Vol.2, No.9, 568-572 (2013) Case Reports in Clinical Medicine
Selective reduction of a triplet heterotopic cervical
pregnancy after embryo transfer
Delphine Delrieu1,2*, Roland Antaki1,2, Simon Phillips1, Isaac-Jacques Kadoch1,2
1OVO Clinic, Montreal, Canada;
*Corresponding Author: delrieu.delphine@gmail.com
2University of Montreal, Department of Obstetrics and Gynaecology, Saint-Luc Hospital (CHUM), Montreal, Canada
Received 16 August 2013; revised 14 September 2013; accepted 10 October 2013
Copyright © 2013 Delphine Delrieu et al. This is an open access article distributed under the Creative Commons Attribution License,
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Cervical pregnancy is rare and heterotopic cer-
vical pregnancy is more uncommon ever. As-
sisted Reproduction Technolog y enhances these
pregnancies. The diagnosis and the treatment
which are in emergency can be sometimes dif-
ficult. This article is a case report of a triplet
heterotopic cervical pregnancy after embryo
transfer, and a scientist review of the literature
found in MEDLINE. To date, in the English lit-
erature, we found only 7 cases report of triplet
heterotopic cervi cal pregnancies.
Keywords: Heterotopic Pregnancy; Cervical
Pregnancy; Ectopic Pregnancy; IVF; Emb ry o
Transfer; Assisted Reproduction Technology
Heterotopic pregnancy is an association between an
intrauterine and an ectopic pregnancy (tubal or more
rarely ovarian, cervical, abdominal). The first description
comes from Duvernay in 1761 during an autopsy [1]. It
is a rare natural phenomenon (less than 1/30000 preg-
nancies) [2,3], but its rate increases with the introduction
of Assisted Reproductive Technology (ART) (0.8% - 3%
after IVF) [4,5].
Cervical pregnancies are very rare (1/2500 - 18000
pregnancy and <1% ectopic pregnancies) [6-9] and het-
erotopic cervical pregnancies, usually resulting from
ART, are even more rare [10].
This is the first report of an ongoing pregnancy after a
selective aspiration of the cardiac fluid of a triplet het-
erotopic cervical pregnancy.
Our patient was a 36 years old, with 3 previous spon-
taneous conceptions and deliveries, with an another
partner. She underwent a tubal ligation after her last de-
livery. A few years later, she consulted with a new part-
ner. Her partner had a normal sperm count. So she un-
derwent a tubal reanastomosis which was unsuccessful
with a bilateral tubal obstruction seen on her post opera-
tive hysterosalpingography. After discussing the alterna-
tives, the couple decided to undergo IVF.
The patient received a long agonist protocol using a
gonadotrophin-releasing hormone (GnRH) agonist (Su-
prefact; Sanofi-Aventis) introduced in the luteal phase of
the previous cycle at a dose of 0.5 mg SC daily and then
decreased to 0.25 mg daily at the initiation of gonad-
otrophin stimulation. The patient received 225 IU daily
of hMG (MENOPUR; Ferring, Canada) that was in-
creased to 300 IU in association with 150 IU of recom-
binant FSH (GONAL-F; EMD Serono Canada). Final
oocyte maturation was triggered by 10000 IU human
chorionic gonadotrophin (Pregnyl, Merck, Canada). The
patient underwent oocyte retrieval 36 hours after receiv-
ing hCG; 14 oocytes were retrieved. After insemination
with sperm, we obtained 9 embryos. The patient had an
ultrasound guided embryo transfer of 3 day3 embryos
(8C2-3, 8C2-3 and 10C2). The transfer technique was
described as easy by the physician. Two weeks later,
hCG level was 186.8 UI/L and 331.5 UI/L two days after.
At 8 weeks and 3 days of amenorrhea, a trichorionic
triamniotic triplet pregnancy with one gestationnal sac in
the cervix was discovered at endovaginal ultrasound. The
3 embryos had a positive heart beat.
After discussing the situation with the couple, they de-
cided to undergo a embryonic reduction of the cervical
Copyright © 2013 SciRes. OPEN ACCESS
D. Delrieu et al. / Case Reports in Clinical Medicine 2 (2013) 568-572 569
pregnancy. They understood and accepted the procedure,
including the risk of bleeding and the risk of losing the
three embryos.
