017.
22. Yu B, Douglas NC, Guarnaccia MM, Sauer MV. Uterine artery embolization as an adjunctive measure to decrease blood loss prior to evacuating a cervical pregnancy. Arch Gynecol Obstet. 2009 May;279(5):721-4. doi: 10,1007/s00404-008-0775-4.
23. Raskin MM. Diagnosis of cervical pregnancy by ultrasound: a case report. Am J Obstet Gynecol. 1978 Jan 15;130(2):234-5.
24. Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol. 1996 Dec;8(6):373-80.
25. Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y. Fast MR imaging in obstetrics. Radiographics. 2002 May-Jun;22(3):563-80.
26. Tamai K, Koyama T, Togashi K. MR features of ectopic pregnancy. Eur Radiol. 2007 Dec;17(12):3236-46.
27. Jung SE, Byun JY, Lee JM, Choi BG, Hahn ST. Characteristic MR findings of cervical pregnancy. J Magn Reson Imaging. 2001;13(6):918-22.
28. Yoshigi J, Yashiro N, Kinoshita T, O'uchi T, Kitagaki H. Diagnosis of ectopic pregnancy with MRI: efficacy of T2*-weighted imaging. Magn Reson Med Sci. 2006 Apr;5(1):25-32.
29. Kataoka ML, Togashi K, Kobayashi H, Inoue T, Fujii S, Konishi J. Evaluation of ectopic pregnancy by magnetic resonance imaging. Hum Reprod. 1999 Oct;14(10):2644-50.
30. Takashima M, Yamasaki M, Fujita I, Ohashi M, Matsuo H, Mochizuki M, Kitagaki H, Kono M. Enhanced magnetic resonance imaging in monitoring of conservative treatment of cervical pregnancy. J Obstet Gynaecol. 1995 Dec;21(6):545-50.
31. Studdiford WE. Cervical pregnancy: A partial review of the literature and a report of two probable cases. Am J Obstet Gynecol. 1945;49(2):169-85.
32. Morton DG. Cervical pregnancy; a report of two cases and a discussion of the treatment. Am J Obstet Gynecol. 1949 May;57(5):910-7.
33. Chetty M, Elson J. Treating non-tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol. 2009;23(4):529-38. doi: 10,1016/j.bpobgyn.2008,12,011
34. Hosni MM, Herath RP, Mumtaz R. Diagnostic and therapeutic dilemmas of cervical ectopic pregnancy. Obstet Gynecol Surv. 2014 May;69(5):261-76. doi: 10,1097/OGX.0000000000000062.
35. Aboulghar MA, Mansour RT, Serour GI. Transvaginal injection of potassium chloride and methotrexate for the treatment of tubal pregnancy with a live fetus. Hum Reprod. 1990;5:887-8.
36. Altaras M, Cohen I, Cordoba M, Ben-Nun I, Ben-Aderet N. Treatment of an interstitial pregnancy with actinomycin D: case report. Br J Obstet Gynaecol. 1988;95:1321-3.
37. Gazvani MR, Emery SJ. Mifepristone and methotrexate: the combination for medical treatment of ectopic pregnancy. Am J Obstet Gynecol. 1999;180:1599-1600.
38. Kenigsberg D, Porte J, Hull M, Spitz IM. Medical treatment of residual ectopic pregnancy: RU 486 and methotrexate. Fertil Steril. 1987;47:702-3.
39. Lindblom B, Hahlin M, Lundorff P, Thorburn J. Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2 alpha. Fertil Steril. 1990;54:404-8.
40. Lang PF, Weiss PA, Mayer HO, Haas JG, Honigl W. Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2 alpha: A prospective randomised study. Lancet. 1990;336:78-81.
41 Marret H, Fauconnier A, Dubernard G, Misme H, Lagarce L, Lesavre M, et al.. Overview and guidelines of off-label use of methotrexate in ectopic pregnancy: Report by CNGOF. Eur J Obstet Gynecol Reprod Biol. 2016;205:105-9.
42. Stika CS. Methotrexate: the pharmacology behind medical treatment for ectopic pregnancy. Clin Obstet Gynecol. 2012 Jun;55(2):433-9. doi: 10,1097/GRF.0b013e3182510a35.
43. Hertz R, Li MC, Spencer DB. Effect of methotrexate therapy upon choriocarcinoma and chorioadenoma. Proc Soc Exp Biol Med. 1956 Nov;93(2):361-6.
44. Tanaka T, Hayashi H, Kutsuzawa T, Fujimoto S, Ichinoe K. Treatment of interstitial ectopic pregnancy with methotrexate: report of a successful case. Fertil Steril. 1982 Jun;37(6):851-2.
45. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol. 2008 Jun;111(6):1479-85.
46. Varma R, Mascarenhas L. Evidence-based management of ectopic pregnancy. Reprod Med Rev. 2001;9(1):49-75.
47. Mitra AG, Harris-Owens M. Conservative medical management of advanced cervical ectopic pregnancies. Obstet Gynecol Surv. 2000 Jun; 55(6):385-9.
48. Chrestiana D, Cheng AB, Panebianco NL, Dean AJ. Pitfalls in cervical ectopic pregnancy diagnosis by emergency physicians using bedside ultrasonography. Am J Emerg Med. 2014 Apr;32(4):397.e1-3. doi: 10,1016/j.ajem.2013,10,055.
49. Vela G, Tulandi T. Cervical pregnancy: the importance of early diagnosis and treatment. J Minim Invasive Gynecol. 2007 Jul-Aug;14(4):481-4.
Cómo citar
Martínez Díaz, R. A., Quintero Avendaño, L. J., García González, C. A., & Fernández De Castro Asis, A. M. (2018). Embarazo ectópico cervical: diagnóstico preciso y enfoque de manejo médico. Reporte de caso. Universitas Medica, 59(1). https://doi.org/10.11144/Javeriana.umed59-1.ecto
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