A 29-year-old G3P2 with two previous cesarean deliveries presents with painless heavy vaginal bleeding at 9 weeks. Ultrasound shows an hourglass-shaped uterus, a ballooned cervix containing a gestational sac below a closed internal os, and Doppler flow surrounding the sac. Cardiac activity is absent and beta-hCG is 9,000 mIU/mL. She is haemodynamically stable. Which is the preferred first-line management?

• A Immediate suction dilatation and curettage
• B Expectant management with weekly beta-hCG
• C Total hysterectomy
• D Systemic multi-dose methotrexate therapy ✓

Explanation

This is a cervical ectopic pregnancy. Because the cervix contains predominantly fibrous tissue and poor smooth muscle, it contracts poorly, so blind evacuation commonly causes catastrophic uncontrollable haemorrhage. In a stable patient without cardiac activity and with beta-hCG under 10,000 mIU/mL, systemic methotrexate is first-line, with uterine artery embolisation reserved as an adjunct for bleeding. Hysterectomy is a last resort in refractory life-threatening haemorrhage, and expectant management risks sudden massive bleeding.

Reference: Berek and Novak's Gynecology, 16th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.