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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Contributed by : Jui Sanjay Nigudkar
Contributed by : Jui Sanjay Nigudkar
Management of live cervical ectopic pregnancy with potassium chloride injection and uterine artery embolization.
Management of live cervical ectopic pregnancy with potassium chloride injection and uterine artery embolization.
Introduction:
Introduction:
Cervical ectopic pregnancy is a rare form of ectopic pregnancy with an incidence of less than 1% of all ectopic pregnancies. It is associated with high morbidity and mortality. There is an increased risk of haemorrhage which has made hysterectomy the presumptive treatment. However, in nulliparous women, timely intervention and conservative management options become essential for preserving fertility and avoiding hysterectomy. Uterine artery embolization is a relatively novel approach for the management of cervical ectopic pregnancy . Here we report a case of cervical ectopic pregnancy in a nulliparous woman managed successfully by intra-amniotic injection of KCl followed by bilateral uterine artery embolization and dilatation and curettage.
Cervical ectopic pregnancy is a rare form of ectopic pregnancy with an incidence of less than 1% of all ectopic pregnancies. It is associated with high morbidity and mortality. There is an increased risk of haemorrhage which has made hysterectomy the presumptive treatment. However, in nulliparous women, timely intervention and conservative management options become essential for preserving fertility and avoiding hysterectomy. Uterine artery embolization is a relatively novel approach for the management of cervical ectopic pregnancy . Here we report a case of cervical ectopic pregnancy in a nulliparous woman managed successfully by intra-amniotic injection of KCl followed by bilateral uterine artery embolization and dilatation and curettage.
Case presentation:
Case presentation:
A 24 year old primigravida, presented with amenorrhea over 8 weeks and pervaginal bleeding since two days. Her UPT was positive. On initial evaluation, the patient's beta-human chorionic gonadotropin (beta-HCG) was 10,680 mIU/mL. Repeat UPT was strongly positive. On examination the patient was tachycardic, blood pressure and her lab investigations were within normal limit. Hb- 10.1gm% , Platelets- 1.2 lakhs, total leukocyte count - 11,600 per microliter, prothrombin time and INR- 13.9/1.09, urine output- 700 ml/24 hours. On per speculum examination- there were clots at the external os of the cervical canal and within the vagina. The abdomen was soft and non-tender. Ultrasonogram showed a gestational sac in the cervical canal with a single live fetus. No intrauterine gestational sac was seen (FIG 1). Duplex sonogram showed increased uterine vascularity , supplying the G-sac (FIG 2).
A 24 year old primigravida, presented with amenorrhea over 8 weeks and pervaginal bleeding since two days. Her UPT was positive. On initial evaluation, the patient's beta-human chorionic gonadotropin (beta-HCG) was 10,680 mIU/mL. Repeat UPT was strongly positive. On examination the patient was tachycardic, blood pressure and her lab investigations were within normal limit. Hb- 10.1gm% , Platelets- 1.2 lakhs, total leukocyte count - 11,600 per microliter, prothrombin time and INR- 13.9/1.09, urine output- 700 ml/24 hours. On per speculum examination- there were clots at the external os of the cervical canal and within the vagina. The abdomen was soft and non-tender. Ultrasonogram showed a gestational sac in the cervical canal with a single live fetus. No intrauterine gestational sac was seen (FIG 1). Duplex sonogram showed increased uterine vascularity , supplying the G-sac (FIG 2).
Fig 1: The typical ‘hourglass’ shape of the uterus- No intrauterine gestation is seen. The cervical canal shows a single gestational sac with yolk sac with a foetal pole. On dynamic scan, the sliding sign was absent.
Fig. 2 -- Significant vascularity is seen in the uterine artery on colour Doppler.
A decision was made to manage the live ectopic with ultrasound guided intra-amniotic potassium chloride injection (FIG 3) and uterine artery embolization to minimize the bleeding ' , followed by dilation and curettage.
A decision was made to manage the live ectopic with ultrasound guided intra-amniotic potassium chloride injection (FIG 3) and uterine artery embolization to minimize the bleeding ' , followed by dilation and curettage.
Fig 3- Intraamniotic KCl was injected.
Interventional technique:
Interventional technique:
Following intra-amniotic KCl injection, absence of cardiac activity in the foetus was confirmed on sonogram. The patient was then taken for uterine artery embolization. From a right femoral access, a pelvic angiogram was performed with the pigtail catheter at L1 level precluding any blood supply from ovarian arteries (FIG 4).
