Approach to Treatment of Cervical Pregnancy: A Case Report

Abstract

CASE: A 25yo G1 at 11wk4d dated by LMP and confirmed with a 10 week ultrasound presents with a possible cervical ectopic pregnancy. Past medical, surgical, and OBGYN histories are unremarkable. A cervical pregnancy was suspected on ultrasound due to low implantation of the gestational sac, and a significant posterior bulge with an hourglass shaped uterus. MRI suggested implantation of the placenta in the posterior uterine and cervical wall due to extreme thinning of these structures. Our institution had previously created a protocol for multidisciplinary management of cesarean scar and cervical pregnancies. She desires fertility preservation, and so consented to combined local and systemic treatment with Methotrexate (MTX). Preprocedural Beta-hCG was 81,514.8 mU/mL. Ultrasound-guided transvaginal intra-gestational sac injection of MTX was performed without complication, though cardiac activity was still present at the conclusion of the procedure. The patient also received an IM injection of MTX before discharge. Serial Beta-hCG are still being followed, and are trending towards zero. CONCLUSION: The optimal management for cervical pregnancies is not known, and decisions around type of management are informed by the patient’s desire for fertility preservation. In this case, a protocol created by a multidisciplinary team was used to guide treatment. This protocol using MTX successfully treated the cervical pregnancy at 11wk4d and avoided a surgery that could complicate future fertility. CLINICAL SIGNIFICANCE: Due to the rare occurrence of cervical pregnancy, there is not a universally accepted treatment protocol. This case shows that medical management can be successful for cervical pregnancies. Clear guidelines must be established for cervical pregnancies to optimize outcomes, and decrease maternal morbidity and mortality and to preserve future fertility.