A 31-year-old G3P2 with two previous cesarean deliveries presents at 9 weeks amenorrhoea with painless vaginal bleeding. Ultrasound shows an empty uterine cavity, a gestational sac implanted in the endocervical canal below a closed internal os, an hourglass uterine shape, and circumferential peritrophoblastic flow on Doppler. She is haemodynamically stable. Best initial management?

• A Systemic methotrexate therapy ✓
• B Suction evacuation under ultrasound guidance
• C Emergency hysterectomy
• D Cervical cerclage followed by continuation of pregnancy

Explanation

The closed internal os, empty cavity, hourglass uterus and absent sliding sign establish cervical ectopic pregnancy. Primary curettage is hazardous because the cervix lacks contractile muscle to arrest bleeding, often provoking massive haemorrhage requiring hysterectomy. In a stable first-trimester patient, systemic methotrexate, sometimes combined with potassium chloride instillation or uterine artery embolisation, resolves the pregnancy while preserving the uterus. Cerclage has no role here.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.