Hydrodissection as a Novel Alternative After Failed Management of a Cervical Pregnancy With Methotrexate: Case Report and Literature Review

Abstract

Cervical ectopic pregnancies (CEPs) are rare and life-threatening diagnoses. Risk factors have been associated with CEPs, yet their etiology and pathogenesis remain unknown. Timely intervention is vital for successful outcomes, yet it is challenged as there is no standardized approach to treatment. We present the case of a 42-year-old woman diagnosed with CEP following five weeks and one day of amenorrhea. The patient was treated with a two-dose regimen of intramuscular methotrexate (MTX) but failed to respond. Ultrasound-guided intrasac MTX injection was considered a secondary treatment. However, spontaneous expulsion was observed after administering lidocaine at different cervical points. Hydrodissection following systemic MTX could present a novel alternative for treating CEP. Expulsion of pregnancy after hydrodissection could be associated with tissue necrosis and/or destabilized implantation of pregnancy, secondary to the effects of MTX. Further research is vital for evaluating the underlying mechanisms for expulsion and the role of hydrodissection following MTX in treating CEP.

Keywords: cervical ectopic pregnancy; cervical pregnancy; ectopic pregnancy; hydrodissection; methotrexate.

Figure 1. Transvaginal ultrasound performed at the initial evaluation shows an anechoic structure with a poorly delimited internal ring observed within the posterior lip of the cervix.

Figure 2. Expelled tissue after administration of lidocaine at 4 o’clock and 8 o’clock.

Figure 3. Cervical tissue changes after systemic methotrexate. Decreased echogenicity of the sac rim (light blue arrow) and degeneration of tissues (yellow arrow).