A case of cervical pregnancy resistant to systemic methotrexate (MTX) administration is presented. A 41 year old patient with cervical pregnancy at 6 weeks 4 days’ gestation was successfully treated by intraamniotic MTX injection through the cervical canal using Tuohy needle after failure of systemic MTX treatment.
Conservative treatment using systemic methotrexate (MTX) administration has widely been applied as an initial treatment of cervical pregnancy while preserving fertility. However, there is no consensus with regard to the optimal treatment because of various success rates, ranging from 55% to 83%. In cases in which resistance to systemic MTX treatment are encountered, intraamniotic MTX injection can be considered as an additional treatment.
Local injection of MTX into the amniotic sac is usually performed under transvaginal ultrasound guidance, in which the injection needle is directed into the gestational sac through the cervical wall. This is more invasive than intraamniotic injection via the cervical canal under transabdominal ultrasound guidance because it can cause bleeding in case of biologically active pregnancy.
Tuohy needle used for epidural block has a bent, blunt, and slant tip to reduce the risk of dural puncture, and this design could facilitate easy access to the gestational sac through the cervical canal, preventing penetration of the needle into the cervical wall.
We report a case of cervical pregnancy of 6 weeks 4 days’ gestation that was successfully treated by intraamniotic MTX injection through the cervical canal using a Tuohy needle after failure of systemic MTX treatment.
Case Report
A 41 year old, gravida 5, para 2 woman presented with amenorrhea at 6 weeks 4 days after her last menstruation. Transvaginal ultrasonography revealed a 25.9 × 10.6 mm sized gestational sac and a single viable fetus with a crown-rump length (CRL) of 5 mm implanted in the uterine cervical canal. The uterine cavity was empty and the initial serum human chorionic gonadotropin (hCG) level was 24,076 mIU/mL.
Initially an alternative-day regimen of systemic MTX administration at 1 mg/kg (days 1, 3, 5, and 7) with folinic acid rescue at 0.1 mg/kg (days 2, 4, 6, and 8) was started. However, serum hCG level continued to gradually increase up to 32,874 mIU/L by day 10. Further progression of the gestational sac (26.4 × 19.1 mm) was seen, and CRL had increased to 5.8 mm with regular fetal heart beat, indicating failure of systemic MTX treatment. The gestational sac was located in the anterior cervical wall, 2 cm from the external os ( Figure 1 , A).
Therefore, we performed amniotic fluid aspiration and intraamniotic MTX injection through the cervical canal under transabdominal ultrasonographic guidance after sedation with intravenous injection of 50 mg pethidine (Jeil Pharm, Seoul, Korea). Tuohy needle (18 gauges; BD Medical System, Franklin Lakes, NJ; Figure 1 , B) was introduced into the cervical canal up to 2 cm from the external os, and 3 mL of amniotic fluid was aspirated. Then 50 mg of MTX was injected into the gestational sac ( Figure 1 , C).
There was no intraoperative bleeding and the patient was stable throughout the whole procedure. Immediately after the procedure, the fetal cardiac beat slowed down and serum hCG level rapidly decreased to 17,818, 13,583, and 7652 on posttreatment days 2, 5 and 7, respectively ( Figure 2 ).
