Ectopic Cervical Pregnancy – Precise Diagnosis and Medical Management Approach. Case Report
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Feb 12, 2018
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Abstract
Cervical ectopic pregnancy is an exotic condition. Its diagnosis and management pose a major challenge given its association with serious maternal outcomes. The clinical suspicion and the judicious application of the diagnostic criteria allow for conservative therapy modalities. In this article, a case of cervical ectopic pregnancy is reported to diagnostic ultrasound imaging and nuclear magnetic resonance in which treatment with Methotrexate was administered. Clinical follow-up of the laboratory test and ultrasound showed complete resolution of the condition. Aspects related to the diagnosis and treatment are reviewed.
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.
How to Cite
Martínez Díaz, R. A., Quintero Avendaño, L. J., García González, C. A., & Fernández De Castro Asis, A. M. (2018). Ectopic Cervical Pregnancy – Precise Diagnosis and Medical Management Approach. Case Report. Universitas Medica, 59(1). https://doi.org/10.11144/Javeriana.umed59-1.ecto
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Case Reports