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Use of Tuohy needle for intraamniotic methotrexate injection through the cervical canal in a cervical pregnancy after failure of systemic methotrexate treatment

2010; Elsevier BV; Volume: 202; Issue: 5 Linguagem: Inglês

10.1016/j.ajog.2010.01.081

1097-6868

Hwa Sook Moon, Jung Hwan Hyun, Kyung Seo Kim, Hyun Jung Kim, Sung Eun Moon, Ja Seong Koo,

Assisted Reproductive Technology and Twin Pregnancy

A case of cervical pregnancy resistant to systemic methotrexate (MTX) administration is presented. A 41 year old patient with cervical pregnancy at 6 weeks 4 days' gestation was successfully treated by intraamniotic MTX injection through the cervical canal using Tuohy needle after failure of systemic MTX treatment. A case of cervical pregnancy resistant to systemic methotrexate (MTX) administration is presented. A 41 year old patient with cervical pregnancy at 6 weeks 4 days' gestation was successfully treated by intraamniotic MTX injection through the cervical canal using Tuohy needle after failure of systemic MTX treatment. Conservative treatment using systemic methotrexate (MTX) administration has widely been applied as an initial treatment of cervical pregnancy while preserving fertility.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar However, there is no consensus with regard to the optimal treatment because of various success rates, ranging from 55% to 83%.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar, 2Kim T.J. Seong S.J. Lee K.J. et al.Clinical outcomes of patients treated for cervical pregnancy with or without methotrexate.J Korean Med Sci. 2004; 6: 848-852Crossref Scopus (34) Google Scholar In cases in which resistance to systemic MTX treatment are encountered,3Farabow W.S. Fulton J.W. Flecther V. Velat C.A. White J.T. Cervical pregnancy treated with methotrexate.N C Med J. 1983; 44: 91-93PubMed Google Scholar intraamniotic MTX injection can be considered as an additional treatment.4Marcovici I. Rosenzweig B.A. Brill A.I. Khan M. Scommegna A. Cervical pregnancy: case reports and a current literature review.Obstet Gynecol Surv. 1994; 49: 49-55Crossref PubMed Scopus (79) Google Scholar, 5Cerveira I. Costa C. Santos F. Santos L. Cabral F. Cervical ectopic pregnancy successfully treated with local methotrexate injection.Fertil Steril. 2008; 90: e7-e10Abstract Full Text Full Text PDF PubMed Scopus (26) Google ScholarLocal injection of MTX into the amniotic sac is usually performed under transvaginal ultrasound guidance, in which the injection needle is directed into the gestational sac through the cervical wall. This is more invasive than intraamniotic injection via the cervical canal under transabdominal ultrasound guidance because it can cause bleeding in case of biologically active pregnancy.6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google ScholarTuohy needle used for epidural block has a bent, blunt, and slant tip to reduce the risk of dural puncture,7Frölich M.A. Caton D. Pioneers in epidural needle design.Anesth Analg. 2001; 93: 215-220Crossref PubMed Scopus (26) Google Scholar and this design could facilitate easy access to the gestational sac through the cervical canal, preventing penetration of the needle into the cervical wall.We report a case of cervical pregnancy of 6 weeks 4 days' gestation that was successfully treated by intraamniotic MTX injection through the cervical canal using a Tuohy needle after failure of systemic MTX treatment.Case ReportA 41 year old, gravida 5, para 2 woman presented with amenorrhea at 6 weeks 4 days after her last menstruation. Transvaginal ultrasonography revealed a 25.9 × 10.6 mm sized gestational sac and a single viable fetus with a crown-rump length (CRL) of 5 mm implanted in the uterine cervical canal. The uterine cavity was empty and the initial serum human chorionic gonadotropin (hCG) level was 24,076 mIU/mL.Initially an alternative-day regimen of systemic MTX administration at 1 mg/kg (days 1, 3, 5, and 7) with folinic acid rescue at 0.1 mg/kg (days 2, 4, 6, and 8) was started. However, serum hCG level continued to gradually increase up to 32,874 mIU/L by day 10. Further progression of the gestational sac (26.4 × 19.1 mm) was seen, and CRL had increased to 5.8 mm with regular fetal heart beat, indicating failure of systemic MTX