Following intra-amniotic KCl injection, absence of cardiac activity in the foetus was confirmed on sonogram. The patient was then taken for uterine artery embolization. From a right femoral access, a pelvic angiogram was performed with the pigtail catheter at L1 level precluding any blood supply from ovarian arteries (FIG 4).
Fig. 4- Pre embolisation pelvic angiogram shows increased vascularity and tortuosity of branches of theleft uterine artery,. Few branches noted from the right uterine artery as well.
The angiogram showed of increased vascularity from both uterine arteries, significantly more from the left.
The angiogram showed of increased vascularity from both uterine arteries, significantly more from the left.
The contralateral internal iliac artery was catheterized using a 4 Fr Cobra catheter and selective catherisation of the uterine artery was performed using a 2.7 Fr microcatheter. and its location was confirmed with a test angiogram (FIG 5)
The contralateral internal iliac artery was catheterized using a 4 Fr Cobra catheter and selective catherisation of the uterine artery was performed using a 2.7 Fr microcatheter. and its location was confirmed with a test angiogram (FIG 5)
Fig 5-Preembolisation selective angiogram of the left uterine artery in the right anterior oblique view shows hypervascularity of the uterus .
Polyvinyl alcohol particles of size 500-700 microns were mixed with iodinated contrast and normal saline in a 1:1 ratio. THe PVA-saline-contrast mixture was injected in slow, interrupted fashion alternating with injection of normal saline, till there was stagnation of the contrast and was stopped when reflux was noted. A check angiogram confirmed embolization of the left uterine artery.
Polyvinyl alcohol particles of size 500-700 microns were mixed with iodinated contrast and normal saline in a 1:1 ratio. THe PVA-saline-contrast mixture was injected in slow, interrupted fashion alternating with injection of normal saline, till there was stagnation of the contrast and was stopped when reflux was noted. A check angiogram confirmed embolization of the left uterine artery.
The identical procedure was then performed on the right uterine artery.
The identical procedure was then performed on the right uterine artery.
Fig 6 Pre embolisation selective right uterine artery, Left anterior oblique view shows a few, mildly tortuous branches of right uterine artery
Post embolization pelvic angiogram showed satisfactory devascularization.(FIG 7)
Post embolization pelvic angiogram showed satisfactory devascularization.(FIG 7)
Fig 7- Pelvic angiogram (post embolization)- shows non-opacification of the both uterine arteries distally and adequate embolization of the lesion with no hypervascularity.
Following UAE- emergency dilatation and curettage with descending cervical artery ligation was done under general anaesthesia. The anterolateral wall of cervix was curetted till grating sensation was felt. Intraoperative blood loss was limited to 150cc.
Following UAE- emergency dilatation and curettage with descending cervical artery ligation was done under general anaesthesia. The anterolateral wall of cervix was curetted till grating sensation was felt. Intraoperative blood loss was limited to 150cc.
Discussion:
Discussion:
Cervical pregnancy is a rare type of ectopic pregnancy; its incidence is 1:16000 to 1:18000 of all pregnancies [1, 2] and 0.1% of all ectopic pregnancies [1]. If the pregnancy is disturbed, it may lead to massive haemorrhage, since the trophoblast can invade the cervical blood supply, which may require hysterectomy to save the patient.[3].
Cervical pregnancy is a rare type of ectopic pregnancy; its incidence is 1:16000 to 1:18000 of all pregnancies [1, 2] and 0.1% of all ectopic pregnancies [1]. If the pregnancy is disturbed, it may lead to massive haemorrhage, since the trophoblast can invade the cervical blood supply, which may require hysterectomy to save the patient.[3].
In the past, cervical ectopic pregnancies were diagnosed at advanced stage where life-threatening profuse haemorrhage would make emergency hysterectomy inevitable resulting in a loss of fertility.[4] Historically, 70% of reported cervical pregnancies have required hysterectomy for treatment [5] According to a review, all cases of cervical ectopic pregnancy extending beyond 12 weeks' gestation, that is, when diagnosed in the second or third trimester, ultimately required hysterectomy [6] but now with the widespread use of transvaginal ultrasound, early diagnosis of cervical ectopic is possible which allows the use of various nonsurgical management methods to preserve the uterus and maintain fertility.
In the past, cervical ectopic pregnancies were diagnosed at advanced stage where life-threatening profuse haemorrhage would make emergency hysterectomy inevitable resulting in a loss of fertility.[4] Historically, 70% of reported cervical pregnancies have required hysterectomy for treatment [5] According to a review, all cases of cervical ectopic pregnancy extending beyond 12 weeks' gestation, that is, when diagnosed in the second or third trimester, ultimately required hysterectomy [6] but now with the widespread use of transvaginal ultrasound, early diagnosis of cervical ectopic is possible which allows the use of various nonsurgical management methods to preserve the uterus and maintain fertility.