At 8 weeks and 4 days of amenorrhea, in the operating
room, the patient had para cervical block with XYLO-
CAÏNE 1%. We used the 7.5 MHZ endovaginal ultra-
sound probe (Voluson E8, GE, Healthcare, Baie d’Urfé,
QC, Canada) with a needle guide. Using an egg collec-
tion needle (OPS 30cm, 19G, CCD, France), we aspi-
rated the amniotic fluid and then the cardiac blood of the
cervical embryo. No heart beat was seen for the cervical
embryo at the end of the procedure, and the intrauterine
embryos had normal heart beat. The procedure was easy
and the patient did not have any pain or bleeding.
A 12 weeks ultrasound showed a dichorionic diamni-
otic ongoing twin pregnancy
The patient had a normal pregnancy that was compli-
cated by premature labor, an emergency C-section was
performed at 25 weeks; she delivered a girl (660 g) and a
boy (620 g).
Heterotopic cervical pregnany is a very rare event.
ART use has increased the rate of heterotopic pregnan-
cies with unusual localisation like cervix or cesaerian
section scar [11,12].
The diagnosis of a cervical pregnancy can be difficult
and delayed [13-15]. The main symptoms are bleeding
during the first trimester, abnormal hCG increase. The
transvaginal ultrasound is usually diagnostic (the first
report has been described by Raskin in 1978) [16] but
magnetic resonance imaging (MRI) has been necessary
in some cases to make the definitive diagnosis [17,18].
The diagnosis is confirmed by finding an empty uterine
cavity, in association with a gestationnal sac with an em-
bryo (with a positive or negative heart beat) in the endo-
cervical canal below the internal os level. A heterotopic
cervical pregnancy can be even more difficult to diag-
nose, because someone can focus on the intrauterine
pregnancy without seeing the cervical one.
Cervical pregnancy is a therapeutic emergency be-
cause of the risk of severe hemorrhage. There were even
recent reports of death following a heterotopic cervical
pregnancy [19].
Different treatments for ectopic cervical pregnancy are
described in the literature: systemic Methotrexate injec-
tion [20-22], uterine artery embolization or ligation [23]
[24], transvaginal ultrasound-guided aspiration [23], KCl
solution [25], Methotrexate [13,26,27] or hyperosmolar
glucose injection into the gestational sac [28], cervical
curettage with balloon tamponnade [29-31] or Shirodkar
cerclage to make hemostasis [32]. Olav describes a hys-
teroscopy resection of a cervical pregnancy because of
bleeding after Methotrexate treatment [33].
There is no consensus on the technique to use for
treatment. Prognostic factors that affects the effective-
ness of the conservative treatment are especially the age
of pregnancy [34,35]. Sometimes, hysterectomy is inevi-
table because of severe bleeding [13,36,37].
In our case, systemic Methotrexate and uterine artery
embolization or ligation were not an option because of
the presence of an ongoing intrauterine pregnancy.
We chose the selective reduction by the fetal heart as-
piration technique, but Sijanovic et al. tried selective
Methotrexate injection, and had a good result [26]. Some
articles describe the injection of KCl in fetal heart or
gestationnal sac [19,38-46]. Some authors injected Ac-
tinomycin D [47]. Jozwiak et al. resected the cervical
pregnancy by hysteroscopy and coagulated the bleeding
sites with roller-ball. The remaining intra uterine preg-
nancy then continued successfully to term [48]. Kim et al.
and Vasiliki et al. aspirated the cervical pregnancy and
achieved hemostasis by compression with pediatric
Foley catheter [30,49].
All these techniques have three goals: minimize the
bleeding, preserve the fertility and the intrauterine preg-
nancy. We have to keep in mind that if these conservative
treatments fail or if the patient starts to bleed severely,
there would no choice but to sacrifice the intrauterine
pregnancy with the first treatments methods described.
The mechanism to explain a cervical pregnancy is un-
clear. Cervical or uterine surgeries in the past (curettage
or cesarean), seem to enhance these ectopic pregnancies
[36,37,50,51]. Does the problem come from an unrecep-
tive endometrium?
For the rare spontaneous cervical pregnancies, some
authors wonder if the transport of the ovum would be too
quick and that the embryo arrives in the uterine cavity
with an unprepared endometrium [52,53].
A chromosomal abnormality in the embryo is another
hypothesis [51,54].