treatment. The gestational sac was located in the anterior cervical wall, 2 cm from the external os (Figure 1, A).Therefore, we performed amniotic fluid aspiration and intraamniotic MTX injection through the cervical canal under transabdominal ultrasonographic guidance after sedation with intravenous injection of 50 mg pethidine (Jeil Pharm, Seoul, Korea). Tuohy needle (18 gauges; BD Medical System, Franklin Lakes, NJ; Figure 1, B) was introduced into the cervical canal up to 2 cm from the external os, and 3 mL of amniotic fluid was aspirated. Then 50 mg of MTX was injected into the gestational sac (Figure 1, C).There was no intraoperative bleeding and the patient was stable throughout the whole procedure. Immediately after the procedure, the fetal cardiac beat slowed down and serum hCG level rapidly decreased to 17,818, 13,583, and 7652 on posttreatment days 2, 5 and 7, respectively (Figure 2).FIGURE 2Changes in serum hCG level before and after intraamniotic local MTX injection and D&EShow full captionD&E, dilation and evacuation; hCG, human chorionic gonadotropin; MTX, methotrexate.Moon. Tuohy needle for intraamniotic methotrexate in cervical pregnancy. Am J Obstet Gynecol 2010.View Large Image Figure ViewerDownload Hi-res image Download (PPT)On posttreatment day 11, the patient visited our hospital with vaginal bleeding and lower abdominal pain. Serum hCG level was 1215 mIU/mL and an enlarged cervix measuring 39.4 × 47.8 mm was observed because of hematoma in the cervical canal. The cervical canal was evacuated using placenta forceps, and no remnant conceptal tissue in the uterine cervix after evacuation was confirmed. Thereafter, the serum hCG level gradually decreased and was eventually normalized (Figure 2).CommentIn the present study, we report a case of cervical pregnancy that was successfully treated with intraamniotic injection of MTX through the cervical canal using a Tuohy needle under transabdominal ultrasound guidance.Intraamniotic MTX injection is usually performed under transvaginal ultrasound guidance using an oocyte collection needle. This method seems to be more invasive than the transcervical approach we used because it penetrates the cervical wall, whereas our method directly approaches the amniotic sac via the cervical canal, which is a natural orifice. Transvaginal ultrasound-guided intraamniotic MTX injection method is exposed to the possibility of infection, resulting from the trauma of the cervical wall as well as severe bleeding in the case of biologically active pregnancy.6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google ScholarTuohy needle is primarily developed for local application of analgesics in epidural block, and this needle has several advantages to measuring units to indicate depth and has a bent, blunt, and slant tip to reduce the risk of dural puncture.7Frölich M.A. Caton D. Pioneers in epidural needle design.Anesth Analg. 2001; 93: 215-220Crossref PubMed Scopus (26) Google Scholar This unique design can facilitate easy access to the gestational sac through the cervical canal, preventing penetration of the injection needle into the cervical wall. For this reason, the Tuohy needle resulted in no bleeding during the procedure.The success rate of primary systemic MTX administration differs among authors, ranging from 55% to 83%.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar, 2Kim T.J. Seong S.J. Lee K.J. et al.Clinical outcomes of patients treated for cervical pregnancy with or without methotrexate.J Korean Med Sci. 2004; 6: 848-852Crossref Scopus (34) Google Scholar Positive fetal cardiac activity, initial serum hCG levels greater than 10,000 mIU/mL, a gestational age of greater than 9 weeks, or a CRL of greater than 10 mm are known to be associated with a high failure rate of primary systemic MTX treatment.8Hajenius P.J. Van der Veen F. Ankum W.M. Cervical pregnancy-a conservative stepwise approach.Hum Reprod. 1999; 14: 2677-2678Crossref PubMed Google Scholar, 9Spitzer D. Steiner H. Graf A. Zajc M. Staudach A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection.Hum Reprod. 