March 23rd, 2018

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Cervical Pregnancy: Misdiagnosis and Hemorrhage After Pharmacologic Therapy at an Early Gestational Age: A Case Report
Authors:  Andrew B. Pressman, M.D., and Jeffery S. Ditkoff, M.D.
  GROUND: Cervical ectopic pregnancy (CEP) is a rare form of ectopic pregnancy known classically for late diagnosis after pronounced hemorrhage requiring treatment with emergent hysterectomy. Advances in ultrasound have led to earlier diagnosis and treatment with methotrexate, thus sparing reproductive function. However, little is known about complications after methotrexate administration.

CASE: A 31-year-old woman, G2P1001, at 6 weeks’ gestational age presented to the emergency department for painless vaginal bleeding. Her β-hCG had trended down to 1,991 from 3,272 over the previous 36 hours. Her examination showed tissue in the cervical os, and an ultrasound showed no intrauterine pregnancy but revealed a cervical mass interpreted as an incomplete abortion. She returned when found to have increasing β-hCG, and a repeat ultrasound was then interpreted as CEP. The CEP was treated successfully with methotrexate, but 1 week later she experienced significant hemorrhage requiring curettage and tamponade with a cervical foley catheter.

CONCLUSION: The current case highlights that upon presentation, early CEP is difficult to distinguish from incomplete abortion. Furthermore, the case shows that significant hemorrhage can occur after methotrexate administration at a much earlier gestational age and with a much smaller gestational sac size than was previously shown.
Keywords:  abortion, incomplete; cervix; gestational age; gestational sac; methotrexate; pregnancy, ectopic; uterine hemorrhage
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