Successful Pregnancy Following Ectopic Pregnancy Treatment with Uterine Artery Embolization: A Case Report
Kristina Foley*, Beena Subba, Adewale Adeyemo
Department of Obstetrics and
Gynaecology, North Middlesex University Hospital, UK
*Corresponding author: Foley Kristina, Department of Obstetrics
and Gynaecology, North Middlesex University Hospital, UK. Email: Kristina.foley@nhs.net
Received Date: 17 April, 2019; Accepted Date: 13 May, 2019; Published Date: 22 May, 2019
Citation: Foley K, Subba B, Adeyemo A (2019) Successful Pregnancy Following
Ectopic Pregnancy Treatment with Uterine Artery Embolization: A Case Report. Arch
Surg Clin Case Rep 2: 111 DOI: 10.29011/ASCR-111/100111
Keywords: Cervical ectopic pregnancy, Ectopic pregnancy, Uterine artery embolization
1.
Introduction
Cervical ectopic
pregnancy is a rare form of ectopic pregnancy and occurs in less than 0.01% of
pregnancies [1]. It occurs when a pregnancy implants itself into the cervical
canal [1]. The aetiology of Cervical ectopic pregnancy is largely unknown, but
possible risk factors include previous dilatation and curettage, Asherman’s
syndrome, previous caesarean section and IVF [2,3]. Cervical ectopic pregnancies
are dangerous, due to possible erosion of the cervical blood vessels causing
life threatening bleeding [4]. Due to the rare occurrence of cervical ectopic
pregnancy, there is no nationalised recommendations or trials as to the most
appropriate treatment option. Treatment options include Methotrexate IM [5],
dilatation and curettage [6], hysterectomy, and since 1995, Uterine Artery
Embolization (UAE) [7]. This case represents a successful outcome following
treatment of cervical ectopic pregnancy treated with UAE. It was effective as a
fertility-sparing method, as she had a further successful live term birth, with
no complications such as miscarriage or premature ovarian insufficiency.
2.
Case
A 43-year-old female
Gradvia 2 Para 0 + 1 presented for booking appointment in the antenatal clinic.
She had a previous pregnancy resulting in a cervical ectopic 7 years prior,
which was successfully treated with uterine artery emobilisation alone. She
continued to attempt pregnancy and was found to have a septated uterus which
was resected 3 years later. She then had a failed round of IVF, before becoming
spontaneously pregnant at 43 years of age. She is known to have 1 large >10
cm fibroid, for which she was admitted with fibroid degeneration during this
pregnancy.
She was seen by
consultant-led care throughout her pregnancy. She received Aspirin and
Cyclogest in pregnancy and had monitoring cervical length and growth scans.
Growth and dopplers remained normal throughout. She was given the option of
mode of delivery and opted for an elective caesarean section. She was delivered
at 38 weeks, and delivered a healthy male infant.
3.
Discussion
As mentioned, cervical
ectopic pregnancies are a rare form of ectopic pregnancy. Presenting complaint
may include vaginal bleeding, with or without pain [3]. Diagnosis is made by
ultrasound scan, where a gestational sac is seen in a widened cervical canal
with an empty uterus [8]. Cervical ectopic on ultrasound can be confused with
the cervical stage of miscarriage [3], and therefore diagnosis should be
accompanied by doppler flow [9]. Before the routine use of USS, diagnosis used
to often be made on dilatation and curettage for presumed incomplete
miscarriage resulting in unexpected haemorrhage, sometimes leading to
hysterectomy, stopping the woman’s ability to have any future pregnancies [10].
Due to the low
incidence rate of cervical ectopic pregnancies, there are no guidelines or
standardised methods for most appropriate treatment. There are numerous
treatment modalities that have been tried in practice. Methotrexate alone is
minimally invasive and has been used at low gestation. It involves an
Intramuscular (IM) injection that selectively targets cytotrophoblastic
tissue of ectopic pregnancies while preserving fertility [5]. It is more
successful at lower gestations, but there is no threshold value of when it is
deemed effective [11]. Although it has low risk of cervical damage, as much as
60% of cases require additional procedures, such as curettage [8], and may have
a prolonged recovery time following persistent bleeding. More invasive and with
higher risks of complications are intra-amniotic injection and systemic uses of
methotrexate [12].
After 12 weeks’
gestation, a more invasive technique may be required such as surgical excision
via curettage. This has a relatively high risk of haemorrhage, requiring blood
transfusion and admission, and higher risk of cervical trauma [8]. Where there
is irretractable bleeding, Foley’s catheter insertion and emergency
hysterectomy have been used as treatment methods [12]. Uterine artery
embolization has been frequently used as treatment of cervical ectopic
pregnancies, as stand-alone therapy or more commonly in conjunction with other
methods. Benefits of UAE include effective control of excessive bleeding, and
as a fertility-sparing method. There are multiple cases of successful live
pregnancies following cervical ectopic treatment with UAE, however, some
complications in future pregnancies has been reported, such as cervical
adhesion and first trimester miscarriages [13].
There are some
reported complications of UAE when used to manage uterine fibroids. These
include problems in future pregnancies such as intra-uterine growth restriction
and pre-term deliveries. However, many of these complications are difficult to
differentiate from complications of pregnancy in a fibroid uterus [14]. Other
reported complications are reduction in ovarian reserve, which is particularly
important when considering this as a fertility-sparing option [14].
There are only a small
handful of papers describing recurrent cervical pregnancies, so rates of
recurrence with different treatment modalities are difficult to determine [15].
However, as cervical damage is a risk factor for cervical ectopic pregnancy, it
might be assumed that further damage to the cervix with certain treatment
modalities may increase the risk of recurrence of cervical ectopic
pregnancy. Treatment modality will depend on gestation at diagnosis, age
of patient, and need for fertility preservation, as well as the physician’s
technical capabilities. Treatment modalities can be combined to produce the
best outcome for the patient.
4.
Conclusion
This case gives an
example of successful treatment of cervical ectopic pregnancy with UAE, and its
use as a fertility-sparing method, allowing for successful subsequent
pregnancy. There are no current guidelines on the best method of treatment for
cervical ectopic pregnancy, and due to its low incidence rate, more case
reports are needed to draw conclusions on the most appropriate treatment method
as well as potential complications. This case gives argument for UAE as a
relatively safe, effective, and fertility-sparing treatment method.
5.
Acknowledgement
We would like to express our gratitude
for the patient for allowing us to present her case.
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