1997; 12: 860-866Crossref PubMed Scopus (73) Google ScholarBased on these results, systemic MTX administration could be an ideal choice when a patient has none of the poor prognostic factors. However, management of cervical pregnancies with unfavorable factors is yet to be established.In our present report, the patient had 2 unfavorable factors: high initial hCG level (24,076 mIU/mL) and presence of fetal cardiac activity with large gestational sac (25.9 × 10.6 mm). Nevertheless, our initial choice was systemic MTX administration because it is noninvasive, does not cause procedure-related hemorrhage, and reduces bioactivity of cervical pregnancy by inhibiting the growth of the trophoblast through the inhibition of deoxyribonucleic acid synthesis and cell division.3Farabow W.S. Fulton J.W. Flecther V. Velat C.A. White J.T. Cervical pregnancy treated with methotrexate.N C Med J. 1983; 44: 91-93PubMed Google Scholar, 6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google ScholarAlthough the initial systemic MTX treatment failed to induce a complete decrease of serum hCG, it resulted in a slow-down in the increase rate of serum hCG and contributed to minimizing the potential for active bleeding during additional procedures. The present study shows that there was no bleeding with an additional injection of intraamniotic MTX using the Tuohy needle.We suggest that subsequent evacuation of conceptus with placenta forceps should be spared for the patients who present with significant vaginal bleeding because evacuation of conceptal tissue by dilation and evacuation itself could cause massive bleeding.In conclusion, we suggest a stepwise conservative approach that consists of initial systemic MTX treatment followed by intraamniotic MTX injection through the cervical canal using a Tuohy needle in selected cases after failure of systemic MTX treatment to minimize the possibility of massive bleeding. Conservative treatment using systemic methotrexate (MTX) administration has widely been applied as an initial treatment of cervical pregnancy while preserving fertility.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar However, there is no consensus with regard to the optimal treatment because of various success rates, ranging from 55% to 83%.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar, 2Kim T.J. Seong S.J. Lee K.J. et al.Clinical outcomes of patients treated for cervical pregnancy with or without methotrexate.J Korean Med Sci. 2004; 6: 848-852Crossref Scopus (34) Google Scholar In cases in which resistance to systemic MTX treatment are encountered,3Farabow W.S. Fulton J.W. Flecther V. Velat C.A. White J.T. Cervical pregnancy treated with methotrexate.N C Med J. 1983; 44: 91-93PubMed Google Scholar intraamniotic MTX injection can be considered as an additional treatment.4Marcovici I. Rosenzweig B.A. Brill A.I. Khan M. Scommegna A. Cervical pregnancy: case reports and a current literature review.Obstet Gynecol Surv. 1994; 49: 49-55Crossref PubMed Scopus (79) Google Scholar, 5Cerveira I. Costa C. Santos F. Santos L. Cabral F. Cervical ectopic pregnancy successfully treated with local methotrexate injection.Fertil Steril. 2008; 90: e7-e10Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Local injection of MTX into the amniotic sac is usually performed under transvaginal ultrasound guidance, in which the injection needle is directed into the gestational sac through the cervical wall. This is more invasive than intraamniotic injection via the cervical canal under transabdominal ultrasound guidance because it can cause bleeding in case of biologically active pregnancy.6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google Scholar Tuohy needle used for epidural block has a bent, blunt, and slant tip to reduce the risk of dural puncture,7Frölich M.A. Caton D. Pioneers in epidural needle design.Anesth Analg. 2001; 93: 215-220Crossref PubMed Scopus (26) Google Scholar and this design could facilitate easy access to the gestational sac through the cervical canal, preventing penetration of the needle into the cervical wall. We report a case of cervical pregnancy of 6 weeks 4 days' gestation that was successfully treated by intraamniotic MTX injection through the cervical canal using a Tuohy needle after failure of systemic MTX treatment. Case ReportA 41 year old, gravida 5, para 2 woman presented with amenorrhea at 6 weeks 4 days after her last menstruation. Transvaginal ultrasonography revealed a 25.9 × 10.6 mm sized gestational sac and a single viable fetus with a crown-rump length (CRL) of 