Curettage is the age-old fertility preserving method, but is associated with a high risk of haemorrhage. It must be supplemented by a mechanical method to reduce bleeding.
Curettage is the age-old fertility preserving method, but is associated with a high risk of haemorrhage. It must be supplemented by a mechanical method to reduce bleeding.
When the gestational period exceeds nine weeks with the presence of cardiac activity demonstrated on ultrasound - in a clinically stable patient, ultrasound guided intra-amniotic potassium chloride may be required to achieve cardiac asystole.[7]
When the gestational period exceeds nine weeks with the presence of cardiac activity demonstrated on ultrasound - in a clinically stable patient, ultrasound guided intra-amniotic potassium chloride may be required to achieve cardiac asystole.[7]
Uterine artery embolization is a minimally invasive procedure that can be performed under mild sedation and has been used as a standalone treatment option or is performed prophylactically prior to pelvic surgeries to minimize intra-operative blood loss. In symptomatic uterine fibroids it has been used both as an alternative for surgical management [8] as well as preoperatively, prior to myoma enucleation where it results in minimal loss of blood and better intraoperative suturing[9,10] and is also considered in patients requiring hysterectomies due to technical reasons (such as very large fibroid >10cm, multiple fibroids, fibroids which are difficult to resect or which are in unfavourable positions). [11] Prophylactic UAE has also been carried out in abnormally invasive placenta- a spectrum involving placenta accreta, increta and percreta- where if performed immediately following a scheduled caesarean, it reduces postpartum haemorrhage and associated complications. [12] UAE is also indicated for cases with PPH who have failed conservative management for any cause of primary or secondary PPH. [13]
Uterine artery embolization is a minimally invasive procedure that can be performed under mild sedation and has been used as a standalone treatment option or is performed prophylactically prior to pelvic surgeries to minimize intra-operative blood loss. In symptomatic uterine fibroids it has been used both as an alternative for surgical management [8] as well as preoperatively, prior to myoma enucleation where it results in minimal loss of blood and better intraoperative suturing[9,10] and is also considered in patients requiring hysterectomies due to technical reasons (such as very large fibroid >10cm, multiple fibroids, fibroids which are difficult to resect or which are in unfavourable positions). [11] Prophylactic UAE has also been carried out in abnormally invasive placenta- a spectrum involving placenta accreta, increta and percreta- where if performed immediately following a scheduled caesarean, it reduces postpartum haemorrhage and associated complications. [12] UAE is also indicated for cases with PPH who have failed conservative management for any cause of primary or secondary PPH. [13]
Uterine artery embolization was first used for cervical ectopic pregnancy management in 1990, following which it has been widely accepted that UAE can control and prevent acute cervical bleeding.[14]Due to occlusion of supplying arteries, subsequent curettage becomes safer, with substantially reduced risk of excessive haemorrhage. There are reports of viable pregnancies after UAE for cervical ectopic pregnancies[7] making it an effective and safe treatment option in women who wish to conceive in the future.
Uterine artery embolization was first used for cervical ectopic pregnancy management in 1990, following which it has been widely accepted that UAE can control and prevent acute cervical bleeding.[14]Due to occlusion of supplying arteries, subsequent curettage becomes safer, with substantially reduced risk of excessive haemorrhage. There are reports of viable pregnancies after UAE for cervical ectopic pregnancies[7] making it an effective and safe treatment option in women who wish to conceive in the future.
Conclusion:
Conclusion:
UAE in the conservative management of first trimester cervical ectopic pregnancies in nulliparous women for preserving the uterus and fertility is an ideal addition for good intra and post-operative outcomes in terms of reduced blood loss and consequently reduced need for emergency hysterectomy.
UAE in the conservative management of first trimester cervical ectopic pregnancies in nulliparous women for preserving the uterus and fertility is an ideal addition for good intra and post-operative outcomes in terms of reduced blood loss and consequently reduced need for emergency hysterectomy.
References:
References:
1. Rock JA, Damario MA. Ectopic pregnancy. In: Rock JA, Jones HW III, editors. Te Linde's operative gynaecology. 9th ed. Lippincott Williams & Wilkins; USA: 2003. pp. 507–536.
1. Rock JA, Damario MA. Ectopic pregnancy. In: Rock JA, Jones HW III, editors. Te Linde's operative gynaecology. 9th ed. Lippincott Williams & Wilkins; USA: 2003. pp. 507–536.
