Especificidades técnicas no tamponamento uterino com balões e algumas dificuldades técnicas / Technical specificities in uterine tamponade with balloons and some technical difficulties

A mortalidade materna é inaceitavelmente alta. A hemorragia pós-parto encontra- se na primeira posição no mundo, tendo como principal causa específica a atonia uterina. Eventualmente, as medidas iniciais e a terapia farmacológica não são efetivas no controle do sangramento, impondo a necessidade de tratamentos invasivos, cirúrgicos ou não. Entre esses, o tamponamento uterino com balão requer recursos locais mínimos e não exige treinamento extensivo ou equipamento muito complexo. Entretanto, algumas dificuldades podem ocorrer durante a inserção, infusão ou manutenção do balão na cavidade uterina, com especificidades relacionadas à via de parto. Após o parto vaginal, a dificuldade mais prevalente é o prolapso vaginal do balão. Na cesárea, as principais dificuldades são a inserção e o posicionamento do balão na cavidade uterina, principalmente nas cesáreas eletivas. Este artigo revisa e ilustra as principais dificuldades e especificidades relacionadas ao tamponamento uterino com balões.

Maternal mortality is unacceptably high. Postpartum hemorrhage is ranked first in the world, with the main specific cause being uterine atony. Eventually, initial measures and pharmacological therapy are not effective in controlling bleeding, imposing the need for invasive treatments, surgical or not. Among these, uterine balloon tamponade requires minimal local resources and does not require extensive training or very complex equipment. However, some difficulties may occur during insertion, infusion, or maintenance of the balloon in the uterine cavity, with specificities related to the mode of delivery. After vaginal delivery, the most prevalent difficulty is vaginal balloon prolapse. In cesarean section, the main difficulty is the insertion and positioning of the balloon in the uterine cavity, especially in elective cesarean sections. This article reviews and illustrates the main difficulties and specificities related to uterine balloon tamponade.

Balões de tamponamento intrauterino na hemorragia pós-parto ­ Atualizações / Uterine balloon tamponade in postpartum hemorrhage ­ Updates

A hemorragia pós-parto continua sendo uma condição relacionada a elevada morbimortalidade materna, sendo essenciais o diagnóstico precoce e o início do tratamento farmacológico. Em caso de falha, os balões de tamponamento uterino são uma alternativa eficiente, com aplicabilidade crescente na prática clínica. Esses dispositivos são seguros, apresentam baixa incidência de eventos adversos e reduzem as taxas de procedimentos cirúrgicos. Existe uma ampla variedade de modelos, tanto industriais quanto artesanais, com acúmulo de relatos na literatura demonstrando sua eficácia. Este artigo descreve os principais balões intrauterinos, com ênfase nos modelos mais novos, aplicabilidade, taxas de sucesso e eventos adversos.(AU)

Postpartum hemorrhage continues to be a condition related to high maternal morbimortality, early diagnosis and initiation of pharmacological treatment are essential. In case of failure, uterine balloon tamponade is an efficient alternative, with increasing applicability in clinical practice. These devices are safe, have a low incidence of adverse events and reduce the overall rates of surgical procedures. There is a wide variety of models, both industrial and artisanal, with an accumulation of reports in the literature demonstrating their effectiveness. This article describes the main intrauterine balloons, with an emphasis on newer models, applicability, success rates and adverse events.(AU)

Intrauterine balloon tamponade for postpartum hemorrhage / Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto

Abstract Introduction: Postpartum hemorrhage is an obstetric emergency with high prevalence and significant morbidity and mortality, especially in areas with reduced access to specialized health services. Objective: To evaluate the effectiveness of intrauterine balloon tamponade in controlling postpartum hemorrhage, with the aim to reduce the need for emergency surgical interventions and decrease maternal mortality. Methods: A systematic review of randomized clinical trials, guided by the Cochrane Handbook for Systematic Reviews of Interventions and reported through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized clinical trials that evaluated the use of different types of balloons for intrauterine tamponade as a strategy for reducing or stopping postpartum hemorrhage compared to other interventions (pharmacological or surgical) were considered for inclusion. Results: Four studies evaluated 498 patients. In 80% of the reported cases, hemorrhage cessation was observed within a mean interval of 15 min after device insertion. The device permanence time was 24 h. No serious adverse events were reported. Due to clinical heterogeneity between studies, it was not possible to perform a quantitative synthesis. Conclusion: We did not find enough evidence to support the routine use of uterine tamponade devices as a protocol practice in the control of refractory postpartum hemorrhage. However, the use of these devices seems to be promising in cases where first line interventions fail and may play an important role in decreasing maternal morbidity and mortality and in uterine preservation.