5 mm implanted in the uterine cervical canal. The uterine cavity was empty and the initial serum human chorionic gonadotropin (hCG) level was 24,076 mIU/mL.Initially an alternative-day regimen of systemic MTX administration at 1 mg/kg (days 1, 3, 5, and 7) with folinic acid rescue at 0.1 mg/kg (days 2, 4, 6, and 8) was started. However, serum hCG level continued to gradually increase up to 32,874 mIU/L by day 10. Further progression of the gestational sac (26.4 × 19.1 mm) was seen, and CRL had increased to 5.8 mm with regular fetal heart beat, indicating failure of systemic MTX treatment. The gestational sac was located in the anterior cervical wall, 2 cm from the external os (Figure 1, A).Therefore, we performed amniotic fluid aspiration and intraamniotic MTX injection through the cervical canal under transabdominal ultrasonographic guidance after sedation with intravenous injection of 50 mg pethidine (Jeil Pharm, Seoul, Korea). Tuohy needle (18 gauges; BD Medical System, Franklin Lakes, NJ; Figure 1, B) was introduced into the cervical canal up to 2 cm from the external os, and 3 mL of amniotic fluid was aspirated. Then 50 mg of MTX was injected into the gestational sac (Figure 1, C).There was no intraoperative bleeding and the patient was stable throughout the whole procedure. Immediately after the procedure, the fetal cardiac beat slowed down and serum hCG level rapidly decreased to 17,818, 13,583, and 7652 on posttreatment days 2, 5 and 7, respectively (Figure 2).On posttreatment day 11, the patient visited our hospital with vaginal bleeding and lower abdominal pain. Serum hCG level was 1215 mIU/mL and an enlarged cervix measuring 39.4 × 47.8 mm was observed because of hematoma in the cervical canal. The cervical canal was evacuated using placenta forceps, and no remnant conceptal tissue in the uterine cervix after evacuation was confirmed. Thereafter, the serum hCG level gradually decreased and was eventually normalized (Figure 2). A 41 year old, gravida 5, para 2 woman presented with amenorrhea at 6 weeks 4 days after her last menstruation. Transvaginal ultrasonography revealed a 25.9 × 10.6 mm sized gestational sac and a single viable fetus with a crown-rump length (CRL) of 5 mm implanted in the uterine cervical canal. The uterine cavity was empty and the initial serum human chorionic gonadotropin (hCG) level was 24,076 mIU/mL. Initially an alternative-day regimen of systemic MTX administration at 1 mg/kg (days 1, 3, 5, and 7) with folinic acid rescue at 0.1 mg/kg (days 2, 4, 6, and 8) was started. However, serum hCG level continued to gradually increase up to 32,874 mIU/L by day 10. Further progression of the gestational sac (26.4 × 19.1 mm) was seen, and CRL had increased to 5.8 mm with regular fetal heart beat, indicating failure of systemic MTX treatment. The gestational sac was located in the anterior cervical wall, 2 cm from the external os (Figure 1, A). Therefore, we performed amniotic fluid aspiration and intraamniotic MTX injection through the cervical canal under transabdominal ultrasonographic guidance after sedation with intravenous injection of 50 mg pethidine (Jeil Pharm, Seoul, Korea). Tuohy needle (18 gauges; BD Medical System, Franklin Lakes, NJ; Figure 1, B) was introduced into the cervical canal up to 2 cm from the external os, and 3 mL of amniotic fluid was aspirated. Then 50 mg of MTX was injected into the gestational sac (Figure 1, C). There was no intraoperative bleeding and the patient was stable throughout the whole procedure. Immediately after the procedure, the fetal cardiac beat slowed down and serum hCG level rapidly decreased to 17,818, 13,583, and 7652 on posttreatment days 2, 5 and 7, respectively (Figure 2). On posttreatment day 11, the patient visited our hospital with vaginal bleeding and lower abdominal pain. Serum hCG level was 1215 mIU/mL and an enlarged cervix measuring 39.4 × 47.8 mm was observed because of hematoma in the cervical canal. The cervical canal was evacuated using placenta forceps, and no remnant conceptal tissue in the uterine cervix after evacuation was confirmed. Thereafter, the serum hCG level gradually decreased and was eventually normalized (Figure 2). CommentIn the present study, we report a case of cervical pregnancy that was successfully treated with intraamniotic injection of MTX through the