Advanced cervical pregnancy: uterus‐sparing therapy initiated with a combination of methotrexate and mifepristone followed by evacuation and local hemostatic measures

Cervical pregnancy accounts for approximately 0.1% of ectopic pregnancies (1). Due to its rarity, treatment is based on case reports and no randomized studies have been carried out to assess the various treatment options. A recent textbook recommends surgical management, usually hysterectomy (1). However, treatment of cervical pregnancy has improved greatly in recent years. The evolvement of non-surgical treatment modalities, such as use of methotrexate (MTX) (2), selective embolization of uterine arteries (3) or a combination of different treatments (3,4) has made uterus-sparing treatment possible. In addition, minimally invasive treatments using currettage and prostaglandin injection, or Shirodkar cerclage of the cervix have been reported (5). Predictors of unsuccessful outcome of MTX treatment of cervical pregnancy, necessitating additional medication or surgical intervention, have included high initial serum levels of human chorionic gonadotrophin (hCG) (> 10.000 IU/l), presence of fetal heart activity, crown-rump length (CRL) measurement above 10 mm and duration of pregnancy exceeding 9 weeks (6). Among the reported cases managed successfully with MTX, the highest pre-treatment levels of serum hCG have been approximately 170.000 IU/l (7). A combination of the antiprogestin mifepristone and MTX improves the results of conservative treatment of extrauterine pregnancy (8,9). We report a cervical pregnancy first diagnosed at the 10th week of pregnancy, with initial serum levels of hCG of approximately 100.000 IU/l, treated successfully with an initial combination of mifepristone and MTX as well as later evacuation and hemostatic measures at the cervix.