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Radiology
Uterine
artery embolisation as an adjuvant in the conservative management of cervical
ectopic pregnancy:
A 34-year-old lady - gravida 2, abortion 1, para 1, live 1, presented with 11.5weeks of amenorrhea and spotting per vaginum for 3-4 days. Her urine pregnancy test was positive, vitals stable with a hemoglobin of 9gm%. She was referred for ultrasonogram which revealed a normal uterine cavity; however, the cervical canal was dilated and showed a live gestation of approx 11.5 weeks (Fig 1). Thus a diagnosis of cervical ectopic pregnancy was made. Her serum human chorionic gonadotropin level was 1, 06,600 IU/L. She was started on methotrexate therapy, followed by transvaginal intracardiac instillation of potassium chloride causing fetal demise (Fig.2). A Doppler scan showed fetal demise with persistent hypervascularity of the endometrium around the ectopic gestational sac (Fig 3). She was planned for a conservative line of management with dilatation and curettage of the product of conception, which had not been absorbed spontaneously.
Due to persistent increased vascularity even on follow up colour Doppler at day 7, preoperative selective embolisation of the uterine arteries was planned. Preoperatively, on the day of dilatation and curettage under general anaesthesia, she was taken for uterine artery embolisation using gel foam (Figs.4&5), following which a dilatation & curettage was performed with a minimal blood loss of 20 - 30cc. Pathological examination of the evacuated specimen confirmed the product of conception with cervical implantation site.
DISCUSSION:
Cervical ectopic pregnancy is a rare form of ectopic gestation, which is usually associated with increased maternal mortality - primarily due to extensive hemorrhage. Hence, for many years, hysterectomy was an important modality in the management of this life threatening complication. However with time, more conservative management has been contemplated from circumsuture to intracervical balloon tamponade to uterine artery ligation, internal iliac ligation or ovarian artery ligation - to the much less invasive angiographic technique of bilateral uterine artery embolisation making the outcome uneventful.
Cervical pregnancy is an ectopic pregnancy in which the implantation site is within the cervical mucosa that lines the endocervical canal. It is rare -comprising an estimated 0.15% of all ectopic pregnancy. The exact etiology of cervical ectopic pregnancy is unknown. Proposed theory implicates it to be due to rapid transport of fertilised ovum and early implantation in the cervical region. A close relationship has been reported between induced abortion, D&C and cervical ectopic pregnancy.
Ultrasonography provides early and more accurate diagnosis allowing successful conservative therapy to be instituted. The sonographic diagnosis of cervical ectopic pregnancy is made by identifying the gestational sac within the cervix excluding the alternative possibility of spontaneous abortion in progress .The gestational sac in cervical pregnancy is typically round or oval and may contain a yolk sac or a fetus with a heart beat ; whereas in spontaneously aborting pregnancy, it is crenated and has no fetal cardiac activity and will decrease in size or disappear within a few days. In some cases, diagnosis can only be made with certainty by obtaining a follow up sonogram one to two days after the first sonogram.
Most of the time, cervical ectopic pregnancy is diagnosed intraoperatively due to presence of extensive life threatening torrential haemorrhage and in the past, hysterectomy had been performed giving preference for patient's life over retainment of patient's fertility. With time, less invasive techniques evolved with an attempt to retain future fertility. The modalities ranged from intracervical ballooning, cervical circumsuture to intracervical obturator or bilateral internal iliac artery / uterine artery ligation along with methotrexate therapy - which is known to cause fetal demise, followed by a dilatation and curettage to remove the products of conception. Methotrexate, a folic acid antagonist, is known to be toxic to trophoblastic tissue causing mild hydropic degeneration to complete dissolution of the trophoblastic. It primarily derails the normal developmental proliferation of the trophoblast stem cell population, as well as a decrease in large granular lymphocyte cell numbers in the decidua. Injection of KCl for cervical ectopic pregnancy is analogous to its use for multi-fetal pregnancy reduction. Direct fetal intracardiac potassium chloride injection effectively causes immediate fetal cardiac arrest. This approach may be adopted in cases of abortion by labor-induction methods at advanced gestations to ensure that the abortus is stillborn .
Hemorrhage in cervical ectopic pregnancy may be massive and fatal following curettage. The mortality rate was first estimated by Rubin et al as between 40- 50% in 1911 and by Baptisti et al reported it to be 6% in 1963 . If conservative measures fail, hysterectomy remains the only option. Even after intracardiac KCl instillation or intravenous methotrexate therapy, spontaneous expulsion of the products of conception may not happen. Inspite of advocating these two options, hypervascularity of the endometrium remained persistent as seen on color doppler and angiographic study in our case. With this persistent hypervascularity, dilatation and curettage could have resulted in massive haemorrhage. Uterine artery embolization before curettage leads to a safe outcome with minimal blood loss and retainment of patients potential fertility in future.
Uterine artery embolisation has a definitive role in the conservative management of cervical ectopic pregnancy, minimizing post D&C blood loss resulting in low morbidity, short hospital stay and preserving the potential future fertility.