cervical canal using a Tuohy needle under transabdominal ultrasound guidance.Intraamniotic MTX injection is usually performed under transvaginal ultrasound guidance using an oocyte collection needle. This method seems to be more invasive than the transcervical approach we used because it penetrates the cervical wall, whereas our method directly approaches the amniotic sac via the cervical canal, which is a natural orifice. Transvaginal ultrasound-guided intraamniotic MTX injection method is exposed to the possibility of infection, resulting from the trauma of the cervical wall as well as severe bleeding in the case of biologically active pregnancy.6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google ScholarTuohy needle is primarily developed for local application of analgesics in epidural block, and this needle has several advantages to measuring units to indicate depth and has a bent, blunt, and slant tip to reduce the risk of dural puncture.7Frölich M.A. Caton D. Pioneers in epidural needle design.Anesth Analg. 2001; 93: 215-220Crossref PubMed Scopus (26) Google Scholar This unique design can facilitate easy access to the gestational sac through the cervical canal, preventing penetration of the injection needle into the cervical wall. For this reason, the Tuohy needle resulted in no bleeding during the procedure.The success rate of primary systemic MTX administration differs among authors, ranging from 55% to 83%.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar, 2Kim T.J. Seong S.J. Lee K.J. et al.Clinical outcomes of patients treated for cervical pregnancy with or without methotrexate.J Korean Med Sci. 2004; 6: 848-852Crossref Scopus (34) Google Scholar Positive fetal cardiac activity, initial serum hCG levels greater than 10,000 mIU/mL, a gestational age of greater than 9 weeks, or a CRL of greater than 10 mm are known to be associated with a high failure rate of primary systemic MTX treatment.8Hajenius P.J. Van der Veen F. Ankum W.M. Cervical pregnancy-a conservative stepwise approach.Hum Reprod. 1999; 14: 2677-2678Crossref PubMed Google Scholar, 9Spitzer D. Steiner H. Graf A. Zajc M. Staudach A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection.Hum Reprod. 1997; 12: 860-866Crossref PubMed Scopus (73) Google ScholarBased on these results, systemic MTX administration could be an ideal choice when a patient has none of the poor prognostic factors. However, management of cervical pregnancies with unfavorable factors is yet to be established.In our present report, the patient had 2 unfavorable factors: high initial hCG level (24,076 mIU/mL) and presence of fetal cardiac activity with large gestational sac (25.9 × 10.6 mm). Nevertheless, our initial choice was systemic MTX administration because it is noninvasive, does not cause procedure-related hemorrhage, and reduces bioactivity of cervical pregnancy by inhibiting the growth of the trophoblast through the inhibition of deoxyribonucleic acid synthesis and cell division.3Farabow W.S. Fulton J.W. Flecther V. Velat C.A. White J.T. Cervical pregnancy treated with methotrexate.N C Med J. 1983; 44: 91-93PubMed Google Scholar, 6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google ScholarAlthough the initial systemic MTX treatment failed to induce a complete decrease of serum hCG, it resulted in a slow-down in the increase rate of serum hCG and contributed to minimizing the potential for active bleeding during additional procedures. The present study shows that there was no bleeding with an additional injection of intraamniotic MTX using the Tuohy needle.We suggest that subsequent evacuation of conceptus with placenta forceps should be spared for the patients who present with significant vaginal bleeding because evacuation of conceptal tissue by dilation and evacuation itself could cause massive bleeding.In conclusion, we suggest a stepwise conservative approach that consists of initial systemic MTX treatment followed by intraamniotic MTX injection through the cervical canal using a Tuohy needle in selected cases after failure of systemic MTX treatment to minimize the possibility of massive bleeding. In the present study, we report a case of cervical pregnancy that was successfully treated with intraamniotic injection of MTX through the cervical canal using a Tuohy needle under transabdominal