1 Department of Obstetrics and Gynaecology and 2 Department of Pathology, Institut Universitari Dexeus, Paseo de la Bonanova 8991, 08017 Barcelona, Spain
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Abstract |
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Key words: cervical twin pregnancy/methotrexate/reproduction/ultrasound
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Introduction |
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This paper describes a case of cervical ectopic twin pregnancy diagnosed ultrasonograpically at 8 weeks gestation, treated conservatively with local administration of methotrexate under ultrasonographic guidance, followed by curettage.
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Case report |
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The patient underwent a new IVF cycle with long protocol obtaining six oocytes, all of them fertilized by conventional IVF. Three embryos were transferred with ultrasound guidance according to conventional techniques (Coroleu et al., 2000) and the three remaining were cryopreserved. Five weeks later one pregnancy was confirmed by transvaginal ultrasound with an 11 mm gestational sac containing one embryo with cardiac activity and a normal cervix uterus. Amniocentesis was performed and showed a fetus with karyotype 46 XY. At 42 weeks a healthy live male was vaginally delivered.
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Discussion |
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The therapeutical approach can be radical or conservative. When radical, a hysterectomy is usually performed when haemorrhage occurs as an emergency situation. The conservative treatment can be surgical or medical. Surgical procedures imply hypogastric or uterine artery ligation or embolization, a curettage with or without cerclage, or the insertion of a Foley probe in the cervical canal. According to the reported cases, curettage seems to increase the haemorragic risk requiring hysterectomy in many occasions. Another therapeutical choice is local administration of methotrexate or potassium chloride (Jurkovic et al., 1996; Carreno et al., 2000
). Methotrexate is an agonist of folic acid that participates in DNA synthesis. It has been used for treatment of choriocarcinoma and ectopic pregnancy due to its capacity to stop proliferative cell activity (Fernandez et al., 1998
). Its first application in the treatment of cervical pregnancies was described by Farabow et al. (Farabow et al., 1983
). Adverse effects of its administration include nausea (50%), vomiting (17%), diarrhoea (14%) and less frequently oral ulcers and stomatitis (5%) (Wiebe, 1999
).
The intra-cervical or intra-amniotic dose of methotrexate is usually 12.5 to 50.5 mg, varying according to different authors (Timor-Tritsch et al., 1994; Mantalenakis et al., 1995
). In the present case methotrexate was administrated into each gestational sac with transvaginal ultrasonographic guidance in a unique dose of 50 mg for each. The local treatment was chosen to avoid the adverse effects of systemic methotrexate administration. Methotrexate alone or combined with procedures such as curettage or cervical tamponade is effective in those ectopic pregnancies of 12 weeks of gestation or less and does not produce adverse effects (Kung et al., 1997
). According to this review 66% (12/18) of patients with complete remission of a cervical ectopic pregnancy treated with methotrexate required additional approaches, cervical curettage being the therapy most commonly used. As in other reports (Balasch et al., 1994
), hysteroscopic follow-up revealed no anatomical or functional changes in the cervix in the case reported here.
As proven in the present case, conservative treatment of cervical ectopic pregnancy is a therapeutic choice, even in the case of a twin pregnancy.
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Acknowledgments |
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Notes |
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References |
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Submitted on July 27, 2000; accepted on November 24, 2000.