Case notes
A 36-year-old nulligravid woman, who had conceived by intrauterine insemination, was referred for a known cervical pregnancy. The ectopic pregnancy was initially diagnosed at 6 weeks 6 days of gestation. Asingle-dose intramuscular injection of systemic methotrexate, 50 mg/m 2 , was administered at 7 weeks’ and again at 9 weeks’ gestation at her local hospital, but these failed to successfully treat the ectopic gestation. The patient subsequently presented to our institution at 11 weeks 1 day for further management. Her human chorionic gonadotropin (hCG) level at that time was 26,861 IU/L. She denied any vaginal bleeding or pain.
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Conclusions
Ultrasound imaging revealed a viable ectopic pregnancy in the posterior cervical stroma ( Figure 1 ) . Of note, the fetus had a nuchal fold measurement of 2.3 mm. The patient underwent a uterine artery embolization on the day of admission; the next day, definitive treatment of the advanced ectopic pregnancy was administered in the operating room. After placement of a vaginal speculum, visualization of the cervix identified a visible defect with prolapsing fetal membranes in the posterior cervix ( Figure 2 ) . Eight milliliters of amniotic fluid were withdrawn and sent for cytogenetic analysis. Then a needle was placed within the fetal thorax, and an intracardiac KCl injection was administeredto ensure fetal demise. Once asystole was achieved, the needle was withdrawn from the fetus, and methotrexate, 80 mg, was instilled into the amniotic cavity. All procedures were performed under continuous ultrasound guidance.
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