ultrasound guidance. Intraamniotic MTX injection is usually performed under transvaginal ultrasound guidance using an oocyte collection needle. This method seems to be more invasive than the transcervical approach we used because it penetrates the cervical wall, whereas our method directly approaches the amniotic sac via the cervical canal, which is a natural orifice. Transvaginal ultrasound-guided intraamniotic MTX injection method is exposed to the possibility of infection, resulting from the trauma of the cervical wall as well as severe bleeding in the case of biologically active pregnancy.6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google Scholar Tuohy needle is primarily developed for local application of analgesics in epidural block, and this needle has several advantages to measuring units to indicate depth and has a bent, blunt, and slant tip to reduce the risk of dural puncture.7Frölich M.A. Caton D. Pioneers in epidural needle design.Anesth Analg. 2001; 93: 215-220Crossref PubMed Scopus (26) Google Scholar This unique design can facilitate easy access to the gestational sac through the cervical canal, preventing penetration of the injection needle into the cervical wall. For this reason, the Tuohy needle resulted in no bleeding during the procedure. The success rate of primary systemic MTX administration differs among authors, ranging from 55% to 83%.1Kirk E. Condous G. Haider Z. Syed A. Ojha K. Bourne T. The conservative management of cervical ectopic pregnancies.Ultrasound Obstet Gynecol. 2006; 27: 430-437Crossref PubMed Scopus (96) Google Scholar, 2Kim T.J. Seong S.J. Lee K.J. et al.Clinical outcomes of patients treated for cervical pregnancy with or without methotrexate.J Korean Med Sci. 2004; 6: 848-852Crossref Scopus (34) Google Scholar Positive fetal cardiac activity, initial serum hCG levels greater than 10,000 mIU/mL, a gestational age of greater than 9 weeks, or a CRL of greater than 10 mm are known to be associated with a high failure rate of primary systemic MTX treatment.8Hajenius P.J. Van der Veen F. Ankum W.M. Cervical pregnancy-a conservative stepwise approach.Hum Reprod. 1999; 14: 2677-2678Crossref PubMed Google Scholar, 9Spitzer D. Steiner H. Graf A. Zajc M. Staudach A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection.Hum Reprod. 1997; 12: 860-866Crossref PubMed Scopus (73) Google Scholar Based on these results, systemic MTX administration could be an ideal choice when a patient has none of the poor prognostic factors. However, management of cervical pregnancies with unfavorable factors is yet to be established. In our present report, the patient had 2 unfavorable factors: high initial hCG level (24,076 mIU/mL) and presence of fetal cardiac activity with large gestational sac (25.9 × 10.6 mm). Nevertheless, our initial choice was systemic MTX administration because it is noninvasive, does not cause procedure-related hemorrhage, and reduces bioactivity of cervical pregnancy by inhibiting the growth of the trophoblast through the inhibition of deoxyribonucleic acid synthesis and cell division.3Farabow W.S. Fulton J.W. Flecther V. Velat C.A. White J.T. Cervical pregnancy treated with methotrexate.N C Med J. 1983; 44: 91-93PubMed Google Scholar, 6Jeng C.J. Ko M.L. Shen J. Transvaginal ultrasound-guided treatment of cervical pregnancy.Obstet Gynecol. 2007; 109: 1076-1082Crossref PubMed Scopus (55) Google Scholar Although the initial systemic MTX treatment failed to induce a complete decrease of serum hCG, it resulted in a slow-down in the increase rate of serum hCG and contributed to minimizing the potential for active bleeding during additional procedures. The present study shows that there was no bleeding with an additional injection of intraamniotic MTX using the Tuohy needle. We suggest that subsequent evacuation of conceptus with placenta forceps should be spared for the patients who present with significant vaginal bleeding because evacuation of conceptal tissue by dilation and evacuation itself could cause massive bleeding. In conclusion, we suggest a stepwise conservative approach that consists of initial systemic MTX treatment followed by intraamniotic MTX injection through the cervical canal using a Tuohy needle in selected cases after failure of systemic MTX treatment to minimize the possibility of massive bleeding.