New paradigm for cervico-isthmic pregnancy: conservative management of cervico-isthmic pregnancy leading to successful deliveries

Abstract

To establish a new treatment option for cervico-isthmic pregnancy (CIP) other than termination by maintaining pregnancy from diagnosis to delivery. MethodsThis retrospective observational study included women diagnosed with CIP at Dongsan Medical Center, Daegu, Korea, from January 2014 to December 2019. Eight patients were diagnosed with CIP using transvaginal ultrasound and met the following inclusion criteria: (1) preserved and closed cervical canal; and (2) more than half of the uterine cavity above the sac was not involved in sac implantation. Five of the eight mothers decided to maintain their pregnancy after an adequate explanation of the possible risks. The same sonographer assessed fetal and maternal status every 1-2 weeks. Intra-and postoperative indicators, delivery information, and neonatal outcomes were also recorded. ResultsThe mean patient age was 36 years. In all cases, placenta accreta spectrum and placenta previa were detected using preoperative ultrasonography. A hysterectomy was performed in three cases, and all patients required intensive care unit (ICU) care. The mean operative time was 156 minutes. The rate of postpartum hemorrhage was 40%. Four viable fetuses were delivered. Birth preceding 34 weeks occurred in one patient, who required neonatal ICU hospitalization for 19 days. ConclusionConservative treatment with careful diagnosis, management, and sufficient consultation could be an alternative treatment option in women with CIP, particularly older mothers, those with subfertility, and those who expect to have limited future opportunities for a successful pregnancy. Therefore, CIP should be treated as a separate disease entity.

Heterotopic cervical and isthmic pregnancy

“…Treatments used to terminate the cervical pregnancy, while preserving the intrauterine pregnancy, included aspiration, curettage, Foley catheter, local injection of potassium chloride or glucose and operative hysteroscopy. However, while none of the pregnancies with an endometrial implant included in that review was located in the uterine isthmus, this condition was present in our case, exposing the patient to a significant risk of placenta accreta spectrum disorder and hysterectomy 2,3 . Furthermore, the ultrasound assessment by MVF and 3D power Doppler demonstrated a massive vascular connection between the two gestational sacs, suggesting a potential risk of hemorrhage during an attempt to preserve the intracavitary pregnancy.…”