* Â Ultrasound Division, ASL Roma B, Rome, Italy;
** Ultrasound Division, Ceprano Hospital, Ceprano, Italy.
Introduction
Cervical pregnancies are extremely rare. Clinical diagnosis is usually made when complications occur, threatening the life and obstetric future of the patient. Early diagnosis and treatment may prevent the complications.
Conservative treatment of the condition is more likely to be successful before 12 weeks of gestation because of lesser trophoblastic infiltration of the cervical walls. Farabow et al [1] was the first who reported the use of Methotrexate (MTX) in treatment of cervical pregnancies. Hung et al [2] analyzed some prognostic factors affecting the outcome of conservative treatment. According to their conclusions the failure of the MTX therapy was generally higher when:
- serum β-hCG levels are greater than 10,000 IU/L;
- gestational age is higher than 9 weeks of amenorrhea;
- fetal cardiac activity is present;
- crown-rump length is greater than 10 mm.
Other authors have reported additional administration of prostaglandins, to prevent hemorrhage during conservative management of viable cervical pregnancies, both systematically [3] and by local instillation [4].
Case report
This is a case of a 45 years G0P0 patient with a long history of infertility. The actual pregnancy was obtained abroad (due to Italian legislation) after egg donation, in vitro fertilization and transfer of two embryos.
Course of the beta-HCG (human chorionic gonadotrophin) levels was normal suggesting regular evolution of the pregnancy. The patient presented to our Ultrasound Department due to vaginal bleeding at 6 weeks + 2 days of gestation and the same day her quantitative serum β-hCG level was 3240 IU/L.
Transvaginal ultrasound examination showed empty uterine cavity and presence of a gestational sac in the middle third of the cervical canal. Regular yolk sac and a 3.3 mm long embryo with discernible heart-beating were observable within the gestational sac. Color Doppler showed poor vascularization of the trophoblast.
The patient was hospitalized and her vital signs were strictly monitored. Systemic intravenous Methotrexate with intramuscular folinic acid (12.5 mg rescue) were administered every two days for four times. Serum beta-hCG levels continued to raise reaching 6800 IU/L and CRL reached 7 mm. Second MTX administration leaded to cessation of embryonic heart-beating.
Following 21 days the patient experienced menstrual/like bleeding. Her beta-hCG levels were decreasing slowly. Hemoglobin levels did not drop significantly.
At day 36 the patient aborted a solid material and following transvaginal ultrasonography did not find any gestational sac or residual material in the cervical canal. At day 45 the beta HCG level was negative.
Images 1, 2, 3, and 4: 7 weeks of gestation, vaginal ultrasonography - cervical pregnancy; the image 1 shows sagittal scan of the uterus with thick endometrium; the images 2 and 3 show sagittal scan of the uterine cervix with the gestational sac within the cervical canal (3.3 mm long embryo is discernible on the image 3); the image 4 shows transverse scan of the uterine cervix with the gestational sac within the cervical canal.