Resumo Introdução: A hemorragia pós-parto trata-se de uma emergência obstétrica com elevada prevalência e morbimortalidade significativa, sobretudo em contextos de baixa acessibilidade a serviços especializados de saúde. Objetivo: Avaliar a efetividade do tamponamento por balão intrauterino no controle da hemorragia pós-parto, redução da necessidade de intervenções cirúrgicas de emergência e redução da mortalidade materna. Métodos: Revisão sistemática de ensaios clínicos randomizados, orientada pelo Cochrane Handbook for Systematic Reviews of Interventions e relatada através do Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Foram considerados como critérios de elegibilidade ensaios clínicos randomizados que avaliaram o uso de diferentes tipos de balão para tamponamento intrauterino enquanto estratégia para a redução ou cessação da hemorragia pós-parto quando comparados a outras intervenções (farmacológicas ou cirúrgicas). Resultados: Quatro estudos avaliaram 498 pacientes para os desfechos preconizados. Em 80% dos casos relatados observou-se a cessação da hemorragia em um intervalo médio de 15 minutos, após a inserção dos dispositivos. O tempo de permanência dos dispositivos foi de 24 horas. Não foram relatados eventos adversos graves. Devido à heterogeneidade clínica entre os estudos, não foi possível realizar síntese quantitativa. Conclusão: Os achados obtidos não fornecem evidências suficientes para sustentar a utilização rotineira dos dispositivos de tamponamento uterino enquanto prática protocolar no controle da hemorragia pós-parto refratária. A utilização destes dispositivos, no entanto, parece ser promissora diante da falha das intervenções de primeira linha, podendo desempenhar um importante papel em termos de redução de morbimortalidade materna e preservação uterina.

Impact of condom balloon tamponade on the rate of obstetric hysterectomy: a ten-year study

Background: The objective of this present study was to assess the efficacy of condom uterine balloon tamponade (C-UBT) in averting the obstetric hysterectomy (OH) in cases of major postpartum haemorrhage (PPH) over a period of 10 years.Methods: A retrospective cohort study from January 2010 to December 2019. A historical cohort was drawn from a group of women who had OH for major PPH between Jan 2010 to December 2014 (Group 1) whereas those from January 2015 to December 2019 were designated as Group 2. Total 305 C-UBT were used in the later period. Women who had OH at <28 weeks were excluded from the study. Primary outcome was to determine the efficacy of C-UBT in averting the risk of OH. Secondary objective was to determine the success rate of C-UBT after five years of useResults: Total 37463 births occurred from January 2010 to December 2014 and 38808 during January 2015 to December 2019. Cases of OH were 33 in the first five years period (Group 1) and 20 in the later (Group 2), p=<05, odds ratio=0.58 with 95% CI 0.335-1.019 favoring C-UBT.  After exclusion of rupture uterus and placenta accreta syndrome, OH for uterine atony alone were 22 (66.6%) for Group 1 and 08 (40%) for Group 2, P=0.01 odds ratio=0.350 (95% CI 0.156-0.788). No OH was done in group 2 for placenta previa. Efficacy of C-UBT was 96%.Conclusions: C-UBT is very safe, cheap and effective option for averting OH and associated physical, emotional and psychosocial morbidity.