2. Cunningham FG, Grant NF, Leveno KJ, Gilstrap LC III, Haut JC, Wenstrom KD, editors. Williams Obstetrics. 21st ed. MC Graw Hill; New York: 1997. Ectopic pregnancy; pp. 883–910.
2. Cunningham FG, Grant NF, Leveno KJ, Gilstrap LC III, Haut JC, Wenstrom KD, editors. Williams Obstetrics. 21st ed. MC Graw Hill; New York: 1997. Ectopic pregnancy; pp. 883–910.
3. Samal SK, Rathod S. Cervical ectopic pregnancy. J Nat Sci Biol Med. 2015 Jan-Jun;6(1):257-60. doi: 10.4103/0976-9668.149221. PMID: 25810679; PMCID: PMC4367055.
3. Samal SK, Rathod S. Cervical ectopic pregnancy. J Nat Sci Biol Med. 2015 Jan-Jun;6(1):257-60. doi: 10.4103/0976-9668.149221. PMID: 25810679; PMCID: PMC4367055.
4. Ding, Wei, Xiaona Zhang, and Pengpeng Qu. "An efficient conservative treatment option for cervical pregnancy: transcatheter intra-arterial methotrexate infusion combined with uterine artery embolization followed by curettage." Medical Science Monitor: International Medical Journal of Experimental and Clinical Research 25 (2019): 1558.
4. Ding, Wei, Xiaona Zhang, and Pengpeng Qu. "An efficient conservative treatment option for cervical pregnancy: transcatheter intra-arterial methotrexate infusion combined with uterine artery embolization followed by curettage." Medical Science Monitor: International Medical Journal of Experimental and Clinical Research 25 (2019): 1558.
5. Hung TH, Jeng CJ, Yang YC, Wang KG, Lan CC. Treatment of cervical pregnancy with methotrexate. International Journal of Gynecology and Obstetrics. 1996;53:243–247.
5. Hung TH, Jeng CJ, Yang YC, Wang KG, Lan CC. Treatment of cervical pregnancy with methotrexate. International Journal of Gynecology and Obstetrics. 1996;53:243–247.
6. Singh, Sweta. "Diagnosis and management of cervical ectopic pregnancy." Journal of Human Reproductive Sciences 6, no. 4 (2013): 273.
6. Singh, Sweta. "Diagnosis and management of cervical ectopic pregnancy." Journal of Human Reproductive Sciences 6, no. 4 (2013): 273.
7. Krissi H, Hiersch L, Stolovitch N, et al. Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol. 2014;182:172–76
7. Krissi H, Hiersch L, Stolovitch N, et al. Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol. 2014;182:172–76
8. Ravina J H, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet. 1995;346:671–672
8. Ravina J H, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet. 1995;346:671–672
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9. Tixier H, Loffroy R, Filipuzzi L. et al. Embolisation artérielle utérine par matériel résorbable avant myomectomie [Uterine artery embolization with resorbable material prior to myomectomy] J Radiol. 2008;89:1925–1929.
10. Ravina J H, Bouret J M, Fried D. et al. [Value of preoperative embolization of uterine fibroma: report of a multicenter series of 31 cases] Contracept Fertil Sex. 1995;23:45–49
10. Ravina J H, Bouret J M, Fried D. et al. [Value of preoperative embolization of uterine fibroma: report of a multicenter series of 31 cases] Contracept Fertil Sex. 1995;23:45–49
11. Dumousset E, Chabrot P, Rabischong B. et al. Preoperative uterine artery embolization (PUAE) before uterine fibroid myomectomy. Cardiovasc Intervent Radiol. 2008;31:514–520.
11. Dumousset E, Chabrot P, Rabischong B. et al. Preoperative uterine artery embolization (PUAE) before uterine fibroid myomectomy. Cardiovasc Intervent Radiol. 2008;31:514–520.
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12. Mok M, Heidemann B, Dundas K, Gillespie I, Clark V. Interventional radiology in women with suspected placenta accreta undergoing caesarean section. Int J Obstet Anesth. 2008;17(03):255–261.
13. Lee H Y, Shin J H, Kim J et al. Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution. Radiology. 2012;264(03):903–909.
13. Lee H Y, Shin J H, Kim J et al. Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution. Radiology. 2012;264(03):903–909.
14. Lobel SM, Meyerovitz MF, Benson CC, et al. Preoperative angiographic uterine artery embolization in the management of cervical pregnancy. Obstet Gynecol. 1990;76:938–41.
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