1 Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer (affiliated to the Sackler School of Medicine, Tel-Aviv University) and 2 Bnei-Zion Medical Center (Technion Faculty of Medicine, Haifa), Israel
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Abstract |
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Key words: cervical pregnancy/heterotopic pregnancy/Shirodkar suture
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Introduction |
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The risk of maternal mortality due to cervical pregnancy was previously reported to be as high as 4050%, and in recent years has dropped to 06% (Wolcott et al., 1988; Ushakov et al., 1996
). However, massive haemorrhage from cervical pregnancy remains a serious cause of maternal mortality. Ushakov et al. have reported an incidence of 29.1% of massive vaginal bleeding at the time of admission to hospital (Ushakov et al., 1996
). In only 20.2% of patients was the bleeding described as mild or spotting. Thus, many patients require emergency methods to control bleeding.
The various treatment modalities used for cervical pregnancy include hysterectomy, as well as more conservative approaches such as: curettage and intracervical balloon tamponade (Heller, 1968), curettage and local prostaglandin injection (Spitzer et al., 1997
), methotrexate (MTX) administration (Oyer et al., 1988
), circumsuture (Scott et al., 1978
; Bernstein et al., 1981
; Davis et al., 1990
), hysteroscopic resection (Ash and Farrell, 1996
), bilateral internal iliac ligation (Nelson, 1979
), descending uterine artery ligation (Ratten, 1983
), selective uterine artery embolization (Simon et al., 1991
; Su et al., 1999
) and intra-arterial MTX followed by selective prophylactic hypogastric artery embolization (Yitzhak et al., 1999
).
We present our experience with a minimally invasive conservative approach, with preservation of the intact uterus, by placement of a Shirodkar cerclage. The purpose of the cerclage was for haemostasis, and while reported in cases in the past (Scott et al., 1978; Bernstein et al., 1981
; Davis et al., 1990
), this modality has not been recommended as the preferred treatment for cervical pregnancy.
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Materials and methods |
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Results |
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Case number 4, the heterotopic pregnancy, ended in normal vaginal delivery at 39 weeks gestation of a male infant, weighing 3010 g, with an Apgar score of 9 and 10 in 1 and 5 min post-partum respectively. Figure 2 demonstrates the intrauterine pregnancy and the cervical suture, 1 month after performance of the Shirodkar cerclage.
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Discussion |
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With the introduction of improved diagnostic techniques, especially the high-resolution ultrasound equipment, cervical pregnancy is being diagnosed much earlier than previously reported (Ushakov et al., 1996) (three of our four cases were diagnosed between 6 and 7 weeks of pregnancy). Sonography improved pretreatment diagnosis up to 81.8% (Ushakov et al., 1996
). Figure 3
demonstrates a viable cervical pregnancy at the gestational age of 6 weeks and 2 days (case 1).
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Scott et al. first reported the successful application of Shirodkar cervical cerclage in cervical pregnancy (Scott et al., 1978). However, in the reported case, the diagnosis of cervical pregnancy was based upon the manual digital examination, and was not supported sonographically. The procedure was performed on an emergency basis after the failure of curettage, and was concomitant to the placement of intra-cervical obturator. Bernstein also reported this procedure (Bernstein et al., 1981
). Again, the diagnosis was done clinically and the McDonald cerclage was placed as an emergency method before planned hysterectomy. The same procedure was described in a heterotopic pregnancy (Davis et al., 1990
), again as a method to control bleeding. To the best of our knowledge, this procedure, especially with the Shirodkar suture, has not gained acceptance as an elective modality of treatment of cervical pregnancy.