Clinical profile of maternal deaths due to postpartum haemorrhage

Background: Postpartum haemorrhage is one of the dreadful complications that occur during delivery. It is often un-anticipated and occurs suddenly and un-expectedly. It is responsible for 20 percent of maternal deaths in developing countries. These deaths are largely preventable. The objective of the study was to find out the clinical profile, associated co-morbid conditions and contributory factors and treatment modalities used in the management.Methods: Retrospective observational study of maternal deaths due to postpartum haemorrhage (PPH) was carried out at tertiary care hospital. The data of maternal deaths for seven years from year 2013 to 2019 was reviewed, compiled and analyzed to draw conclusions.Results: There were 18 maternal deaths (19%) due to PPH out of total 86 maternal deaths. The average age of the woman who died due to PPH was 24 years. Ninety five percent of the cases of PPH were due to atonic uterus. Seventy percent of the cases had reported in advanced stage of shock with average blood loss of more than two to three litres. Poor general condition due to delay in reaching to tertiary care hospital was predominant feature. Sixty percent women underwent obstetric hysterectomy. Massive blood transfusion was given in fifty percent cases. Severe pregnancy induced hypertension, severe anaemia and severe concealed accidental haemorrhage were common associated factors in sixty percent of maternal deaths.Conclusions: Postpartum haemorrhage is still a common cause of maternal death. Early detection, prompt aggressive management, adequate blood replacement, use of uterine balloon tamponade and non-pneumatic anti-shock garment, timely transfer to higher centre and timely decision for surgical interventions can prevent maternal deaths.

Successful reduction of acute puerperal uterine inversion with use of Bakri postpartum balloon

Acute puerperal inversion is rare but potentially fatal obstetric emergency and prompt recognition will enable immediate repositioning of uterus before it becomes edematous and incarcerated. Manual repositioning along with use of uterine balloon tamponade is simple and effective way for repositioning of inverted uterus as well as prevention of recurrence.

A study of the efficacy and safety of the balloon tamponade in the management of atonic post-partum hemorrhage

Background: The most common cause of post-partum hemorrhage (PPH) is uterine atony. Treatment for atony follows a well-defined stepwise approach, including drugs and mechanical interventions followed by surgery as a last resort. Early use of intrauterine balloon tamponade is a way of limiting ongoing uterine blood loss while initiating other measures and can be readily implemented by providers with minimal training.Methods: This prospective interventional study was conducted in 112 consecutive patients attended department of obstetrics and gynecology, Gandhi Medical College and Associated Sultania Zanana Hospital, Bhopal, Madhya Pradesh, India, in one year of study period.Results: In this study most of the patients had gestational age >37 weeks [83 (74.1%)]. Most of the patients in the study had vaginal delivery [64 (57.1%)]. In 84 (75%) patients Bakri balloon was used followed by Burke balloon in 17 (15.2%) patients, condom catheter in 7 (6.2%) patients and CG balloon in 4 (3.6%) patients. Different types of balloons were used according to availability of balloon at the time of management. Most of the patients [71 (63.3%)] had trans-vaginal route of balloon placement and 41 (36.7%) patients underwent trans-abdominal balloon placement. Most of the patients 69 (61.65%), responded to tamponing within 20 minutes of balloon placement while 9 patients had negative tamponade and continued to bleed. Bakri balloon tamponade was most commonly used in 84 (75.0%) patients. CG balloon and condom catheter were used only in 4 (3.6%) and 7 (6.3%) patients respectively. Tamponading was effective and successful in 103 (92%) patients.Conclusions: PPH is still a leading but preventable cause of maternal morbidity and mortality. In the majority of cases, relatively simple methods are used to avert a disaster, although these are not always employed. Uterine tamponade using intrauterine balloons appears to be an effective tool in the management of PPH.

Aplicación del Balón de Bakri ante hemorragia obstétrica postparto. Presentación de un caso / Application of Bakri's Balloon to postpartum obstetric hemorrhage. Case Presentation

RESUMEN La hemorragia obstétrica pos parto complica el 10,5 % de los nacimientos a nivel mundial y está relacionada con una elevada morbimortalidad perinatal. El manejo de esta complicación abarca el tratamiento médico y de ser refractario, habrá que recurrir a un tratamiento quirúrgico basado en taponamiento endouterino con gasas o balón, suturas compresivas uterinas, devascularización pelviana y la embolización arterial. Si todos estos procedimientos no tuvieran efectividad, entonces hay que realizar un tratamiento radical como la histerectomía obstétrica. Se presenta un caso de una gestante 37.5 semanas, nulípara, atendida en el Hospital Dr. Gustavo Aldereguía Lima de Cienfuegos. Se le induce el parto por rotura prematura de membranas, que evoluciona hacia la fase activa y se decide realizar parto instrumentado por fórceps para abreviar período expulsivo por variedad no fisiológica y alteración del bienestar fetal. Se extrae recién nacido femenino con peso de 4025 g, diagnosticándose hemorragia obstétrica mayor por atonía uterina, que no resuelve con el tratamiento médico convencional y se decide realizar manejo conservador del útero mediante compresión endouterina con balón de Bakri. Se logra contractilidad uterina y una evolución clínica satisfactoria. Este procedmimento quirúrgico se describió por primera vez a nivel mundial desde finales del siglo XX y es introducida en Cuba en el año 2016. La provincia de Cienfuegos ha implementado desde entonces estas prácticas conservadoras, logrando en el caso referido reducir la hemorragia, disminuir la morbimortalidad obstétrica y conservar la fertilidad en pacientes con paridad no satisfecha.

