CASE REPORT Combined treatment with temporary intraoperative balloon occlusion of common iliac arteries and hysteroscopic endocervical resection with postoperative cervical balloon for intractable cervical pregnancy in an infertile woman Jehn-Hsiahn Yang, M.D.,a Jin-Chung Shih, M.D.,a Kao-Lang Liu, M.D.,b and Yu-Shih Yang, M.D., Ph.D.a a
Department of Obstetrics and Gynecology, and b Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine
Objective: To describe treatment of an intractable cervical pregnancy that failed intracervical Foley catheter tamponade and uterine artery embolization followed by curettage of gestational tissue. Design: Case report. Setting: Tertiary-care university hospital. Patient(s): A 37-year-old infertile woman who achieved an 8-week cervical pregnancy after IVF-ET. Intervention(s): Temporary intraoperative balloon occlusion of bilateral common iliac arteries in combination with hysteroscopic endocervical resection of the gestational tissue, followed by postoperative intracervical balloon compression for 3 days. Main Outcome Measure(s): Serial serum b-hCG concentrations. Result(s): Complete removal of gestational products with preservation of fertility. Conclusion(s): Temporary balloon occlusion of bilateral common iliac arteries in combination with hysteroscopic endocervical resection of cervical pregnancy was effective in the treatment of intractable cervical pregnancy and preserved the woman’s future fertility. (Fertil Steril 2007;88:1438.e11–3. 2007 by American Society for Reproductive Medicine.) Key Words: Cervical pregnancy, balloon occlusion of common iliac artery, hysteroscopic endocervical resection
Cervical pregnancy is a rare form of ectopic pregnancy, but occasionally might be life threatening because of massive vaginal bleeding. Its incidence is reported to vary from 1 in 1,000 to 1 in 18,000 pregnancies (1, 2). For several decades, hysterectomy was the only treatment for cervical pregnancy. However, some conservative treatments have been undertaken to avoid hysterectomy and preserve fertility, including systemic or local injection with methotrexate (3, 4), cervical cerclage after curettage (1), intracervical Foley catheter tamponade (5), bilateral internal iliac artery ligation (6), descending uterine artery ligation (7), selective uterine artery embolization (UAE) (8, 9), and hysteroscopic resection (10). These procedures are used either alone or in combination. In this report, we present a woman with cervical pregnancy for whom both the intracervical Foley catheter tamponade and UAE followed by curettage failed treatment. Received December 22, 2006; revised and accepted January 5, 2007. Reprint requests: Yu-Shih Yang, Department of Obstetrics and Gynecology, National Taiwan University Hospital, 7 Chung-Shan South Road, 100, Taipei, Taiwan (FAX: þ886-2-2341-8557; E-mail:
[email protected]. ntu.edu.tw).
CASE REPORT A 37-year-old woman had primary infertility due to unexplained factor for 2 years. She underwent uterine curettage for endometrial polyps, followed by IVF-ET 1 month later at a private clinic. A total of 23 oocytes were retrieved and 5 embryos were transfered 3 days later. Unfortunately, she suffered from severe ovarian hyperstimulation syndrome and was admitted to that private clinic for 18 days when intravenous albumin administration and abdomial paracentesis were done. Transvaginal sonography revealed two gestational sacs with one viable fetus located below the internal cervical os at 7 weeks’ gestation (Fig. 1A). She experienced sudden onset of massive vaginal bleeding 2 days later. The serum b-hCG level was 27,529 mIU/mL and the hemoglobin was 9.5 g/dL, which dropped to 9.1 g/dL in spite of transfusion of packed red blood cells of 4 units. Intracervical Foley catheter tamponade was done, but the vaginal bleeding persisted. Bilateral UAE with coarse Gelfoam particles was then carried out, followed by curettage of gestational tissue under the transabdominal sonographic monitoring. The vaginal bleeding persisted, however, and another UAE was done
1438.e11 Fertility and Sterility Vol. 88, No. 5, November 2007 Copyright ª2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/07/$32.00 doi:10.1016/j.fertnstert.2007.01.033
FIGURE 1 (A) Transvaginal sonography revealed two gestational sacs with one viable fetus 39 days after transvaginal oocyte retrieval (TVOR). (B) Power Doppler imaging demonstrated a cervical mass containing numerous tortuous and dilated blood vessels 57 days after TVOR. The ectopic trophoblastic invasion into the cervical stroma results in vascular communication beds in the implantation site and establishes abundant peritrophoblastic arterial flows.
with temporary balloon occlusion of bilateral common iliac arteries (CIA). The patient and her family were appropriately counseled with respect to the surgical and procedural risks incurred. Institutional review board approval was not obtained, because the treatment for this patient was part of our routine procedure. Instead, she signed a general surgical and anesthetic informed consent for the procedure. On the day of surgery, both femoral arteries were punctured using the standard Seldinger technique (11), with placement of 8-Fr sheath introducers. The 5-Fr balloon catheters (maximal occlusive diameter 25 mm; Goodtec, Gifu, Japan) were then inserted and placed in the CIA. The bilateral CIA locations below the aortic bifurcation were easily identified using the guide wire without contrast-enhanced angiography. The fluoroscopy time and the dosimetry of fetal exposure were 2.4 minutes and 1.8 mGy, respectively (12). Endocervical resection was done using a 12-degree resectoscope with an outer diameter of 8 mm (Olympus Optical, Tokyo, Japan). The distending media of 10% dextrose solution was delivered into the endocervical canal by simple gravity flow from 70 cm above the patient (13). Through the resectoscope, we saw the admixture of gestational tissue and blood clots occupying the posterior aspect of cervical canal below the internal cervical os. The endocervical resection was done with simultaneous inflation of bilateral CIA balloon catheters and was under the transabdominal sonographic monitoring. The blood loss was dramatically decreased as both CIAs were occluded by the balloons, which were deflated for 1 minute every 15 minutes to avoid ischemic damage to the lower extremities. The procedure was accomplished using the cutting loop for blunt dissection of the gestational tissue without the use of electricity. Separated materials were then removed by grasping forceps. After hysteroscopic examination comfirming the complete removal of gestational tissue, electrocoagulation was done using the rollerball with power set at 30 W to achieve a hemostasis. The surgery took 80 minutes and the blood loss was estimated to be 400 mL.