Case 18 : Contributed
by Dr. Ashish Wasnik
Other Cases
A 34-year-old lady - gravida 2, abortion 1, para 1, live 1, presented with 11.5weeks of amenorrhea and spotting per vaginum for 3-4 days. Her urine pregnancy test was positive, vitals stable with a hemoglobin of 9gm%. She was referred for ultrasonogram which revealed a normal uterine cavity; however, the cervical canal was dilated and showed a live gestation of approx 11.5 weeks (Fig 1). Thus a diagnosis of cervical ectopic pregnancy was made. Her serum human chorionic gonadotropin level was 1, 06,600 IU/L. She was started on methotrexate therapy, followed by transvaginal intracardiac instillation of potassium chloride causing fetal demise (Fig.2). A Doppler scan showed fetal demise with persistent hypervascularity of the endometrium around the ectopic gestational sac (Fig 3). She was planned for a conservative line of management with dilatation and curettage of the product of conception, which had not been absorbed spontaneously.
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Fig.1
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Fig.
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Fig.3
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Due to persistent increased vascularity even on follow up colour Doppler at day 7, preoperative selective embolisation of the uterine arteries was planned. Preoperatively, on the day of dilatation and curettage under general anaesthesia, she was taken for uterine artery embolisation using gel foam (Figs.4&5), following which a dilatation & curettage was performed with a minimal blood loss of 20 - 30cc. Pathological examination of the evacuated specimen confirmed the product of conception with cervical implantation site.
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Fig.4
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Fig.5
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DISCUSSION:
Cervical ectopic pregnancy is a rare form of ectopic gestation, which is usually associated with increased maternal mortality - primarily due to extensive hemorrhage. Hence, for many years, hysterectomy was an important modality in the management of this life threatening complication. However with time, more conservative management has been contemplated from circumsuture to intracervical balloon tamponade to uterine artery ligation, internal iliac ligation or ovarian artery ligation - to the much less invasive angiographic technique of bilateral uterine artery embolisation making the outcome uneventful.
Cervical pregnancy is an ectopic pregnancy in which the implantation site is within the cervical mucosa that lines the endocervical canal. It is rare -comprising an estimated 0.15% of all ectopic pregnancy. The exact etiology of cervical ectopic pregnancy is unknown. Proposed theory implicates it to be due to rapid transport of fertilised ovum and early implantation in the cervical region. A close relationship has been reported between induced abortion, D&C and cervical ectopic pregnancy.
Ultrasonography provides early and more accurate diagnosis allowing successful conservative therapy to be instituted. The sonographic diagnosis of cervical ectopic pregnancy is made by identifying the gestational sac within the cervix excluding the alternative possibility of spontaneous abortion in progress .The gestational sac in cervical pregnancy is typically round or oval and may contain a yolk sac or a fetus with a heart beat ; whereas in spontaneously aborting pregnancy, it is crenated and has no fetal cardiac activity and will decrease in size or disappear within a few days. In some cases, diagnosis can only be made with certainty by obtaining a follow up sonogram one to two days after the first sonogram.
Most of the time, cervical ectopic pregnancy is diagnosed intraoperatively due to presence of extensive life threatening torrential haemorrhage and in the past, hysterectomy had been performed giving preference for patient's life over retainment of patient's fertility. With time, less invasive techniques evolved with an attempt to retain future fertility. The modalities ranged from intracervical ballooning, cervical circumsuture to intracervical obturator or bilateral internal iliac artery / uterine artery ligation along with methotrexate therapy - which is known to cause fetal demise, followed by a dilatation and curettage to remove the products of conception. Methotrexate, a folic acid antagonist, is known to be toxic to trophoblastic tissue causing mild hydropic degeneration to complete dissolution of the trophoblastic. It primarily derails the normal developmental proliferation of the trophoblast stem cell population, as well as a decrease in large granular lymphocyte cell numbers in the decidua. Injection of KCl for cervical ectopic pregnancy is analogous to its use for multi-fetal pregnancy reduction. Direct fetal intracardiac potassium chloride injection effectively causes immediate fetal cardiac arrest. This approach may be adopted in cases of abortion by labor-induction methods at advanced gestations to ensure that the abortus is stillborn .
Hemorrhage in cervical ectopic pregnancy may be massive and fatal following curettage. The mortality rate was first estimated by Rubin et al as between 40- 50% in 1911 and by Baptisti et al reported it to be 6% in 1963 . If conservative measures fail, hysterectomy remains the only option. Even after intracardiac KCl instillation or intravenous methotrexate therapy, spontaneous expulsion of the products of conception may not happen. Inspite of advocating these two options, hypervascularity of the endometrium remained persistent as seen on color doppler and angiographic study in our case. With this persistent hypervascularity, dilatation and curettage could have resulted in massive haemorrhage. Uterine artery embolization before curettage leads to a safe outcome with minimal blood loss and retainment of patients potential fertility in future.
Uterine artery embolisation has a definitive role in the conservative management of cervical ectopic pregnancy, minimizing post D&C blood loss resulting in low morbidity, short hospital stay and preserving the potential future fertility.