Department of Obstetrics and Gynecology, Division of Reproductive Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
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Abstract |
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Key words: arterial embolization/cervical pregnancy/heterotopic pregnancy/selective fetal reduction
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Introduction |
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There are only a few case reports in the literature of heterotopic cervical pregnancy. Bratta et al. (1996) reported successful resolution of a heterotopic cervical pregnancy with intrauterine methotrexate. Davies et al. (1990) performed digital evacuation of a cervical pregnancy followed by cervical cerclage to control haemorrhage at 10 weeks. Demise of the intrauterine pregnancy occurred at 13 weeks gestation. In 1996 Monteagudo et al. (1996) described a stable heterotopic cervical pregnancy which was managed with transvaginal ultrasound-guided selective reduction with potassium chloride in the first trimester followed by Caesarean section at 34 weeks for the intrauterine gestation. Frates et al. (1994) reported a similar experience. This is the first reported case in which embolization was performed successfully to control haemorrhage in a case of a bleeding cervical pregnancy concurrent with a viable intrauterine pregnancy. The risks of radiation exposure and altered intrauterine blood flow considerations are discussed.
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Case report |
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The patient's past history was significant for pelvic inflammatory disease 13 years earlier. She had a right-sided ectopic pregnancy that was managed conservatively, followed by a left-sided ectopic which required a left salpingectomy. There was a remote history of elective pregnancy termination. There was no other history of surgery or medical conditions.
The patient was admitted to hospital at 8 weeks after IVF embryo transfer with a diagnosis of bleeding heterotopic cervical pregnancy. The ß-human chorionic gonadotrophin was 154 509 IU/l and haemoglobin was 11.1 g/dl on admission. The cervix was visualized and noted to be ballooning with blood trickling from a small os. She continued to have intermittent bleeding overnight and the haemoglobin the following morning had fallen to 9.6 g/dl. An magnetic resonance image was obtained which confirmed the presence of an intracervical ectopic pregnancy in addition to a viable intrauterine pregnancy (Figure 1).
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Later the same day the patient was counselled by the radiologist that the procedure would probably not result in dangerous radiation exposure to the intrauterine fetus; however the lack of experience with this procedure in pregnancy was also discussed. The common femoral artery was catheterized with a flexible angiographic catheter through which the uterine arteries were cannulated. Pledgets of gelfoam (Gelfoam; Upjohn, Kalamazoo, MI, USA) were used to embolize the uterine arteries bilaterally. Fluoroscopy time was 8.2 min resulting in a radiation exposure of less than 10 rads to the intrauterine fetus. The patient experienced uterine cramping and the bleeding subsided overnight.
An ultrasound the following morning confirmed continued viability of both fetuses and a transvaginal ultrasound-guided selective reduction of the cervical pregnancy was performed. Lidocaine (1%) was injected into the cervix and a 16-gauge needle inserted through the cervix into the cardiac region of the intracervical embryo: 2 mEq of KCl were injected and cardiac asystole was obtained. An ultrasound was performed 4 days after the selective reduction which showed an intact intrauterine fundal pregnancy at 8 weeks after IVF embryo transfer with the non-viable cervical pregnancy measuring 5.5 by 1.5 cm. The patient was observed in hospital for 6 days following the arterial embolization procedure, and then was discharged as she had no further bleeding.
At 9 weeks and 1 day following IVF embryo transfer the patient returned to hospital with bleeding. The haemoglobin was 9.3 g/dl on admission. Ultrasound confirmed viability of the intrauterine fetus and loss of the cervical embryonic pole and gestational sac with only a small echogenic area in the cervix. The patient was observed in hospital and transfused with two units of packed red blood cells 2 days after admission. A temperature rise to 37.9°C occurred on the fifth hospital day, and blood, urine, and cervical cultures were performed. The patient was started on i.v. cefazolin (Ancef; SmithKline Beecham, PA, USA) 1 g every 8 h. An episode of heavy bleeding occurred on the following day and the haemoglobin dropped to 7.4 g/dl. Two additional units of packed red blood cells were given. The temperature increased to 38°C and blood cultures grew Escherichia coli. A subsequent ultrasound showed demise of the intrauterine fetus. The patient wished to proceed with hysterectomy in view of the heavy bleeding and infection. The antibiotics were changed to gentamicin (gentamicin sulphate; Novopharm, Toronto, Canada) and clindamycin (Dalacin C; Upjohn), and the patient was taken to the operating room for a total abdominal hysterectomy.
The patient's haemoglobin remained stable at 9.2 g/dl throughout the post-operative period. The i.v. antibiotics were changed to a 10-day course of oral cephalexin (Keflex; Eli Lilly, Indianapolis, IN, USA) 500 mg four times daily on the first post-operative day. Histopathology findings confirmed the presence of a cervical pregnancy with severe chorioamnionitis. The patient was discharged home from hospital on the sixth post-operative day with plans for supportive psychotherapy by a clinical psychologist.
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Discussion |
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This is the first reported case of the use of uterine artery embolization in a heterotopic cervical pregnancy to control bleeding and preserve a viable intrauterine gestation. An essential element for preserving the uterus in cases of cervical pregnancy is interruption of the arterial supply. The cervix is perfused mainly by the uterine arteries while the ovarian vessels contribute more to perfusion of the uterine fundus. Uterine arterial interruption is preferable to internal iliac artery ligation because of the extensive pelvic collateral circulation. In this case the bleeding from the cervical placental bed was initially controlled but the collateral circulation was sufficient to sustain viability of both fetuses. The altered intrauterine blood supply in addition to the radiation exposure to the intrauterine fetus are both risks to this procedure that have not been well studied.
The subsequent complication encountered with this patient was the development of sepsis 2 weeks after the KCl injection into the cervical pregnancy. Following the uterine artery embolization and selective fetal reduction, the cervical products of conception remained in the cervix. This necrotic tissue served as a culture medium for E. coli and resulted in systemic sepsis.
As there have been a few case reports of successful outcomes with heterotopic cervical pregnancies (Frates et al., 1994; Monteagudo et al., 1996
), it is attractive to the patient and the physicians involved to try conservative management. This case demonstrates the danger of conservative management of heterotopic pregnancy with uterine artery embolization which resulted in necrotic tissue in the cervical os which subsequently led to severe chorioamnionitis and maternal sepsis. Although initial measures aimed at conservation of the intrauterine fetus are possible, the cost of maternal safety may be too high.
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Notes |
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References |
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Submitted on June 23, 1998; accepted on November 4, 1998.