As mentioned before, these ectopic pregnancies are
more common after ART and specially after IVF [40,48,
55-58]. Furthermore, in the english literature, we found
only 7 cases report of triplet heterotopic cervical preg-
nancies (6 with intrauterine twins and one with cervical
twins) [5,28,44,59-62]. None of them were spontaneous,
all these pregnancies were the result of embryo transfer
after IVF. So we can say that IVF and transferring more
than one embryo are risk factors for heterotopic preg-
Historically, many women with a cervical ectopic or
heterotopic cervical pregnancy underwent hysterectomy.
With the development of transvaginal ultrasound, the
diagnosis of these rare pregnancies has become easier
and quicker. A conservative method should be tried first,
Copyright © 2013 SciRes. OPEN ACCESS
D. Delrieu et al. / Case Reports in Clinical Medicine 2 (2013) 568-572
especially as these pregnancies are in infertile patients
undergoing ART. This is the first report of an ongoing
pregnancy after a selective aspiration of the cardiac fluid
of a triplet heterotopic cervical pregnancy.
[1] Duvernay, G.J. (1761) Oeuvres anatomiques. Joubert, Pa-
[2] De Voe, R.W. and Pratt, J.H. (1948) Simultaneous intra
uterin and extra uterin pregnancy. American Journal of
Obstetrics & Gynecology, 56, 1119-1126.
[3] Harris, J. and Finberg, M.D. (1997) Ultrasonography in
obstetrics and gynaecology: Ultrasound evaluations in
multiple gestations. 3rd Edition, W B Saunders company,
Harcourt Brace and company, 102-128.
[4] Raziel, A., Friedler, S., Herman, A., Strassburger, D.,
Maymon, R. and Ron-el, R. (1997) Recurrent heterotopic
pregnancy after repeated in-vitro fertilization treatment.
Human Reproduction, 12, 1810-1812.
[5] Seow, K.M., Hwang, J.L., Tsai, Y.L., Lin, Y.H., Hsieh,
B.C. and Huang, S.C. (2002) Transvaginal colour Dop-
pler diagnosis and assessment of a heterotopic cervical
pregnancy terminated by forceps evacuation following in
vitro fertilisation and embryo transfer. BJOG, 109, 1072-
[6] Celik, C., Bala, A., Acar, A., Gezgine, K. and Akyurek, C.
(2003) Methotrexate for cervical pregnancy. A case report.
The Journal of Reproductive Medicine, 48, 130-132.
[7] Marcovici, I., Rosenzweig, B.A., Brill, A.I., Khan, M.
and Scommegna, A. (1994) Cervical pregnancy: Case re-
ports and a current literature review. Obstetrical and Gy-
necological Survey, 49, 49-55.
[8] Qasim, S.M., Bohrer, M.K. and Kemmann, E. (1996) Re-
current cervical pregnancy after assisted reproduction by
intra-fallopian transfer. Obstetrics & Gynecology, 87, 831-
[9] Van de Meerssche, M., Verdonk, P., Jacquemyn, Y., Ser-
reyn, R. and Gerris, J. (1995) Cervical pregnancy: Three
case reports and a review of the literature. Human Re-
production, 10, 1850-1855.
[10] Gun, M. and Mavrogiorgis, M. (2002) Cervical ectopic preg-
nancy: A case report and literature review. Ultrasound in
Obstetrics & Gynecology, 19, 297-301.
[11] Condous, G., Okaro, E. and Bourne, T. (2003) The con-
servative management of early pregnancy complications:
A review of the literature. Ultrasound in Obstetrics &
Gynecology, 22, 420-430.
[12] Maymon, R., Halperin, R., Mendlovic, S., Schneider, D.
and Herman, A. (2004) Ectopic pregnancies in a Caesar-
ean scar: Review of the medical approach to an iatrogenic
complication. Human Reproduction Update, 10, 515-523.
[13] Bartosch, C., Brandão, O. and Montenegro, N. (2011)
Cervical ectopic pregnancy: Hysterectomy specimen ex-
amination clarifies the cause of first trimester pregnancy
bleeding. Fertility and Sterility, 95, 1091-1093
[14] Modayil, V., Ash, A. and Raio, C. (2011) Cervical ectopic
pregnancy diagnosed by point-of-care emergency depart-
ment ultrasound. The Journal of Emergency Medicine, 41,
[15] Shavell, V.I., Abdallah, M.E., Zakaria, M.A., Berman,
J.M., Diamond, M.P. and Puscheck, E.E. (2012) Misdi-
agnosis of cervical ectopic pregnancy. Archives of Gyne-
cology and Obstetrics, 285, 423-426.
