Conservative management of cervical pregnancy with subsequent fertility

Letters

Volume 163 Number 3

Fig. 2. Radiograph showing placement of thumbtack (lateral).

tack your patient ingested can be expected. Fortunately, as seen in the accompanying photographs, the lateral view clearly shows the placement of the tack in the sacrum. I commend the authors for bringing more attention to this rarely needed but invaluable maneuver.

William J. Mann, MD Department of Obstetrics and Gynecology, State University of New York at Stony Brook, Stony Brook, NY 11794-8091

Reply To the Editors: Space limitations clearly prevented a com-

prehensive review of all the possible complications and requisite caveats that should accompany the use of stainless steel thumbtacks for control of presacral hemorrhage. Dr. Mann's points are both well taken: Only noncorrosive metals should be selected, and appropriate surgical history should be provided to radiologists as a matter of courtesy to avoid unnecessary confusion. (Of course, they might also be confused as to why anyone was still using wire to close incisions!) Two additional points deserve mention. First, the risk for subsequent development of sacral osteomyelitis with this technique is unknown but must be kept in mind during patient follow-up. Second, although it would certainly be unusual to encounter (twice, no less) presacral venous plexus hemorrhage during cytoreductive surgery for ovarian cancer, Dr. Mann's two cases clearly illustrate that the technique may be required in situations other than elective presacral neurectomy. Bruce Patsner, MD Division of Gynecologic Oncology, Monmouth Medical Center, Long Branch, NJ e7740

Early pregnancy failure-appropriate terminology To the Editors: I was excited to see the title of the Clinical Opinion by Pridjianand and Moawad (Pridjian G, Moa-

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wad A. Missed abortion: still appropriate terminology? AM] OBSTET GYNECOL 1989;161:261-2). However, after carefully reading the article it appears that even the new terms they recommend are already outdated. I concur that advances in ultrasonography have changed our concepts about early pregnancy failure. Until recently, the accepted ultrasonographic definition for "missed abortion" was a crown-rump length of 15 mm without evidence of cardiac activity. I A "blighted ovum" or anembryonic pregnancy was a gestational sac ~25 mm mean sac diameter without an embryo.2 The introduction of the vaginal probe has allowed a high degree of resolution in spite of magnification. This results in a form of "sonomicroscopy" wherein structures that cannot be seen with the naked eye can be imaged. Investigators have reported seeing a cardiac signal with M-mode technology before being able to image the actual embryo. 3 This should not be surprising since the embryonic disc, amnion, and yolk sac are present even in the early gestational sac. They are simply too small to be imaged even with the sonomicroscopy capability currently available. Therefore the classic distinction between blighted ovum and missed abortion becomes blurred. Most anembryonic pregnancies are not truly without embryos. They simply lose viability before our ability to image them. Furthermore, in many cases there is initial early embryonic development with subsequent loss of viability and then embryonic resorption.' This then ultimately results in the sonographic appearance of an "empty sac." I agree with the authors that there may be different causes for intrauterine pregnancy failure. Certainly, the earlier it occurs, the more likely it is related to chromosomal polyploidy, whereas in later failures abnormalities of implantation, placentation, associated fibroids, or infection may be causative. I applaud the authors' attempt to update terminology but I would suggest that they go even further as outlined above. Steven R. Goldstein, MD Department of Obstetrics and Gynecology, New York University School of Medicine, 530 First Ave., Suite 5£, New York, NY 10016 REFERENCES 1. Jeanty P, Romero R. Obstetrical ultrasound. New York: McGraw-Hill, 1984:45-7. 2. Nyberg DA, Laing FC, Filly RA. Threatened abortion: sonographic distinction of normal and abnormal gestation sacs. Radiology 1986;158:393-6. 3. Fine C, Cortier M, Doubilet P. Fetal heart rates: values throughout gestation. J Ultrasound Med 1988;7:S105. 4. Goldstein SR. Endovaginal ultrasound. New York: Alan R Liss, 1988: 50-1.

