Painless vaginal bleeding is reported by 90 percent of women with a cervical pregnancy-a third of these have massive hemorrhage (Ushakov, 1997). As pregnancy progresses, a distended, thin-walled cervix with a partially dilated external os may be evident. Above the cervical mass, a slightly enlarged uterine fundus can be felt. Identification of cervical pregnancy is based on speculum examination, palpation, and TVS. Sonographic indings typical of cervical pregnancy are shown and described in Figure 19-10. MR imaging and 3-D sonography have also been used to confirm the diagnosis Q ung, 2001; Sherer, 2008).
Cervical pregnancy may be treated medically or surgically. Conservative management strives to minimize hemorrhage, resolve the pregnancy, and preserve fertility. In many centers, including ours, methotrexate has become the first-line therapy in stable women, and administration follows protocols listed in Table 19-1 (Verma, 2011; Zakaria, 2011). he drug has also been injected directly into the gestational sac, alone or with systemic doses Qeng, 2007; 1urji, 2015). Others describe MTX infusion combined with uterine artery embolization"chemoembolization" (Xiaolin, 2010).
FIGURE 19-10 Cervical pregnancy. Transvaginal sonographic findings may include: (1) an hourglass uterine shape and ballooned cervical canal; (2) gestational tissue at the level of the cervix (black arrow); (3) absent intrauterine gestational tissue (white arrows); and (4) a portion of the endocervical canal seen interposed between the gestation and the endometrial canal. (Used with permission from Dr. Elysia Moschos.)
With MTX regimens, resolution and uterine preservation are achieved for gestations < 12 weeks in 91 percent of cases (Kung, 1997). In selecting appropriate candidates, Hung and colleagues (1i996) noted higher risks of systemic MTX treat ment failute in those with a gestational age >9 weeks, �-hCG levels > 10,000 mIU/mL, crown-rump length > 10 mm, and fetal cardiac activity. For this reason, many induce fetal death with intracardiac or intrathoracic injection of potas sium chloride. With a single-dose intramuscular protocol, an
MTX dose between 50 and 75 mg/m2 X BSA is typical. To resolve fetal cardiac activity, a sonographically guided fetal intracardiac injection of 2 mL (2 mEq/mL) potassium chlo ride solution can be given (Verma, 2009). Song and associ ates (2009) described management of 50 cases and observed regression.
As an adjunct to medical or surgical therapy, uterine artery embolization has been described either as a response to bleeding or as a preprocedural preventive tool (Hirakawa, 2009; Zakaria, 2011). Also, in the event of hemorrhage, a 26F Foley catheter with a 30-mL balloon can be placed intracervically and inlated to efect hemostasis by vessel tamponade and to monitor uterine drainage. The balloon remains inlated for 24 to 48 hours and is gradually decompressed over a few days (Ushakov, 1997).
Although conservative management is feasible for many women with cervical pregnancies, suction curettage or hysterectomy may be selected. Moreover, hysterectomy may be required with bleeding uncontrolled by conservative methods. Because of the close proximity of the ureters to the ballooned cervix, urinary tract injury rates are a concern during hysterectomy.