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Heterotopic Pregnancy

Michael Cooney, MD
Mary C Frates, MD
Peter M Doubilet, MD, PhD

March 21, 1995

Presentation

A 38-year-old woman, seven weeks pregnant following induced ovulation and intrauterine insemination, develops vaginal bleeding.

Imaging Findings

Transabdominal sonogram
Endovaginal sonogram
Endovaginal scans with Doppler
Transvaginal sonographic guidance during therapy
Follow-up transabdominal sonogram

Transabdominal and endovaginal sonograms reveal two gestational sacs, one in the uterus (arrows) and the other in the cervix (arrows). Endovaginal scans with Doppler indicate an embryo in each sac (crown rump length=9mm) with cardiac activity corresponding to a gestational age of 7 weeks.

Management

Under transvaginal sonographic guidance, potassium chloride (KCl) was injected into the cervical embryo causing the heartbeat to stop (arrow). Follow up transabdominal scan confirmed the presence of a normal live intrauterine pregnancy (arrow). Increased echotexture and vascularity was noted in the cervix (arrow). This appearance gradually diminished through the course of the pregnancy; however, the cervix did remain hypervascular. The patient delivered a healthy neonate approximately 7 months later by elective cesarean section.

Diagnosis

Coexistent intrauterine and cervical pregnancies

Discussion

Cervical pregnancy is a rare form of ectopic pregnancy, although its prevalence may be increased in patients undergoing in vitro fertilization. In the past, the standard treatment was often hysterectomy due to uncontrollable hemorrhage from the abnormal implantation site. Ultrasound permits early and accurate diagnosis of cervical pregnancy and new treatment options are now available. Conservative procedures for pregnancy ablation (including dilatation and evacuation after angiographic uterine artery embolization and ultrasound-guided KCl injection) allow safe termination of cervical ectopic pregnancies with preservation of the uterus. Although emergent embolization is indicated when life-threatening hemorrhage is present, KCl injection with transvaginal sonographic guidance has been used safely and is the preferred procedure in clinically stable patients. It can be performed safely on an outpatient basis without anaesthesia, ionizing radiation or intravenous contrast and preserves future fertility.

References

1. Frates MC, Benson CB, Doubilet PM, DiSalvo DN, Brown DL, Laing FC, et al. Cervical ectopic pregnancy: results of conservative treatment. Radiology 1994;191:773-775.

2. Jankowitz J, Leake J, Huggins G, Gazaway P, Gates E. Cervical ectopic pregnancy:review of the literature and report of a case treated by single dose methotrexate therapy. Obstet Gynecol Surg 1990; 45:405-414.

3. Meyerovitz MF, Lobel SM, Harrington DP, Bengston JM. Preoperative uterine artery embolzation in cervical pregnancy. J Vasc Intervent Radiol 1991;2:95-97.

4. Weyerman PC, Verhoeven ATM, Alberta AT. Cervical pregnancy after in vitro fertilization and embryo transfer. Am J Obstet Gynecol 1989;161:1145-46.

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