K.E.M. Radiology
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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Contributed by : Jui Sanjay Nigudkar
Management of live cervical ectopic pregnancy with potassium chloride injection and uterine artery embolization.
Introduction:
Cervical ectopic pregnancy is a rare form of ectopic pregnancy with an incidence of less than 1% of all ectopic pregnancies. It is associated with high morbidity and mortality. There is an increased risk of haemorrhage which has made hysterectomy the presumptive treatment. However, in nulliparous women, timely intervention and conservative management options become essential for preserving fertility and avoiding hysterectomy. Uterine artery embolization is a relatively novel approach for the management of cervical ectopic pregnancy . Here we report a case of cervical ectopic pregnancy in a nulliparous woman managed successfully by intra-amniotic injection of KCl followed by bilateral uterine artery embolization and dilatation and curettage.
Case presentation:
A 24 year old primigravida, presented with amenorrhea over 8 weeks and pervaginal bleeding since two days. Her UPT was positive. On initial evaluation, the patient's beta-human chorionic gonadotropin (beta-HCG) was 10,680 mIU/mL. Repeat UPT was strongly positive. On examination the patient was tachycardic, blood pressure and her lab investigations were within normal limit. Hb- 10.1gm% , Platelets- 1.2 lakhs, total leukocyte count - 11,600 per microliter, prothrombin time and INR- 13.9/1.09, urine output- 700 ml/24 hours. On per speculum examination- there were clots at the external os of the cervical canal and within the vagina. The abdomen was soft and non-tender. Ultrasonogram showed a gestational sac in the cervical canal with a single live fetus. No intrauterine gestational sac was seen (FIG 1). Duplex sonogram showed increased uterine vascularity , supplying the G-sac (FIG 2).
Fig 1: The typical ‘hourglass’ shape of the uterus- No intrauterine gestation is seen. The cervical canal shows a single gestational sac with yolk sac with a foetal pole. On dynamic scan, the sliding sign was absent.
Fig. 2 -- Significant vascularity is seen in the uterine artery on colour Doppler.
A decision was made to manage the live ectopic with ultrasound guided intra-amniotic potassium chloride injection (FIG 3) and uterine artery embolization to minimize the bleeding ' , followed by dilation and curettage.
Fig 3- Intraamniotic KCl was injected.
Interventional technique:
Following intra-amniotic KCl injection, absence of cardiac activity in the foetus was confirmed on sonogram. The patient was then taken for uterine artery embolization. From a right femoral access, a pelvic angiogram was performed with the pigtail catheter at L1 level precluding any blood supply from ovarian arteries (FIG 4).
Fig. 4- Pre embolisation pelvic angiogram shows increased vascularity and tortuosity of branches of theleft uterine artery,. Few branches noted from the right uterine artery as well.
The angiogram showed of increased vascularity from both uterine arteries, significantly more from the left.
The contralateral internal iliac artery was catheterized using a 4 Fr Cobra catheter and selective catherisation of the uterine artery was performed using a 2.7 Fr microcatheter. and its location was confirmed with a test angiogram (FIG 5)
Fig 5-Preembolisation selective angiogram of the left uterine artery in the right anterior oblique view shows hypervascularity of the uterus .
Polyvinyl alcohol particles of size 500-700 microns were mixed with iodinated contrast and normal saline in a 1:1 ratio. THe PVA-saline-contrast mixture was injected in slow, interrupted fashion alternating with injection of normal saline, till there was stagnation of the contrast and was stopped when reflux was noted. A check angiogram confirmed embolization of the left uterine artery.
The identical procedure was then performed on the right uterine artery.
Fig 6 Pre embolisation selective right uterine artery, Left anterior oblique view shows a few, mildly tortuous branches of right uterine artery
Post embolization pelvic angiogram showed satisfactory devascularization.(FIG 7)
Fig 7- Pelvic angiogram (post embolization)- shows non-opacification of the both uterine arteries distally and adequate embolization of the lesion with no hypervascularity.