We report the serial changes in transvaginal ultrasound findings and serum human chorionic gonadotropin (hCG) level in a patient with a cervical pregnancy treated successfully with systemic methotrexate (MTX). A 40-year-old woman, para 1, was diagnosed to have a cervical pregnancy after a 2.6-cm gestational sac with a 0.7-cm viable fetus was found on transvaginal ultrasound in the endocervical canal. She was treated with a multiple-dose systemic MTX–folinic acid regime (1 mg/kg MTX intramuscularly on days 1, 3, 5 and 7 with 0.1 mg/kg folinic acid intramuscularly on days 2, 4, 6 and 8)1. Two weeks later, we noticed a sub-optimal fall in hCG level. There was enlargement of both the gestational sac and the fetal pole but the fetal heart pulsation ceased. A second course of MTX was given. The hCG level continued to fall while the gestational sac continued to enlarge for 6 weeks, at which point it started to reduce in size (Figure 1). The hCG level and the cervix returned to normal 10 weeks after the commencement of MTX therapy.

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Figure 1. Correlation of serum human chorionic gonadotropin (hCG) level (equation image) and size of cervical gestational mass with time after administration of methotrexate (MTX) (equation image).

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An increase in the size of the gestational mass after MTX treatment has been described in both tubal2, 3 and cervical4, 5 pregnancies but its correlation with serum hCG level was not reported. The enlargement resulted from edematous changes and hemorrhage of the trophoblastic tissues, and a heterogeneous mass was formed as the blood clots organized. This phenomenon may cause concern of rupture in tubal pregnancy, but this is less likely in cervical pregnancy when the bleeding is usually revealed and further treatment then decided6. We noticed a continual fall in hCG level despite an enlarging gestational mass. Serial hCG was used to monitor the treatment response and conservative management continued when the patient was in a stable condition. A sub-optimal fall of serum hCG levels in cervical pregnancy does not necessarily indicate a failure of treatment. A repeat course of MTX may well be justified, if the clinical condition of the patient allows it.


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S.-F. Yim*, K. W. K. Lo*, S. S. C. Chan*, T.-H. Cheung*, * Department of Obstetrics Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong