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2011-05-14-11 Answer to the case of the week #297 © Lau

Answer to the case of the week #297

July 7-21, 2011.

WL Lau, MD., LL Chan, MD. KS Chan, MD., WC Leung, MD.

Department of Obstetrics and Gynaecology, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China.

Case report

This is a case of a 35-year-old woman, G5 P0 A4 , who was admitted to our gynaecological emergency unit with vaginal bleeding and 6 weeks amenorrhoea.
Her personal history included 2 spontaneus abortions in the 1 st trimester and 2 ectopic tubal pregnancies. Both tubal pregnancies were surgically treated via laparoscopy.
On admission, vaginal examination revealed a closed cervical os with no vaginal bleeding. The uterus was anteverted and bulky in size. Conventional transvaginal 2D-ultrasound on admission showed a 0.5 cm gestation sac-like structure at the isthmic portion of the uterus. Inside the sac was a small fetal pole without detected heart rate. The admission diagnosis was missed abortion.

Patient was rescanned in 2 weeks and ultrasound exam revealed a gestation sac with the fetus, CRL corresponded with 7 weeks of gestation. The gestational sac was located in the cervical portion of the uterus. 3D-ultrasound (multi-planar and render mode) was employed to demonstrate the cervical pregnancy for better patient counseling (Article).
The patient was treated with a single dose of intramuscular injection of methotrexate (50 mg/m2). The pre-treatment plasma beta-HCG level was 5344 IU/ml and was decreased to 3 IU/ml 8 weeks after treatment. Patient had her period 16 weeks after treatment. There were no maternal complications.

Images 1-4: 7 weeks, images show gestational sac with the fetus located in the cervix.



Images 5,6: 3D multi-planar mode. Image 6 is using power Doppler.


Images 7,8: 3D-render mode of the cervical pregnancy.


Image 9: 3D-image, arrow indicates the intracervical pregnancy.

Videos 1,2: Video 1 shows the sagittal view of the uterus with the cervical pregnancy, uterine cavity has high endometrium but no sign of pregnancy within the cavity. Video 2 is using power Doppler to demonstrate the vascularization around the gestational sac.

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