[16] Raskin, M.M. (1978) Diagnosis of cervical pregnancy by
ultrasound. A case report. American Journal of Obstetrics
& Gynecology, 130, 234-235.
[17] Jung, S.E., Byun, J.Y., Lee, J.M., Choi, B.G. and Hahn,
S.T. (2001) Characteristic MR findings of cervical preg-
nancy. Journal of Magnetic Resonance Imaging, 13, 918-
922. http://dx.doi.org/10.1002/jmri.1131
[18] Okamoto, Y., Tanaka, Y.O., Nishida, M., Tsunoda, H.,
Yoshikawa, H. and Itai, Y. (2003) MR imaging of the ute-
rine cervix: Imaging-pathologic correlation. R adiographic s,
23, 425-445. http://dx.doi.org/10.1148/rg.232025065
[19] Gyamfi, C., Cohen, S. and Stone, J.L. (2004) Maternal
complication of cervical heterotopic pregnancy after suc-
cessful potassium chloride fetal reduction. Fertility and
Sterility, 82, 940-943.
[20] Aboulfoutouh, I.I., Youssef, M.A., Zakaria, A.E., Mady,
A.A. and Khattab, S.M. (2011) Cervical twin ectopic pre-
gnancy after in vitro fertilization-embryo transfer (IVF-
ET): Case report. Gynecological Endocrinol ogy, 27, 1007-
1009. http://dx.doi.org/10.3109/09513590.2011.569785
[21] Kirk, E., Condous, G., Haider, Z., Syed, A., Ojha, K. and
Bourne, T. (2006) The conservative management of cer-
vical ectopic pregnancies. Ultrasound in Obstetrics &
Gynecology, 27, 430-437.
[22] Yim, S.F., Lo, K.W., Chan, S.S. and Cheung, T.H. (2004)
Correlation of transvaginal ultrasound findings and serum
beta-hCG level in cervical pregnancy. Ultrasound in
Obstetrics & Gynecology, 24, 694-695.
[23] Bianchi, P., Salvatori, M.M., Torcia, F., Cozza, G. and
Mossa, B. (2011) Cervical pregnancy. Fertility and Ste-
rility, 95, e3-4.
[24] Nadisauskiene, R., Vaicekavicius, E., Taraseviciene, V. and
Simanaviciūte, D. (2007) Conservative treatment of cer-
vical pregnancy with selective unilateral uterine artery
embolization. Medicina (Kaunas), 43, 883-886.
[25] Polak, G., Stachowicz, N., Morawska, D. and Kotarski, J.
(2011) Treatment of cervical pregnancy with systemic
methotrexate and KCI solution injection into the gesta-
tional sac: Case report and review of literature. Gineko-
logia Polska, 82, 386-389.
[26] Sijanovic, S., Vidosavljevic, D. and Sijanovic, I. (2011)
Copyright © 2013 SciRes. OPEN ACCESS
D. Delrieu et al. / Case Reports in Clinical Medicine 2 (2013) 568-572 571
Methotrexate in local treatment of cervical heterotopic
pregnancy with successful perinatal outcome: Case report.
Journal of Obstetrics and Gynaecology Research, 37,
[27] Andrés, M.P., Campillos, J.M., Lapresta, M., Lahoz, I.,
Crespo, R. and Tobajas, J. (2012) Management of ectopic
pregnancies with poor prognosis through ultrasound guid-
ed intrasacular injection of methotrexate, series of 14
cases. Archives of Gynecology and Obstetrics, 285 , 529-
533. http://dx.doi.org/10.1007/s00404-011-2044-1
[28] Suzuki, M., Itakura, A., Fukui, R., Kikkawa, F., Kawai, S.,
Itakura, A., Masaki Suzuki, M., Ohno, Y., Ito, T. and Mi-
zutani, S. (2007) Successful treatment of a heterotopic
cervical pregnancy and twin gestation by sonographically
guided instillation of hyperosmolar glucose. Acta Obste-
tricia et Gynecologica Scandinavica, 86, 381-383.
[29] Fylstra, D.L. and Coffey, M.D. (2001) Treatment of cer-
vical pregnancy with cerclage, curettage and balloon tam-
ponade. A report of three cases. The Journal of Repro-
ductive Medicine, 46, 71-74.
[30] Kim, M.G., Shim, J.Y., Won, H.S., Lee, P.R. and Kim, A.
