Neo-adjuvant methotrexate to aid minimally invasive surgery in cervical ectopic pregnancy: A case report

Abstract

Cervical ectopic pregnancies account for <1% of ectopic pregnancies. Early diagnosis may reduce the morbidity and mortality associated with treatment. A 43-year-old woman, gravida 4 para 2, presented at 5 + 6 weeks of gestation of pregnancy via in vitro fertilisation with painless vaginal bleeding. Her initial serum β-hCG level was 51,495 mIU/mL. Ultrasound showed a live ectopic pregnancy within the upper cervical canal with no sliding sign. Surgery was avoided initially due to risk of haemorrhage. Multi-dose systemic intramuscular methotrexate was used in an alternate-day regimen with rescue folic acid to arrest further pregnancy development. Repeat ultrasound seven days later showed absent cardiac activity. Serum β-hCG remained high at 91,764 mIU/mL. A suction dilatation and curettage was performed to remove the pregnancy from the cervix, with an estimated blood loss of 50 mL. The patient was discharged and her serum β-hCG declined to an undetectable level over three months of follow-up. This case adds to the small body of evidence in the management of live cervical ectopic pregnancy. Neo-adjuvant multi-dose methotrexate was successfully used to reduce the risk of haemorrhage associated with surgical management.

Keywords: Case report; Cervical ectopic; Early pregnancy; Ectopic; Methotrexate.

Fig. 1

Transvaginal ultrasound at 6 + 3 weeks of gestation. A gestational sac is seen within the upper cervical canal (crown rump length 6.1 mm, yolk sac 3.6 mm) with fetal cardiac activity. Sliding sign was negative.

Fig. 2

Timeline depicting serum β-hCG level and interventions in the management of cervical ectopic pregnancy.

Fig. 3

Transabdominal ultrasound at 7 + 2 weeks of gestation. A gestational sac (crown-rump length 6.3 mm, yolk sac 5.2 mm) is visualised within the cervical canal with absent fetal cardiac activity. There is distension of the cervix and lower part of the uterus.