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Successful Treatment for a Heterotopic Intrauterine and a Twin Cervical

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Successful Treatment for a Heterotopic Intrauterine and a Twin Cervical IMAJ • VOL 13 • FEBRUARY 2011 CASE COMMUNICATIONS Dilation and Curettage: Successful Treatment for a Heterotopic Intrauterine and a Twin Cervical Pregnancy Dana Vitner MD, Lior Lowenstein MD MSc, Michael Deutsch MD, Nizar Khatib MD and Zeev Weiner MD Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel pregnancies, enabling the caregivers to Serum beta-human chorionic gonadotro- KEY WORDS: cervical pregnancy, heterotopic offer conservative treatment. This new pin level was 10,000 mIU/ml 3 days prior pregnancy, dilation and curettage approach reduced the morbidity and to her admission. IMAJ 2011; 13: 115–116 mortality rate and greatly improved On admission, the patient’s vital signs fertility preservation [1,3]. were stable and the abdomen was soft Cervical twin pregnancy is an ex- with no signs of peritoneal irritation. A tremely rare event, with only a few cases speculum and bimanual gynecological reported in the literature. It is reason- examination revealed a small amount of ervical pregnancy represents a rare able to claim that women with this type cervical bleeding with blood clots, and C type of ectopic pregnancy [1-5], rep- of pregnancy are at a higher risk for a normal-size anteverted uterus with orted to be less than 0.1% of all preg- massive hemorrhage due to the wider normal bilateral adnexae. Transvaginal nancies [2,4,5]. Possible risk factors for implantation area and the increased sonography revealed a single intrauterine cervical pregnancy are: prior uterine vascularity [4]. We present the case of a gestational sac, irregular in shape, with no surgery such as cesarean section, dilation rare event of a triplet pregnancy: a single embryo or yolk sac [Figure A]. In addition, and curettage, the use of an intrauterine intrauterine gestation combined with two gestational sacs were demonstrated in device, and in vitro fertilization [2,4,5]. two cervical gestational sacs. the cervix; one containing an embryo and Cervical pregnancy is a potentially life- a fetal heart beat and a second sac with a threatening condition that may present yolk sac without an embryo [Figure B]. with an unexpected profuse bleeding PATIENT DESCRIPTION Transvaginal sonography findings were secondary to the erosion of cervical A 47 year old primipara woman was unequivocal; the intrauterine pregnancy blood vessels [2]. In the past, cervical referred to the emergency room at 5.5 looked abnormal. All other laboratory pregnancy commonly presented with weeks gestation complaining of vaginal tests were normal. massive hemorrhage leading to hyster- bleeding. Three and a half weeks earlier, Termination of pregnancy was of ectomy and even death in extreme cases the patient underwent an intrauterine course recommended following the ultra- [2-4]. Improvements in ultrasound reso- transfer of three embryos in an IVF cycle sonic findings. After discussion, surgical lution resulted in earlier detection of such with egg donation due to ovarian failure. intervention was preferred considering [A] Single intrauterine gestational sac. [B] Two cervical gestational sacs. GS1 = gestational sac with an embryo, GS2 = gestational sac with a yolk sac. A B 115 CASE COMMUNICATIONS IMAJ • VOL 13 • FEBRUARY 2011 the risk of massive hemorrhage following individual original location could not be to be further evaluated [5]. We chose the medical abortion. Uterine artery catheter- identified. surgical conservative approach by D&C of ization prior to the D&C was considered, the uterine cavity and the cervical canal, but because of the relatively early gesta- estimating that it was the least risky for tion and the presumed ease of the surgical COMMENT our patient. procedure, it was declined. Painless vaginal bleeding is the char- Review of the relevant literature dem- The operation was carried out dur- acteristic clinical presentation of cer- onstrates that the occurrence of a cervical ing the day by two senior and experi- vical pregnancy and the etiology in pregnancy combined with an intrauterine enced surgeons. Before the operation, most cases is unknown. In the past, pregnancy is quite an exceptional event. a senior hematologist was notified