A 33-year-old female was admitted to our hospital on April 2, 2020, with a complaint of amenorrhoea for 40 days, followed by vaginal bleeding for 4 days. The patient’s medical history indicated laparoscopic right salpingectomy for ectopic pregnancy in 2016 (para 0-0-2-0). The menstrual history suggested the last menstrual period to be February 23, 2020, followed by amenorrhoea for 33 days.

On March 26, 2020, the serum human chorionic gonadotropin (serum hCG) was 4502 mIU/mL.

On March 31, the patient experienced heavy menstrual bleeding lasting for 3 days with no abdominal pain. On the same day, serum hCG level was 5732 mIU/mL, a B-mode ultrasound indicated an abnormal echo in the uterus (a dark area about 0.9 $\times$ 0.5 cm in size seen at a distance of 4.4 cm from the fundus), and the presence of fluid was also observed in the recto-uterine pouch (2.7 cm). The patient request to be discharged from the hospital.

On April 2, 2020, the patient was admitted to our hospital. The differential diagnosis was early pregnancy, threatened abortion, and incomplete abortion. The patient was a young woman, unmarried, and had no children. The purpose of management was to preserve the patient’s fertility and reduce complications such as adhesions of the cervical and uterine cavity and cervical stenosis. The patient had less bleeding, quick recovery, and short hospital stay, which provided good conditions for the next pregnancy. It could also save money.

On April 3, vaginal bleeding was decreased, and the serum hCG was 9402 mIU/mL. On the same day, a routine blood test showed white blood cells (WBC) count of 3.77 $\times$ 10E12/L and a hemoglobin (Hb) value of 115 g/L.

On April 4, the serum hCG was 11666.8 mIU/mL, and a repeat B-mode ultrasound revealed a normal uterine size with endometrium of 0.6 cm. There was no gestational sac in the uterus or lower uterine segment. The cervix had a gestational sac echo of 1.4 $\times$ 0.6 $\times$ 1.5 cm. The yolk sac, punctate germ, and heart tube pulsation were seen inside the posterior cervix. The fluid in the recto-uterine pouch was 1.3 cm. These findings indicated cervical pregnancy (Fig. 1). A gynecological examination, which is a routine examination for vaginal bleeding after pregnancy, was performed. It is necessary to rule out bleeding from cervical lesions, incarceration of incomplete abortion in the cervix, or threatened abortion. Careful examination indicated a slightly enlarged and soft cervix, normal uterine size, and no tenderness.

Fig. 1.

Case 1. Cervical enlargement was noted. Gestational sac size of about 1.4 $\times$ 0.6 $\times$ 1.5 cm was found in the cervix, and the heart tube pulsation and punctate germ were seen inside. Cervical pregnancy was diagnosed.

On April 4, under the guidance of B-mode ultrasound, 2 mL of KCL was injected into the gestational sac, and 75 mg of MTX was injected into the cervix. There was less vaginal bleeding after the intervention. The ultrasound scan showed no significant changes in the gestational sac. Observation was recommended.

On April 6, the repeated serum hCG value was 13735 mIU/mL. A routine blood test revealed the following values: WBC, 3.74 $\times$ 10E12/L; Hb, 110 g/L. The remaining parameters were normal. The high serum hCG values indicated treatment failure.

On April 7, lauromacrogol was injected into the edge of the gestational sac with the guidance of B-mode ultrasound.

On April 8, at 15:00 h, intrauterine visualization and vacuum aspiration were performed under direct vision and negative pressure suction. After the surgery, a Foley balloon was used to compress and stop bleeding. After 6 h, a small amount of light blood fluid was noted in the balloon, and half the amount of the liquid in the balloon was released.

On the second day morning, the Foley catheter was removed. After the operation, B-ultrasound review showed that the cervix was normal in size, and no pregnancy was seen. The patient was followed up for serum hCG on April 9 (4588 mIU/mL), April 15 (335 mIU/mL), and April 22 (6 mIU/L).

A 26-year-old female was admitted to our hospital on March 30, 2020, complaining of amenorrhoea for 40 days, followed by vaginal bleeding for 2 days. The medical history indicated a cesarean section in 2015. In 2018, hysteroscopy was performed for removal of residual products of conception after an induced abortion (para 1-0-1-1). The menstrual history suggested the last menstrual period of February 20, 2020, with normal volume and characteristics.

On March 29, the amount of vaginal bleeding after activity was less. On the second day, the amount of vaginal bleeding increased, and it was more than the normal menstruation.

On March 30, the patient was admitted to our hospital. B-mode ultrasound revealed the anterior uterine size; the separable uterine cavity was about 0.22 cm. The cervix had a gestational sac echo of 1.4 $\times$ 1.0 $\times$ 0.6; the yolk sac was visible inside, and there was a small amount of obvious germ tissue. No obvious primitive cardiovascular fluctuation was noted. The cervical canal was not significantly dilated, and the size of the bilateral ovaries was normal. There was no obvious abnormality in the echo. The anechoic dark area behind the uterus was 1.3 cm thick (Fig. 2). A gynecological examination revealed that the cervix was enlarged, the uterine size was normal, and there was no tenderness.

Fig. 2.