ABSTRACT Obstetric hemorrhage after delivery complicates 10.5% of births worldwide and is related to high perinatal morbidity and mortality. Its management includes medical treatment and if refractory, it will be necessary to resort to a surgical treatment based on uterine tamponade with gauze or balloon, uterine compression sutures, pelvic devascularization and arterial embolization. If all these procedures are not effective, then a radical treatment such as obstetric hysterectomy should be performed. The case of a 37.5 week, nulliparous pregnant woman, attended at the Dr. Gustavo Aldereguía Lima Hospital in Cienfuegos is presented. Labor is induced due to premature rupture of membranes that evolves into the active phase and it is decided to perform instrumental delivery by forceps to shorten the expulsive period by non-physiological variety and alteration of fetal well-being. A female 4025 g weight newborn was obtained, with greater obstetric hemorrhage due to uterine atony, which does not resolve with conventional medical treatment and it was decided to perform conservative management of the uterus by means of Barki´s balloon uterine compression. Uterine contractility and a satisfactory clinical evolution are achieved. This surgical procedure was first described worldwide by the end of the 20th century and was introduced in Cuba in 2016. Since then, the Cienfuegos province has implemented these conservative practices. In the case presented it was possible to reduce bleeding. In addition it reduces obstetric morbidity and mortality and preserves fertility in the patient with unmet parity.

An observational study to compare between conventional condom balloon catheter with CG balloon

Background: Postpartum haemorrhage (PPH) is a life-threatening complication of delivery. The most common cause of PPH is uterine atony. Intrauterine balloon tamponade has been suggested as an effective, easily administered minimally invasive treatment option to control uterine bleeding while preserving the mother’s ability to bear additional children.Methods: Twenty women with normal vaginal delivery were studied over a period of six months, 10 were inserted conventional balloon tamponade and rest 10 were inserted CG balloon and outcome studied in terms of time to assemble, leakage, expulsion, lumen occlusion, volume of fluid used, time to arrest bleeding, cost, drainage port, inflation deflation interval.Results: Most of the women were para 4 or more, unbooked belonging to age group of 20-30. Mean time to assemble Condom balloon tamponade was 1.8min   and that in CG balloon was 1.2 minute. There was leakage and expulsion in two and lumen occlusion in three in the conventional balloon catheter. In the second group there was  no leakage ,lumen occlusion  or expulsion . There is uterine drainage port present in CG balloon which is characteristic of it which helps in determining the actual blood loss in real time. The inflation deflation interval and mean volume of fluid are almost same in both the groups.Conclusions: Both conventional balloon and CG balloon are effective and lifesaving in low resource setting with few advantages of CG balloon over conventional balloon tamponade.

Incidence of postpartum hemorrhage based on the use of uterotonics. Maternal outcomes in an intermediate complexity hospital in Bogotá, Colombia, 2016 / Incidencia de hemorragia posparto con base en el uso terapéutico de uterotónicos. Resultados maternos en un hospital de mediana complejidad de Bogotá, Colombia, 2016