Response declined Conservative management of cervical pregnancy with subsequent fertility To the Editors: I read the article by Bachus et al. in the February, 1990, issue with great interest (Bachus KE,

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Letters

September 1990 Am J Obstet Gynecol

Stone D, Suh B, Thickman D. Conservative management of cervical pregnancy with subsequent fertility. AM J OBSTET GYNECOL 1990;162:450-1). However, I question the wisdom of performing suction curettage in the patient mentioned in the article. As reported, this procedure resulted in violent hemorrhage. Fortunately, in this patient the profuse hemorrhage that resulted in reduction of hematocrit from 38% to 28%, despite administration of packed red blood cells, was controlled by the means described by the authors. Not every patient with this problem is a candidate for suction curettage because this procedure may result in not only violent hemorrhage as described by the authors, but also life-threatening hemorrhage with inherent severe medical and legal complications. I respectfully disagree with the statement that "this approach should be considered a standard of care in those patients desiring future fertility." This may imply that the clinician may perform suction curettage in all such patients, which frankly may result in severe and lifethreatening hemorrhage. I would like to propose that medical rather than surgical management of these patients may be lifesaving in this condition. The administration of methotrexate into the gestational sac or systemic use of methotrexate, which is successfully used in tubal and cervical pregnancy, is an excellent medical approach. Methotrexate, 1 mg/kg, alternating on a daily basis with folinic acid, 0.1 mg/kg (total of four doses) has been suggested. In their report Oyer et al. I used only two doses of the above regimen and successfully treated cervical pregnancy without the occurrence of severe hemorrhage. These drugs should be used only if serum transaminase and other laboratory test results are normal. In summary, individualization of patients with cervical pregnancy who wish future fertility is in order, and a decision should be made whether a surgical approach or medical treatment is indicated, as outlined above, for the best management for such patients.

Jahangir Ayromlooi,

MD

Department of Obstetrics and Gynecology, UMDNJ-Robert Wood Johnson Medical School, St. Peter's Medical Center, 254 Easton Ave., New Brunswick, NJ 08903

REFERENCE 1. Oyer R, Tarakjian D, Lev-Toaff A, Friedman A, Chatwani

A. Treatment of cervical pregnancy with methotrexate. Obstet Gynecol 1988;71:469-71.

Reply To the Editors: We thank Dr. Ayromlooi for his interest

in and comments concerning our article. This allows further discussion about treatment options for this interesting, yet sometimes terrifying condition. When we stated that this approach be considered a standard of care in those patients desiring future fertility, we were referring to conservative means of management as opposed to hysterectomy. The purpose of this article was not necessarily to advocate surgical

means of treatment compared with methotrexate therapy, but in light of Dr. Ayromlooi's comments that "medical rather than surgical management of these patients may be lifesaving," we think that a more complete description of the benefits, risks, and outcomes of these two methods is necessary. It is apparent from the cases in the literature, that most cases of cervical pregnancy are not diagnosed preoperatively. I. 2 Clinicians perform curettage for what is thought to be an incomplete or inevitable abortion only to encounter the hemorrhage associated with this rare form of ectopic pregnancy. Obviously, in this situation mechanical packing or surgical therapy are the only methods available, and familiarity with the method described can avoid significant morbidity. A large Foley balloon, with or without adjunctive cerclage, can be applied expeditiously to control hemorrhage. Its effectiveness has been reported" 4 and avoids the need for more extensive surgery such as internal iliac artery ligation or hysterectomy. The "wisdom of performing suction curettage" in this patient because of the inherent hemorrhage potential is questioned by Dr. Ayromlooi. The concern is that if performed in all patients with cervical pregnancy, life-threatening hemorrhage may result. Admittedly, curettage of this form of ectopic pregnancy does carry a risk of significant hemorrhage because of the poor contractile properties around the implantation site within the cervix and transfusion of up to 6 units has been reported. s Despite the blood loss, none of the patients reported who were treated by the techniques described in our report have required more definitive therapy. It is hoped that increased early detection of cervical pregnancy by clinical and ultrasonographic methods will result in preoperative preparation that will reduce the need for transfusion. This hemorrhage, however, is not unique to surgical management as Dr. Ayromlooi implies. Medical management with methotrexate also has similar bleeding potential. Of the 10 patients with cervical pregnancy treated with methotrexate reported in the literature, two had reports of large hemorrhages that ultimately led to hysterectomy.2 Furthermore, these bleeding episodes occurred up to 18 days after methotrexate therapy.2.6 This is disconcerting because the patient at this point may already be home. One additional patient required hysterectomy for persistence of the cervical mass after this medical therapy, 7 and one patient had hemorrhage that ultimately was controlled with adjunctive use of internal iliac ligation and intracervical balloon tamponade." This medication also carries a risk of toxicity that cannot be ignored. Stomatitis and elevated serum transaminase levels limited therapy in two of the reported 10 cases.7.9 In fact, the patient in the case cited by Dr. Ayromlooi had methotrexate use discontinued after two of the four planned doses because of hepatic toxicity.9 We agree that not all patients with cervical preg-