Case 2. Cervical enlargement was noted. Gestational sac size of about 1.4 $\times$ 1.0 $\times$ 0.6 cm was found in the cervix, and the heart tube pulsation and punctate germ were seen inside. Cervical pregnancy was diagnosed.

On March 31, serum hCG was $>$10000 mIU/L. On the same day, under B-mode ultrasound guidance, lauromacrogol was injected into the edge of the gestational sac.

On April 1, intrauterine visualization and vacuum aspiration were performed under direct vision and negative pressure suction. After the surgery, a Foley balloon was used to compress and stop bleeding. After 4 h, a small amount of light bloody liquid was noted in the balloon, and half the amount of liquid in the balloon was released. After 2 h of observation, there was no obvious bleeding in the vagina, and the Foley catheter was removed.

On the next day, a B-ultrasound review after the operation showed that the cervix was normal in size, and no pregnancy was seen. The patient was followed up for serum hCG on April 2 (7468 mIU/L), April 8 (549 mIU/L), and April 15 (9 mIU/L).

The causes may be related to endometrial damage, abnormal uterine environment, rapid transport of fertilized ovum into the endocervical canal, or delayed development.

The diagnostic criteria include the history of amenorrhoea, painless vaginal bleeding, gynecological examination revealing a normal uterine size, texture that is not soft, pendulous cervix, with or without bluish-purple color, extensible outer cervix, and thin edge, and increased serum hCG. The maximum level of hCG to be considered for the treatment will be determined based on the patient’s specific condition. The current highest hCG level does not exceed 14,000 mIU/mL.

The diagnostic criteria for ultrasound examination include an empty uterine cavity, large cervical canal, visible gestational sac in the cervical canal below the internal os of the cervix, abundant blood flow signals around the gestational sac, occasional heart tube pulsation, closure of the internal os of the cervix [32], and absence of any pregnancy material in the uterine cavity on fractional curettage.

The reasons could be attributed to a gestational age of more than 9 weeks, administration of serum hCG $>$10000 U/L, and the presence of an ultrasound fetal heart [33, 34].

There are several treatment methods, and the conventional treatment methods include total hysterectomy, a combination of Mifepristone and MTX, a combination of MTX and hysteroscopy, curettage, and uterine artery embolization. At present, it is confirmed that a combination of drug treatment and intrauterine visualization systems, and vacuum aspiration is an effective treatment. With the advancement of diagnosis and treatment technology, it is possible to employ a conservative treatment to preserve the uterus and fertility in cervical pregnancy [35]. Early gestational trophoblasts do not invade very deep into the cervical wall, and conservative treatment is often very successful. The key to success lies in early diagnosis and early treatment [36, 37].

While capturing the nutrition of the embryo, drug treatment also reduces the blood supply to the pregnancy site, thereby avoiding massive vaginal bleeding and causing minimal damage to the patient. One-time intrauterine visualization and vacuum aspiration allow for a clear view of the gestational sac implantation position, and a very accurate one-time local suction can completely draw the embryo, rendering the treatment complete and thorough. The duration of hospitalization was short. Serum hCG decreased rapidly, and a longer duration of hospital stay for observation was not required. Intraoperative hemorrhage that may occur due to lack of cervical muscle tissue, more muscle fibers, and direct negative pressure vacuum aspiration can be avoided, and the systemic and local side effects of MTX can be reduced. MTX is a chemotherapeutic drug associated with great toxic side effects [33, 34] and can cause elevated liver enzymes, bone marrow suppression, and even death.

Hysteroscope electrotomy directly damages the cervical fibrous tissue, which easily adheres, causing amenorrhea and abdominal pain. The complications of UAE include postoperative pain, pelvic infection, local tissue necrosis of the bladder and rectum, and amenorrhoea. The incidence rate varies from about 5.7% for intraprocedural complications, 37.3% for minor complications and about 5% for major complications within the first year after UAE [38]. It requires expensive digital imaging technology and involves a high cost, and the most serious complication is pulmonary embolism, which is rare but life-threatening [26]. It may cause uterine endometrium damage and intrauterine ovarian injury, affecting the patient’s fertility function to varying degrees [39, 40, 41].

In recent years, the clinical application of lauromacrogol in treating esophageal and gastric varices and cesarean uterine scar pregnancy [25, 26, 34, 42] has achieved its therapeutic purposes. Hence, it was chosen in the trial for cervical pregnancy. Before application, the patients and their families were well informed, and signed informed consent was obtained. The limitation of the study is there are relatively few cases at present. Despite this, it is found that compared with other methods, the effect of lauromacrogol is definite and significant, safe and feasible, lower cost, and with fewer side effects. Moreover, the serum hCG decreased rapidly, the length of hospital stay was short, and patients’ recovery was quick. Thus, this method can be generalized within a clinical trial. Hospitals where B-ultrasound and visualization system are available can perform the procedure. Multicenter studies can be carried out if sufficient data are gathered.

Lauromacrogol is a sclerosing foam agent which mainly causes a small area of vascular sclerosis, oppression, and blockage at the local injection site but does not enter the uterine arteriovenous, distant vessels, and ovarian vessels, thereby avoiding damage to the ovaries and allowing the uterus and ovaries to obtain sufficient blood supply [25, 43]. Combining this medication with intrauterine visualization system and vacuum aspiration has a definitive therapeutic effect, and the application can be promoted clinically.