ABSTRACT Objective: To describe the incidence of obstetric postpartum haemorrhage (PPH), defined by the use of uterotonic drugs, as well as the interventions performed, and maternal outcomes in the first 24 hours. Materials and methods: A series of cases of pregnant women who presented PPH after vaginal delivery or cesarean section between February 1 and October 31, 2016, in a public intermediate complexity institution in Bogotá. Consecutive sampling was used. Sociodemographic, clinical and risk factors for PPH were measured. Variables measured were the cause of PPH, the degree of shock, estimated postpartum bleeding, frequency of activation of the "obstetric red code," interventions performed, admission to an intensive care unit, blood transfusions, and maternal mortality. A descriptive analysis was performed. Results: Out of 1633 births (1080 vaginal deliveries and 553 cesarean deliveries), 35 cases (2.1%) (26 and 9, respectively) were identified and the "obstetric red code" was activated in 11 cases (0.67%). There was no maternal mortality. The main cause of PPH was uterine hypotonia in 29/35 (82%), and 82.8% of the cases resolved with medical treatment. Uterine tamponade was required in 4/35 (11.4%) women to control bleeding, and surgical management was required in 2/35 (5.6%) women: haemostatic sutures in 1/35 (2.8%) and hysterectomy in 1/35 (2.8%). Conclusions: The use of more reproducible criteria for the identification of severe PPH and timely initiation of treatment could be safer and more effective in terms of maternal outcomes.

RESUMEN Objetivo: Describir la incidencia de hemorragia obstétrica posparto (HPP) severa por el uso de medicamentos uterotónicos, como también las intervenciones realizadas y los desenlaces maternos en las primeras 24 horas. Materiales y métodos: Serie de casos de gestantes que presentaron HPP luego de parto vaginal o cesárea entre el 1 de febrero y el 31 de octubre de 2016, según el uso terapéutico de uterotónicos, en una institución pública de mediana complejidad en Bogotá. Muestreo consecutivo. Se midieron las características sociodemográficas, clínicas y los factores de riesgo para HPP. Como desenlace se determinó la causa de la hemorragia, grado de choque, sangrado posparto estimado, activación del código rojo obstétrico, intervenciones realizadas, ingreso a unidad de cuidado intensivo, necesidad de transfusión sanguínea y mortalidad. Se realizó análisis descriptivo. Resultados: De 1.633 nacimientos (1.080 partos y 553 cesáreas) se presentaron 35 (2,1 %) casos de HPP por uso de oxitócicos (26 y 9 respectivamente), y se activó el código rojo obstétrico en 11 casos (0,67 %). No hubo mortalidad materna. La principal causa de HPP fue hipotonía uterina 29/35 (82 %), y en el 82,8 % de los casos se resolvió con manejo médico; 4/35 (11,4 %) requirió taponamiento uterino adicional para control del sangrado; 2/35 (5,6 %) de las mujeres requirió manejo quirúrgico: sutura hemostática 1/35 (2,8 %) e histerectomía 1/35 (2,8 %). Conclusiones: La identificación de HPP severa por criterios más reproducibles para iniciar el tratamiento oportuno podría ser más efectiva y segura en cuanto a resultados maternos.

Clinical effect of elastics draw off balloon catheter for 24 hours on preventing bleeding after transurethral plasmakinetic resection of prostate / 中国综合临床

Objective To investigate the clinical effect of elastics drawing off balloon catheter for 24 hours on preventing bleeding after transurethral plasmakinetic resection of prostate (TUPKRP).Methods Seven hundred patients with benign prostatic hyperplasia (BPH) underwent TUPKRP in the Eighth People's Hospital of Shanghai from Jan.2005 to Jun.2013 were randomly divided into control group (298 cases) and experiment group (402 cases).Patients in control group after transurethral resection of the bladder were given treatment as follow:the bladder was placed with F22 cavity catheter,which were fixed on the medial femoral traction;prostate wound edge was pressed for 2-3 d and saline continuous irrigated bladder for avoiding infection.Patients in experiment group were given the same treatment with control group beside prostate wound pressed for 24 h.The days (1st,3rd,5th) of bleeding after operation,cases of hematuria turn clear,cases of postoperative blood transfusion and operation bleeding were recorded.Results Cases of hematuria disappeared postoperation at 1 st,3rd,5th days after operation were 52,42,24 cases in control group and 34,22,10 cases in experiment group.The differences were significant(x2 =6.608,9.279,7.624 ;P =0.010,0.002,0.006).Cases of blood transfusion and reoperation in experiment group were 6 and 2 cases,lower than that in control group(15,9 cases ; x2 =4.955,5.264 ; P =0.026,0.022).Conclusion The method of elastics drawing off balloon catheter for 24 hours improved the effect of preventing bleeding after TUPKRP.