MTX treatment of cervical pregnancy was first reported in 1988 (Oyer et al., 1988) and since then it has gained widespread acceptance. Indeed, in the four cases that presented to our department between 1994 and 1999, MTX administration (either intracervical or systemic) was the treatment of choice, and all four cases resolved successfully. However, the next two cases (first patients in this study) failed to respond to MTX therapy, beta levels did not recede and massive cervical bleeding ensued. Prior to offering the patients a hysterectomy, as a life saving procedure, the option of placing a cervical suture as a hemostatic procedure, together with aspiration of the cervical pregnancy, was suggested. The patients agreed to undergo this new procedure, and their recovery was uneventful. In the next case (number 3), which presented at 6 + 3 weeks gestation with vaginal bleeding with diagnosis of viable cervical pregnancy, the placement of Shirodkar suture (along with aspiration) was offered as the first option and performed successfully. Patient number 4 presented with a heterotopic pregnancy, a normal intrauterine 8 week pregnancy, as well as a cervical pregnancy (Figure 1
). Naturally, MTX therapy could not be offered and she too was treated by cervical suture, successfully.
Heterotopic pregnancies, i.e. combined intra- and extrauterine pregnancy, occur rarely among spontaneous pregnancies, with an estimated rate of 1 in 30 000 pregnancies (Bello et al., 1986; Bearman et al., 1986
). However, among patients who have undergone IVF therapy, the incidence is much higher, approaching 1% (Bearman et al., 1986
; Dor et al., 1991
; Goldman et al., 1992
). Combined intrauterine and cervical pregnancy is even rarer. As more women with a past history of recurrent abortions, as well as cervical interventions such as dilatation and curettage and cerclage, utilize assisted reproductive techniques, the rate of heterotopic cervical pregnancy will undoubtedly rise (Ushakov et al., 1996
). Carreno et al. have described treatment of heterotopic cervical pregnancy with reduction of the cervical pregnancy with the aid of saline injection into the gestational sac in the cervix (Carreno et al., 2000
). Although the outcome was favourable, we think this method carries a great risk of haemorrhage and therefore suggest our method should be considered the treatment of choice in these cases. Peleg et al. have also described conservative treatment of combined intrauterine and cervical pregnancy (Peleg et al., 1994
). However, they have used intra-arterial MTX, which did not preserve the intrauterine pregnancy.
In our opinion, this new modality, i.e. placing a cervical Shirodkar cerclage as treatment of cervical pregnancy, has many advantages: (i) control of the massive bleeding created by the invasion of the cervical tissue by trophoblast, thus alleviating the need for hysterectomy and/or the need of transfusion of blood products. The Shirodkar suture, placed higher in the cervix, can contribute to better haemostasis; (ii) avoidance of the systemic side-effects of parenteral MTX administration such as nausea, vomiting, hepatic disorders, stomatitis and decreased white blood cell counts (Kojima et al., 1990); (iii) safety and applicability in cases of heterotopic pregnancy with an intact intrauterine pregnancysystemic therapy cannot be applied, and the cerclage allows continuation of the intrauterine pregnancy; (iv) another possible advantage of this treatment modality is a quicker response rapid decline of HCG levels. Whereas in MTX therapy, it can take between 5 and 60 days (Kojima et al., 1990
), in our small series of three cases (the heterotopic pregnancy was not included), HCG levels dropped substantially within 56 days and returned to normal over a mean period of 21 days. The mean hospitalization time in the study group (6 days, with a range of 59 days) is also much shorter than mean time in the patients treated with MTX only in our department (14 days). One must, of course, bear in mind the possible disadvantages of Shirodkar cervical cerclage. The procedure takes place under general anaesthesia and it can be associated with complications (such as haemorrhage and bladder injury), especially in the hands of inexperienced physicians. Our patients did not suffer from any of those complications.
In summary, we have shown here our experience of treatment of cervical pregnancy with the use of Shirodkar cervical suture. By serving as a useful haemostatic technique, this therapy should be offered, in our opinion, as an alternative treatment in cervical pregnancy. It should not serve only as an emergency option when massive bleeding occurs after failure of other treatment modalities, but as a primary option, thus reducing the rate of inevitable hysterectomy, the need for blood transfusions and preservation of fertility. This approach will also avoid the systemic side effects of MTX, shortens the hospitalization period and should be the only treatment option in heterotopic pregnancy. More experience is needed in order to validate our preliminary results, although the incidence of cervical pregnancy makes this difficult.
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Notes |
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References |
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accepted on October 2, 2001.