Critical Appraisal OF Cervical Pregnancy Management

For a long time, it was rare to see a case of cervical pregnancy (CP) throughout the journey in the field of obstetrics. Recently, the circumstances showed dramatic changes and I think not uncommonly every one elsewhere in the field may face this problem to some extent and the CP term strikes his/her ears. This may be attributed to an actual increase in CP rate that go parallel to widespread application of Assisted Reproduction Techniques (ART) procedures all over the world on one hand and earlier diagnosis owing to liberal utilization and more familiarity with Transvaginal Sonography (TVS) on the other hand [1]. Totally, CP was reported to be one in nine thousand pregnancies while it represented about two percent of ART ectopic pregnancies [2]. The maternal impact of this calamity is markedly variable. It may pass unnoticed, causing a little harm or catastrophic with late discovery and presentation with a life-threatening hemorrhage. The exact etiology is still unexplained and the patient commonly presented by delayed menstruation with or without bleeding and infrequent pain. Diagnosis of a pure CP is based on TVS. Sonographic criteria’s specific to the case include empty uterine corpus while cervix is enlarged and barrel shaped, presence of gestational sac below the internal os, Color Doppler demonstrated a peritrophoblastic blood flow around the gestational sac and no sliding sign. Management is greatly different depending upon timing of diagnosis, case presentation, operator experience and available health facilities [1].


Background
For a long time, it was rare to see a case of cervical pregnancy (CP) throughout the journey in the field of obstetrics. Recently, the circumstances showed dramatic changes and I think not uncommonly every one elsewhere in the field may face this problem to some extent and the CP term strikes his/her ears. This may be attributed to an actual increase in CP rate that go parallel to widespread application of Assisted Reproduction Techniques (ART) procedures all over the world on one hand and earlier diagnosis owing to liberal utilization and more familiarity with Transvaginal Sonography (TVS) on the other hand [1]. Totally, CP was reported to be one in nine thousand pregnancies while it represented about two percent of ART ectopic pregnancies [2]. The maternal impact of this calamity is markedly variable. It may pass unnoticed, causing a little harm or catastrophic with late discovery and presentation with a life-threatening hemorrhage. The exact etiology is still unexplained and the patient commonly presented by delayed menstruation with or without bleeding and infrequent pain. Diagnosis of a pure CP is based on TVS. Sonographic criteria's specific to the case include empty uterine corpus while cervix is enlarged and barrel shaped, presence of gestational sac below the internal os, Color Doppler demonstrated a peritrophoblastic blood flow around the gestational sac and no sliding sign. Management is greatly different depending upon timing of diagnosis, case presentation, operator experience and available health facilities [1].

Management
When we take a journey through such challenging morbidity, it was wonderful to find an extreme disparity in dealing with it. Let us start from earlier discovered cases, if you confront a stable CP case with HCG<1000miu or showed progressive decrease of the titer, you are not in need to do anything, just wait till became negative and this found satisfactory. Also, for those early cases, if the sac was evident, simply we can aspirate it through TVS guided needle aspiration utilizing egg recruitment needle used in in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) cycles. Hemodynamically stable cases with evident cardiac pulsations, a lot of medications are available and found effective. First of which is Methotrexate that could be given intralesional through Ultrasound (US) guidance or systemically. It may be successful alone in terminating the problem or integrated with other methods. Other medications like absolute ethanol, Potassium chloride (KCL), local prostaglandins, hyperosmolar glucose and vasopressin were found effective alone or with other conservative lines. I think this may be a good option especially for those in low resource areas with insufficient experience in dealing with CP. In areas where more advanced tools are available, TVS guided laser ablation or high intensity focused US (HIFU) could effectively and safely overcome the problem. There is a lot of conservative surgical procedures that could be performed when medical treatment failed or patient presented by considerable bleeding. It encompasses evacuation of CP, site compression after evacuation and devascularization. Evacuation and gentle curettage either conventional or through hysteroscopy are considered the standard intervention in a considerable number of patients cervicovaginal junction. It can suit most of situations and societies [3]. Cervical stay sutures and transvaginal uterine artery ligation and uterine artery embolization before evacuation and termination or with other medications was found successful [4]. Other devascularization methods include; Laparoscopic or transabdominal compression and devascularization by cervical cerclage, uterine artery ligation or internal iliac artery ligation which is the last resort of devascularization procedures before going to hysterectomy and were found effective in this aspect. Advanced cases could be managed conservatively by partial trachelectomy to excise ectopic site followed by reformation of cervix or even trachelectomy with insertion of a permanent abdominal cerclage suture to avoid hysterectomy. Certainly, hysterectomy remains the final solution that should be done when other alternatives failed to control such calamity without hesitation and irrespective of fertility consideration if the patient life is under threat [5,6].
The key of success in management of CP; is the early establishment and intervention. Early intervention means much little efforts, less invasive and more conservative tools and consequently the best outcome. Actually, there is a tremendous need to achieve this goal and I suggest implementing a program entitled "To Make CP more familiar". Such optimizing comprehensive program include all aspects and domains related to CP. It describes information regarding definition, incidence, and magnitude of problem, possible etiology, clinical presentation, differential diagnosis, investigations and detailed lines of treatment from expectancy, medications, conservative surgery up to hysterectomy and how to tailor this according to situation. This could be conducted in different ways; poster presentations, live sessions, zoom meeting, webinars, case discussion, video presentations and others in favor of exchanging experience and construct as can as possible clear guidelines for the best interference in fighting such challenging calamity.

Conclusions
The critical step in such morbidity is the expectation and early diagnosis as at that time, the interference will be so simple, easy, cheap and effective.
Still there are a lot of weapons that enable obstetricians to engage in this battle and achieve victory before losing the uterus.
Expectation and early discovery are the milestone of success in conservative management.
There is a tremendous need to increase awareness and knowledge about CP among obstetricians to gain the best outcome.