Treatment of Endobronchial Hemorrhage Using Balloon Tamponade and Bronchial Artery Embolization / 계명의대학술지

Endobronchial hemorrhage is common complication of bronchoscopic biopsy. There are several hemostatic methods including cold saline irrigation, topical vasoactive substance instillation, tranexamic acid treatment, and balloon tamponade. Insertion of balloon catheter into bronchoscopic working channel is relatively simple and useful method for the selective hemostasis. Here, we report a case of 75-year-old female patient who had hemorrhage during endobronchial biopsy with flexible bronchoscopy. Since primary treatments such as cold saline irrigation and epinephrine instillation had been failed to stop hemorrhage, balloon catheter was immediately inserted into the bleeding site for temporal hemostasis. And then, bronchial artery embolization was followed for the additional treatment of hemorrhage. We suggest to use balloon catheter as a bridge therapy before bronchial artery embolization.

Application of balloon tamponade hemostasis in abdominal surgery / 国际外科学杂志

Balloon tamponade hemostasis has been applicated for 50 years,and its appropriate usage can obtain exact curative effect with less adverse reactions.In recent years,with the continuous improvement in surgical therapy,balloon tamponade technique in treating various types of bleeding has accumulated many successful experiences.This paper intends to review the advances in balloon compression technology for recent years.

Case Review: Post Partum Vulvo-vaginal Haematomas and Options of Management

Vulvo-vaginal haematomas are not an uncommon obstetric complication. Despite advances in obstetric care, practice and technique, vulvo-vaginal haematomas do occur especially in complicated vaginal deliveries. Various management options are available for vulvo-vaginal haematomas. We describe three cases of vulvo-vaginal haematomas with different severity and presentations which were managed in different manners i.e. local haemostasis control, laparotomy with hysterectomy, and transarterial embolisation. The choice of treatment options would mainly depend on the clinical presentations, availability of expertise as well as facilities. Early identification is crucial.

Balón de Bakri en hemorragia en Medellín (Colombia): reporte de caso y revisión de la literatura / A case report and literature review regarding the Bakri balloon in postpartum hemorrhage in Medellín (Colombia)

Objetivo: presentar un caso de atonía uterina que no respondió al manejo inicial y en el que se utilizó el balón de Bakri con control satisfactorio de la hemorragia. Se revisó la literatura respecto a la técnica quirúrgica de su inserción, las cointervenciones a administrar y las complicaciones relacionadas con su uso. Materiales y métodos: se presentó el caso y se realizó una búsqueda bibliográfica en las bases de datos electrónicas de MEDLINE/Pubmed, Lilacs, SciELO, Ovid, Elsevier, EBSCO y Cochrane a partir de los términos "taponamiento con balón" y "hemorragia posparto". Para ello se buscaron artículos de revisión, series de caso, reportes de caso y experimentos clínicos publicados entre 1980 y 2010. Conclusiones: el balón de Bakri ha demostrado ser una opción en el protocolo de manejo de las pacientes con Hemorragia Posparto (HPP), ya que constituye un método no invasivo y con pocas complicaciones.

Objective: presenting a case of uterine atony which did not respond to initial management; the Bakri balloon was then used with satisfactory control of postpartum hemorrhage (PPH). The literature regarding the surgical technique for its insertion, the co-interventions to be administered and the complications related to its use were reviewed. Materials and methods: the case was presented and a bibliographic search was made of the MEDLINE/ PubMed, Lilacs, Scielo, Ovid, Elsevier, EBSCO and Cochrane databases based on the terms "Balloon tamponade", "postpartum hemorrhage". Review articles, case series, case reports and clinical experiments were sought which had been published from 1980 to 2010. Conclusions: Bakri balloon for managing PPH has been shown to be an option in the protocol for managing these patients, as it is a non-invasive method and has few complications.

Two cases of cervical pregnancy associated with multiple risk factors in elderly gravida / 대한산부인과학회잡지

Cervical pregnancy is a rare life-threatening form of ectopic pregnancy. The exact etiology of cervical pregnancy is not known, but several contributing factors have been considered. Probably a combination of factors leads to cervical pregnancy. The first case was required hysterectomy. The second case was successfully treated with a unique combination of precurettage cerclage, suction curettage and postcurettage balloon tamponade. Conservative treatment has evolved in recent years, with a considerable reduction in the number of hysterectomies. We present two cases of cervical pregnancy associated with multiple risk factors in elderly gravida, with brief reviews.