Author
Information
More Vibha*,
Panchbudhe Shruti**, Mali Kimaya***,
Satia MN****
(*
Assistant Professor, ** Assistant Professor, *** Assistant Professor, ****
Professor
Department
of Obstetrics and Gynecology, Seth G.S. Medical
College and K.E.M
Hospital, Mumbai,
India.)
Abstract
We report a case of heterotopic
pregnancy, cervical-intrauterine, conceived with in-vitro fertilization. She
was successfully managed with conservative systemic Methotrexate therapy.
Introduction
Heterotopic
pregnancy is coexistence of intra- and extrauterine pregnancy and is rare.
Cervical- intrauterine is a rare variety of heterotopic pregnancy. Cervical
pregnancy is a rare and life-threatening form of ectopic
pregnancy. Improved sonographic techniques have allowed earlier diagnosis
and successful attempts at conservative management.
Case
report
A 43 year old woman, married for 12
years, gravida 2, abortion 1, with 7 weeks of gestation was referred to us in
view of non-viable cervical ectopic and intrauterine pregnancy after in-vitro
fertilization and embryo transfer. She had no complaints. Findings of
diagnostic hysteroscopy and laproscopy done 10 years ago were normal. Findings
with bilateral tubes patent and was started on treatment. She had conceived
once with ovulation induction and intrauterine insemination. She developed a
missed abortion for which dilatation and curettage was done. She underwent
hysteroscopy and cervical dilatation five years later. Hysteroscopic findings
were normal. Endometrial TB-PCR was positive for mycobacterium tuberculosis
complex. She was treated with antitubercular therapy for 6 months. She then underwent ovarian hyperstimulation with long protocol, 6 embryo were retrieved of which 4 embryos were transferred. She conceived in the same cycle. She was started on
progesterone support and low dose aspirin. Serum β-hCG level was 593 mIU/mL 15
days after the embryo transfer. After 6 weeks ultrasonography was done. It
showed non viable twin gestation. Gestational sac 1 corresponding to 6.4 weeks
was low lying in the uterus and gestational sac 2 corresponding to 5.4 weeks
was located in the cervix. Then she was referred to our institute for further
management.
Figure 1: Ultrasonic scan showing
intrauterine (solid arrow) and cervical (hollow arrow) pregnancy.
On
examination her vital parameters were stable. Systemic examination showed no
abnormality. Her abdomen was soft and non tender. On per speculum examination
the external os was closed, the cervix was slightly enlarged. There was no
bleeding. Bimanual pelvic examination was deferred so as not to disturb the
cervical ectopic pregnancy. Serum β-hCG levels on admission was 54,112 mIU/ml.
Hemogram , hepatic function and renal function tests were within normal limits.
Conservative management with Methotrexate administration was
undertaken in an attempt to preserve her fertility. The regimen consisted of
intramuscular Methotrexate 50 mg (1 mg/kg) on day 1, 3 and 5 and Folinic acid
5mg (0.1 mg/kg) on day 2, 4 and 6. The patient was monitored with serial β-hCG
and ultrasound with Doppler flow.
Serial β-hCG levels
Day (since hospitalization)
|
Serum β-hCG levels
(mIU/ml)
|
1
|
54,112
|
3
|
37,635
|
5
|
28,759
|
7
|
15,557
|
15
|
578
|
22
|
79
|
37
|
< 2 mIU/ml
|
Ultrasonography showed a decrease in size of both gestational sacs and
Doppler showed decreased peak systolic velocity. She was monitored for
Methotrexate toxicity with complete blood count and hepatic function test. She
was then discharged on day 15 with advised to follow-up with β-hCG level after
one week or if she had any complaints like bleeding per vaginum or pain in abdomen.
Subsequent menstrual periods were normal.
Discussion
Heterotopic
pregnancy is coexistence of intra- and extrauterine pregnancy. The prevalence
is low in spontaneous pregnancy(1 in 30,000).[1] With the use
of ovulation induction and assisted reproductive techniques; the incidence of
heterotopic pregnancy has risen up to 0.75%-1.5%.[1] As opposed to ectopic pregnancy
which are diagnosed and treated at preclinical stage. Heterotopic pregnancies
are often diagnosed after clinical symptoms and signs develop. Cervical-
intrauterine is a rare variety of heterotopic pregnancy. Cervical ectopic pregnancy is uncommon and life threatening. The
incidence reported occurring in 1 of 8628 deliveries.[2] Its incidence is increasing as a result of
in-vitro fertilization.[1]. The other predisposing factors include cervical dilatation and curettage and
previous cesarean section.
Cervical ectopic pregnancy is frequently confused with neoplastic
growth or spontaneous abortion. Ultrasonographic diagnosis is useful in the
early detection of cervical pregnancy. Ultrasonographic findings include the
hourglass uterus or dilated cervix. Doppler flow sonography is helpful only in
distinguishing abortions in progress from those with vascular implantation in
the cervix.
Management of cervical ectopic is surgical or medical. Surgical
management includes dilatation and curettage, in early cervical pregnancy or
hysterectomy in uncontrolled, life-threatening bleeding,. Preoperative
preparation prior to dilatation and
curettage to reduce vascularity includes
transvaginal ligation of cervical branch of uterine artery, Shirodkar cerclage,
uterine artery embolization, or intracervical vasopressin injection. To control
post evacuation bleeding, Foley catheter with a 30 ml balloon is inflated. Medical therapy can be used as primary
treatment for cervical pregnancy or adjunct to surgical treatment. It includes
systemic Methotexate alone, systemic Methotexate with local (intraamniotic or intracervical) injection of
either Methotexate or potassium chloride.
References
1. Mark A. Damario, John A. Rock. Ectopic Pregnancy. Te Linde’s
Operative Gynaecology 10th ed. New
Delhi: Wolters Kluwer Health- Lippincott Williams
& Wilkins 2008;pp. 819-821
2. Ushakov FB, Elchalal U, Aceman PJ, Schenker JG. Cervical pregnancy:
past and future. Obstet Gynecol
Surv 1997;52: 45–59.
3.
Weyerman PC, Verhoeven ATM, Alberda ATM. Cervical pregnancy
after in vitro fertilization and embryo transfer. Am J Obstet
Gynecol 1989;161:1145–1146.
Citation
More V, Panchbudhe S, Mali K, Satia
MN. Heterotopic Pregnancy After IVF-ET. JPGO Volume 1 Issue 2, February 2014,
available at :http://www.jpgo.org/2014/02/heterotopic-pregnancy-after-ivf-et.html