(2009) Conservative management of spontaneous hete-
rotopic cervical pregnancy using an aspiration cannula
and pediatric Foley catheter. Ultrasound in Obstetrics &
Gynecology, 33, 733-734.
[31] Okeahialam, M.G., Tuffnell, D.J., O’Donovan, P. and Sa-
pherson, D.A. (1998) Cervical pregnancy managed by
suction evacuation and balloon tamponade. European
Journal of Obstetrics & Gynecology and Reproductive
Biology, 79, 89-90.
[32] Mashiach, S., Admon, D., Oelsner, G., Paz, B., Achiron,
R. and Zalel, Y. (2002) Cervical Shirodkar cerclage may
be the treatment modality of choice for cervical preg-
nancy. Human Reproduction, 17, 493-496.
[33] Olav, I. (2011) Tubal-cervical twin pregnancy. Reviews in
Obstetrics and Gynecology, 4, 3-4.
[34] Bai, S.W., Lee, J.S., Park, J.H., Kim, J.Y., Jung, K.A.,
Kim, S.K. and Park, K.H. (2002) Failed methotrexate treat-
ment of cervical pregnancy. Predictive factors. The Jour-
nal of Reproductive Medicine, 47, 483-488.
[35] Hung, T.H., Shau, W.Y., Hsieh, T.T., Hsu, J.J., Soong, Y.K.
and Jeng, C.J. (1998) Prognostic factors for an unsatisfac-
tory primary methotrexate treatment of cervical preg-
nancy: A quantitative review. Human Reproduction, 13,
2636-2642. http://dx.doi.org/10.1093/humrep/13.9.2636
[36] Parente, J.T., Ou, C.S., Levy, J. and Legatt, E. (1983)
Cervical pregnancy analysis: A review and report of five
cases. Obstetrics Gynecology, 62, 79-82.
[37] Vela, G. and Tulandi, T. (2007) Cervical pregnancy: The
importance of early diagnosis and treatment. The Journal
of Minimally Invasive Gynecology, 14, 481-484.
[38] Al-Azemi, M., Ledger, W.L., Lockwood, G.M. and Bar-
low, D.H. (1999) Successful transvaginal ultrasound-guided
ablation of a cervical pregnancy in a patient with simul-
taneous intrauterine pregnancy after in vitro fertilization
and embryo transfer. Human Fertility, 2, 67-69.
[39] Chen, D., Kligman, I. and Rosenwaks, Z. (2001) Hetero-
topic cervical pregnancy successfully treated with transva-
ginal ultrasound-guided aspiration and cervical-stay sutures.
Fertility and Sterility, 75, 1030-1033.
[40] Frates, M.C., Benson, C.B., Doubilet, P.M., Di Salvo, D.N.,
Brown, D.L., Laing, F.C., et al. (1994) Cervical ectopic
pregnancy: Results of conservative treatment. Radiology,
191, 773-775.
[41] Kumar, S., Vimala, N., Dadhwal, V. and Mittal, S. (2004)
Heterotopic cervical and intrauterine pregnancy in a spon-
taneous cycle. European Journal of Obstetrics & Gyneco-
logy and Reproductive Biology, 112, 217-220.
[42] Monteagudo, A., Tarricone, N.J., Timor-Tritsch, I.E. and
Lerner, J.P. (1996) Successful transvaginal ultrasound-
guided puncture and injection of a cervical pregnancy in a
patient with simultaneous intrauterine pregnancy and a
history of a previous cervical pregnancy. Ultrasound in
Obstetrics & Gynecology, 8, 381-386.
[43] Olah, K.S. (2003) Massive obstetric haemorrhage result-
ing from a conservatively managed cervical pregnancy at
delivery of its twin. British Journal of Obstetrics & Gynae-
cology, 110, 956-957.
[44] Prorocic, M. and Vasiljevic, M. (2007) Treatment of he-
terotopic cervical pregnancy after in vitro fertilization-em-
bryo transfer by using transvaginal ultrasound-guided as-
piration and instillation of hypertonic solution of sodium
chloride. Fertility and Sterility, 88, 969.e3-969.e5.
[45] Wu, M.Y., Chen, H.F., Chen, S.U., Chao, K.H., Yang, Y.S.,
Huang, S.C., Lee, T.Y. and Ho, H.N. (1995) Heterotopic
pregnancies after controlled ovarian hyperstimulation and
assisted reproductive techniques. Journal of the Formosan
Medical Association, 94, 600-604.
