2003-03-18-10 Cervical pregnancy © Cuillier www.thefetus.net/
Early diagnosis of cervical pregnancy after in vitro fertilization and management by uterine embolization.
Fabrice Cuillier* MD, Kuhl E.** MD, Orvain E.* MD.
* Department of Obstetrics and Gynecology, Hôpital Félix Guyon, rue des Topazes, 97400 Saint-Denis, Reunion Island, France. Ph : 0262 90 55 22. Fax : 0262 90 77 30
**Departement of Radiology, Hôpital Félix Guyon, rue de Topazes, 97400 Saint-Denis, Reunion Island, France.
Cervical pregnancies are extremely rare (one in 98,000). We present a case of cervical pregnancy after egg donation, in vitro fertilization and embryo transfer. The clinical diagnosis is usually made when complications are present, jeopardizing the life and obstetric future of the patient. An early diagnosis and treatment can prevent future complications. So cervical ectopic pregnancy can be managed conservatively. In this report, the authors describe the use of uterine embolization in the management of one case of viable cervical pregnancy.
A 40-year-old subfertile patient, without children, was undergoing her first in-vitro fertilization cycle at a private center when she conceived (ovocyte implantation : 24th October 2002). At five weeks¹ gestation (28th November 2003), the patient consult for metrorrhagia without pain. A transvaginal ultrasound scan done initially showed an empty uterine cavity without a gestational sac. As the diagnosis of miscarriage was still doubtful at this time, a repeat viability scan was scheduled one weeks later. Unfortunately, the patient presented three days prior to her scheduled scan with an episode of light vaginal bleeding. A transvaginal scan then revealed a viable cervical pregnancy with a crown-rump length (CRL) of 5 mm (Fig. 1 and 2).
Abdominal ultrasound. Longitudinal medial section. The uterus is empty, the cervix appears to be raised by the paracervical pregnancy.
Transvaginal ultrasound. Transverse section through the cervix with visualization the endocervical canal. The embryo sac is situated laterally.
She was admitted the same day in our institution. Her quantitative serum bhCG (b human chorionic gonadotrophin) level was 41 000 IU/L. Her blood pressure was 100/60 mm Hg and her pulse 125/mn. On physical examination, the uterus and cervix were enlarged and the patient experienced vaginal bleeding with clots but her vital signs remained stable. After multidisciplinary review, we performeda uterine embolization, without complication (Fig. 3 and 4).
Figure N°3 :
Pre-embolization angiography of the cervical pregnancy (a- right uterine artery. b- left uterine artery).
Figure N°4 :
Angiography performed immediately after embolization. Almost all neovascularization within the mass has disappeared (a- right uterine artery. b- left uterine artery).
We performed a dilatation and a curettage. Then we put a cerclage around the cervix. Thereafter, only vaginal spotting was noted but the patient was not transfused. The serum bhCG level had also by then dropped to 3399 IU/L on November 29 and 1416 on November 30th . The cerclage ablation was on day two and the patient was finally discharged from the ward two days after admission. The serum bhCG level had then dropped to 381 IU/L on December 2. The patient had one her last period on December 29 and the serum bhCG level was not detectable.