whereas the incidence has increased from 1 in 10,000 - 50,000 spontaneous pregnancies , with assisted reproductive technology procedures , the incidence is up to 1% , a 70-fold increased risk .
there are several approaches for heterotopic cervical pregnancy management , and generally the purpose of conservative management is fertility preservation : surgical treatments including uterine artery ligation and embolization , foley catheter insertion , and cervical curettage with or without cerclage , while medical treatments include transvaginal potassium chloride ( kcl ) or methotrexate ( mtx ) injection . in 1994 , frates et al .   reported the first live birth of a heterotopic cervical pregnancy , which was managed with transvaginal ultrasound - guided selective reduction with kcl .
since then , a few more live births from heterotopic cervical pregnancy have been reported .
we present the case of a rare event of a heterotopic pregnancy in which it was possible to maintain the intrauterine pregnancy ( iup ) to term without complications and reviewed the literature to suggest the best treatment for a successful pregnancy outcome .
a 36-year - old woman visited our medical center to seek treatment for primary infertility . at her first visit ,
dilatation and curettage was performed due to a missed abortion that was conceived by the first cycle of ivf - et . in this cycle ,
a total of seven oocytes were retrieved , five oocytes were fertilized by intracytoplasmic sperm injection , and two embryos were transferred .
the initial serum b - hcg level was 191.44 miu / ml 11 days after embryo transfer , and follow - up levels were 1,540 miu / ml and 7,970 miu / ml at 15 days and 18 days after et , respectively . at 4 weeks and 5 days of gestation , an 8 mm gestational sac with a yolk sac
was seen in the intrauterine cavity and a 3 mm gestational sac - like shadow was seen in the cervical canal in the first tvs ( figure 1a ) .
the patient was hemodynamically stable at the time of presentation ( hemoglobin 11.5 g / dl ) . at 5 weeks+2 days of gestation ,
follow - up sonography confirmed a heterotopic cervical pregnancy ( figure 1b - d ) . after explaining the treatment options to the patient , she wanted to try to conserve the iup .
she decided on transvaginal pregnancy reduction of the cervical pregnancy , accepting the risk of severe bleeding and a potential need for emergency hysterectomy .
selective reduction of the cervically located gestational sac was planned , with readiness for hysterectomy .
careful intracervical gestational sac reduction without harming the endometrial area was carried out with ovum forceps under abdominal ultrasound guidance .
the postoperative course was uneventful with a postoperative hemoglobin level of 11.3 g / dl .
the patient was discharged on the seventh postoperative day in good health , with an intact iup ( figure 2 ) . with regular check - ups ,
the iup followed without any complications , and an emergency cesarean section was performed at 40 weeks+5 days of gestation due to failure to progress .
an uncomplicated birth of a live newborn weighing 3,360 g occurred ; the apgar scores were 8 and 9 at 1 and 5 minutes , respectively .
written informed consent was obtained from the patient for publication of this case report and the accompanying images , and this report was approved by the institutional review board of cha gangnam medical center .
heterotopic cervical pregnancy is extremely rare and most cases are associated with assisted reproductive technology .
early diagnosis of heterotopic cervical pregnancy can provide the opportunity for successful conservative management . in general
, the aims of a conservative approach are the protection of a coexisting iup , the minimization of blood loss , and fertility preservation . however , there are no specific recommendations for the best treatment of heterotopic cervical pregnancy , and there is no universally accepted treatment modality . therefore , we reviewed the literature to identify the best treatment of heterotopic cervical pregnancy for a successful pregnancy outcome .
up to the present , a total of 37 cases of heterotopic cervical pregnancy , including the one described here , have been reported in the english language literature .
only four cases of heterotopic cervical pregnancy had been conceived spontaneously and naturally [ 4 - 7 ] : the other patients had received infertility treatment . in the 30 cases
in which preserving the iup was attempted , the attempt was successful in 25 cases : 24 were live births , but one case was followed up to 12 weeks of gestational age and in 5 cases , intrauterine fetal demise occurred . among the 24 live births , the cases are classified according to the absence or presence of major obstetric complications in tables 1 and 2 , respectively . in 16 cases ,
the iup was preserved and followed up until birth without any complications ( table 1 ) . on the other hand ,
the iup was preserved with major obstetric complications including placenta accreta , severe bleeding , and subsequent hysterectomy in eight cases ( table 2 ) .
different techniques were attempted to eliminate the cervical embryo . among them , the following factors should be considered .
mtx is an agonist of folic acid that participates in dna synthesis and has the capacity to stop proliferative cell activity .
transvaginal ultrasound - guided intra - amniotic injection of mtx can be successfully used for cervical pregnancy treatment , but the risk of systemic adverse effects , such as thrombocytopenia , leukopenia , elevated serum liver enzymes , and especially the teratogenic effect , should be taken into consideration .
however , this technique may result in the radiation of the viable iup , and influence on endometrial receptivity , which could decrease future fertility .
although several cases have been managed by kcl injection , there is a possibility of major bleeding because of the remaining products of conception .
if chorionic tissue remains in the cervix , bleeding , cervical mass infection that could cause intrauterine infection , premature rupture of the membrane , and postpartum bleeding can sometimes occur , and placenta accreta remains a risk because of the possibility of chorionic infiltration to the cervix . in this literature review ,
58.3% ( 7 out of 12 ) of the cases developed serious complications when evacuation was not performed , regardless of the initial procedure , while 91.7% ( 11 out of 12 ) whose treatment included complete evacuation of the cervical pregnancy had no major complications .
in fact , the complication of the other one case was placenta abruption , which might not have been associated with remnant chorionic tissue in the cervix .
we described a case of heterotopic cervical pregnancy that was successfully treated and reviewed the literature .
although a general treatment strategy can not be suggested because of the small number of cases , complete removal of the cervical conception should be considered for a successful pregnancy outcome .
 heterotopic pregnancy is rare event and the risk is increased with assisted reproductive technology procedures . 
 heterotopic cervical pregnancy is even more unusual . 
 we report a rare case of heterotopic cervical pregnancy that was managed successfully . 
 a 36-year - old women who conceived by ivf - icsi was diagnosed with heterotopic cervical pregnancy . 
 she visited the emergency room with vaginal bleeding at 5 weeks of gestation and underwent careful intracervical gestational sac reduction with forceps under abdominal guidance the next day . 
 the postoperative course was uneventful and with regular check - ups , the intrauterine pregnancy ( iup ) progressed unremarkably through 41 weeks with delivery of a healthy newborn . 
 we reviewed a total of 37 cases of heterotopic pregnancy that have been reported in the english language literature . 
 there have been many attempts to eliminate the cervical embryo while preserving the iup , and complete cervical evacuation is important in order to avoid infection , bleeding , and premature birth . 
Introduction
Case report
Discussion