and diagnosis was often delayed, resulting To the best of our knowledge this is the alerted. Novo-7 (Coagulation Factor VII in life-threatening hemorrhage often first case report describing a heterotopic Recombinant, Novo Nordisk, Israel) was leading to emergency hysterectomy and pregnancy composed of one intrauterine prepared along with 4 units of blood for even death [1,2,4,5]. Improvements in and two cervical pregnancies that were transfusion if required. The patient was ultrasound resolution resulted in earlier diagnosed and terminated uneventfully given a full and detailed explanation detection of such pregnancies. This new by evacuation and curettage at a relatively regarding the risks of her condition and approach reduced the morbidity and early stage of pregnancy. the possibility of hysterectomy if circum- mortality rates and improved fertility Corresponding author: stances required it, and she signed an preservation [1,3]. To prevent possible Dr. D. Vitner informed consent form. complications, termination of cervical Dept. of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa 31096, Israel Dilatation and curettage of the uterine pregnancy is recommended as early as Phone: (972-50) 206-4574, (972-77) 549-1310 cavity and the cervical canal were carried possible. email: [email protected] out uneventfully under general anesthe- Attempts have been made to treat References sia. The material from the uterus and the cervical pregnancies using conserva- 1. Hirakawa M, Tajima T, Yoshimitsu K, et al. Uterine cervix was sent together without separat- tive measures such as; intra-amniotic/ artery embolization along with the administration of methotrexate for cervical ectopic pregnancy: ing them. At the end of the curettage, a cardiac injection of potassium chloride technical and clinical outcomes. AJR Am J single suture of vicryl 0 (Polyglactin 910, or methotrexate, hypogastric iliac artery Roentgenol 2009; 192 (6): 1601-7. Ethicon, Johnson & Johnson, Israel) was ligation, embolization, hysteroscopic 2. Agdi M, Tulandi T. Surgical treatment of ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol placed in the cervix to control bleeding. resection, intra-amniotic aspiration with 2009; 23 (4): 519-27. Transvaginal ultrasound at the end of placement of cervical sutures, and intra- 3. Majumdar A, Gupta SM, Chawla D. Successful management of post-in-vitro fertilization cervical the procedure confirmed the complete amniotic injection of hypertonic solution heterotropic pregnancy. J Hum Reprod Sci 2009; 2 evacuation of the gestational sacs from the [1,5]. In recent years, with the medical (1): 45-6. cervix and the uterine cavity. The patient treatment (mainly methotrexate) of extra- 4. Trojano G, Colafiglio G, Saliani N, et al. Successful management of a cervical twin pregnancy: neo- was discharged on postoperative day 2 in uterine pregnancy gaining popularity, it adjuvant systemic methotrexate and prophylactic good condition with no vaginal bleed- was also attempted for cervical pregnancy. high cervical cerclage before curettage. Fertil Steril 2009; 91 (3): 935.e17-9. ing. The histopathology report described Although conservative management is 5. Shah AA, Grotegut CA, Likes CE 3rd, et al. the products of conception; however, preferred in most cases today, the cost- Heterotopic cervical pregnancy treated with transvaginal ultrasound-guided aspiration resulting effectiveness of this approach compared in cervical site varices within the myometrium. Fertil D&C = dilation and curettage with the classic surgical approach needs Steril 2009; 91 (3): 934.e19-22. Capsule Chronic fatigue syndrome studies point to possible contamination in XMRV findings The stormy debate over a potential cause of chronic fatigue 14-month-old row intensified when four papers appeared in syndrome (CFS) is nearing hurricane force. It prompted Retrovirology suggesting that reports linking the virus XMRV headlines suggesting that researchers have reached a dead to CFS were based on false positives. end, scores of blog posts from disappointed patients, and Science 2011; 331: 17 accusations that scientists had gone beyond their data. The Eitan Israeli “Our country, right or wrong. When right, to be kept right; when wrong, to be put right” Carl Schurz (1829-1906), German-born American revolutionary, statesman and reformer 116 .
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