Yang. Hysteroscopic removal of cervical pregnancy. Fertil Steril 2007.
2 days later. The bleeding decreased gradually after that but increased again 10 days later. The serum b-hCG concentration was 8,041 mIU/mL on the day before the second UAE and 3,998 mIU/mL 11 days later. Because of the persistently active gestatinal tissue, the patient was transfered to our department for further management. The transvaginal sonography revealed a cervical mass measuring 4.7 3.6 cm that contained several serpentine and sonolucent areas. Power Doppler imaging depicted numerous tortuous and dilated blood vessels within this mass (Fig. 1B). To eradicate the persistent gestational tissue, we planned to perform hysteroscopic endocervical resection in combination Fertility and Sterility
Immediately after the operation, a 24-Fr Foley balloon catheter (Rusch, Kamunting, Malaysia) was placed at the cervical canal, and 50 mL of normal saline was infused into the balloon to achieve a broad hemostatic effect. Intramuscular methotrexate (50 mg) was injected on the following day, and the 24-Fr Foley balloon catheter was removed 3 days after surgery. She was discharged uneventfully the next day, when the serum b-hCG concentration was 289 mIU/mL. Histologic examination revealed chorionic villi and trophoblastic cells existing within hemorrhagic necrotic materials. The serum b-hCG concentration was 7 mIU/mL 19 days after hysteroscopic endocervical resection. An office hysteroscopic examination 3 months later demonstrated a cervical diverticulum below the internal cervical os. DISCUSSION To the best of our knowledge, this is the first report using temporary CIA occlusion in combination with hysteroscopic 1438.e12
endocervical resection with balloon for management of intractable cervical pregnancy. Although the etiology of cervical pregnancy is unknown, the cause of cervical pregnancy in this case is possibly due to the precedent curettage for endometrial polyp. Reports have found that previous curettage is a great risk of subsequent occurrence of cervical pregnancy, in which 81%–95% of patients with cervical pregnancy have had previous curettage (1, 2). We therefore recommend that women who have an endometrial polyp and desire to achieve a pregnancy in later years should undergo transcervical resection rather than curettage, because the latter bears the risks of subsequent occurrence of cervical pregnancy. In 1996, Ash and Farrell for the first time used hysteroscopy for the resection of a cervical pregnancy (10). A more advanced gestation would probably enlarge and distort the cervix. The ectopic trophoblastic invasion into the cervical stroma may furthermore result in vascular communication beds in the implantation site of cervix. Operative hysteroscopy enables us to confirm the location of the cervical pregnancy by direct visualization. Through hysteroscopy, the cervical pregnancy can be resected completely and the bleeding vessels coagulated (10, 14). Several vascular blockade procedures have been developed to minimize blood loss during treatments for cervical pregnancy, including internal iliac artery ligation (15), uterine artery ligation (16), and UAE (17). However, the potentially harmful effect on subsequent pregnancies is an important concern. A relatively high rate (41.2%) of early miscarriage in subsequent pregnancies was observed after laparoscopic coagulation of uterine vessels in the treatment of symptomatic myomas (18). Women who become pregnant after UAE are also at risk for malpresentation (17% vs. 5%), preterm birth (28% vs. 5%–10%), cesarean delivery (58% vs. 22%), and postpartum hemorrhage (13% vs. 4%–6%) compared with the general population (19). The American College of Obstetricians and Gynecologists has suggested that there is insufficient evidence in the current literature to ensure safety of UAE in women desiring to retain their fertility. Uterine artery embolization should be considered to be investigational or relatively contraindicated in women wishing to retain fertility (20). Temporary balloon occlusion of CIA is generally used in the repair of abdominal aortic aneurysm (21). It has also been used for bleeding control during cesarean hysterectomy for placenta percreta (12). Because the blockade of vascular flow to the uterus is temporary, there is no need to worry about uterine damage that might affect subsequent pregnancies. Compared with internal iliac artery occlusion, balloon occlusion of CIA can be used to overcome collateral flow from the external iliac and femoral arteries, thus significantly decreasing hemorrhage. However, prolonged occlusion of the CIA may be associated with reperfusion injury, thrombosis, and/or embolism of the lower extremities. Therefore, the occlusion time should be as short as possible. In conclusion, temporary balloon occlusion of bilateral CIA in combination with hysteroscopic endocervical resec1438.e13
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tion of cervical pregnancy is effective in the treatment of intractable cervical pregnancy. This combined treatment has the advantage of preserving the woman’s future fertility.
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