[46] Yazicioglu, H.F., Turgut, S., Madazli, R., Aygu, M., Cebi,
Z. and Sonmez, S. (2004) An unusual case of heterotopic
twin pregnancy managed successfully with selective feti-
cide, Ultrasound in Obstetrics & Gynecology, 23, 626-
[47] Brand, E., Gibbs, R.S. and Davidson, S.A. (1993) Advanced
cervical pregnancy treated with actinomycin-D. British
Journal of Obstetrics & Gynaecology, 100, 491-492.
[48] Jozwiak, E.A., Ulug, U., Akman, M.A. and Bahceci, M.
(2003) Successful resection of a heterotopic cervical preg-
nancy resulting from intracytoplasmic sperm injection.
Fertility and Sterility, 79, 428-430.
[49] Moragianni, V.A., Hamar, B.D., McArdle, C. and Ryley,
D.A. (2012) Management of a cervical heterotopic preg-
nancy presenting with first-trimester bleeding: Case report
and review of the literature. Fertility and Sterility, 98,
[50] Dicker, D., Feldberg, D., Samuel, N. and Goldman, J.A.
Copyright © 2013 SciRes. OPEN ACCESS
D. Delrieu et al. / Case Reports in Clinical Medicine 2 (2013) 568-572
Copyright © 2013 SciRes. OPEN ACCESS
(1985) Etiology of Cervical Pregnancy: Association with
Abortion, Pelvic Pathology, IUDs and Ascherman’s Syn-
drome. Journal of Reproductive Medicine, 30, 25-27.
[51] Ushakov, F.B., Elchalal, U., Aceman, P.J. and Schenker, J.G.
(1997) Cervical pregnancy: Past and future. Obstetrical &
Gynecological Survey, 52, 45-59.
[52] Burg, E. (1969) Uberdie Zervikate Schwangershaft. Zentralb
Gynaecol, 103, 1131-1132.
[53] Studdiford, W.E. (1945) Cervical pregnancy: A partial
review of the literature and a report of two probable cases.
American Journal of Obstetrics and Gynecology, 49, 169-
[54] Tasha, I., Kroi, E., Karameta, A., Shahinaj, R. and Manoku,
N. (2010) Prevalence of Gestational Trophoblastic Disease in
Ectopic Pregnancy. Journal of Prenatal Medicine, 4, 26-29
[55] Hofmann, H.M., Urdl, W., Höfler, H., Hönigl, W. and Ta-
mussino, K. (1987) Cervical pregnancy: Case reports and
current concepts in diagnosis and treatment. Archives of
Gynecology and Obstetrics, 241, 63-69.
[56] Karande, V.C., Flood, J.T., Heard, N., Veeck, L. and Muasher,
S.J. (1991) Analysis of ectopic pregnancies resulting from
in Vitro fertilization and embryo transfer. Human Repro-
duction, 6, 446-449.
[57] Sieck, U.V., Hollanders, J.M., Jaroudi, K.A. and Al-Took,
S. (1997) Cervical pregnancy following ultrasound-guided
embryo transfer. Methotrexate treatment in spite of high
β-HCG levels. Human Reproduction, 12, 1114-1117,
[58] Tal, J., Haddad, S., Gordon, N. and Timor-Tritsch, I. (1996)
Heterotopic pregnancy after ovulation induction and assisted
reproductive technologies: A literature review from 1971
to 1993. Fertility and Sterility, 66, 1-12.
[59] Kawai, S., Itakura, A., Masaki Suzuki, M., Ohno, Y., Ito,
T. and Mizutani, S. (2004) Cervical pregnancy managed
in our hospital. Sanfujinnka no Jissai, 53, 1411-1426.
[60] Nitke, S., Horowitz, E., Farhi, J., Krissi, H. and Shalev, J.
(2007) Combined intrauterine and twin cervical pregnancy
managed by a new conservative modality. Fertility and Ste-
rility, 88, 706.e1-706.e3.
[61] Ujvari, E., Krizsa, F., Sebestyen, A., Varbiro, S. and Paulin, F.
(2006) Successful management of intrauterine twin and con-
comitant cervical pregnancy: A case report. Fetal Diagnosis
Therapy, 21, 181-184.
[62] Vitner, D., Lowenstein, L., Deutsch, M., Khatib, N. and
Weiner, Z. (2011) Dilation and curettage: Successful treat-
ment for a heterotopic intrauterine and a twin cervical
pregnancy. Israel Medical Association Journal, 13, 115-116.