A 39-year-old woman, gravida 3 para 2, at 7 weeks gestation comes to the emergency department for vaginal bleeding that began 3 hours ago and has soaked through a pad. Since her arrival, the bleeding has subsided. She reports no abdominal pain or cramping. Her first prenatal visit is in 1 week. The patient has a history of HIV, contracted 3 years ago through unprotected sexual intercourse, but she has declined treatment as she has felt "healthy." She has no previous surgeries. The patient's 2 prior pregnancies ended in uncomplicated term vaginal deliveries; the last delivery was 4 years ago. Her last Pap test, 4 years ago, was normal. She has smoked half a pack of cigarettes a day for 13 years but does not drink alcohol or use illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 82/min. BMI is 24 kg/m². Abdominal examination shows no tenderness or masses. The external genitalia have no lesions. Speculum examination reveals minimal bright red blood in the vaginal vault. The cervix is closed and there is a 3-cm, firm, white, irregular mass on the anterior cervix that bleeds when touched with a cotton applicator. Laboratory results are as follows: A bedside transvaginal ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_c025_1a32_8f63_e7ba4d265b0f_MD0005_00 Human papillomavirus (HPV) is a common sexually transmitted virus that causes cervical cancer. In immunocompetent women, HPV usually causes a transient infection. Immunosuppressed patients (eg, HIV infection) are unable to clear HPV and are at increased risk for persistent HPV infection that can progress to cervical dysplasia and cancer. Therefore, patients newly diagnosed with HIV are recommended to have a Pap test immediately after diagnosis followed by close interval screening. In patients with HIV, invasive cervical cancer is an AIDS-defining illness. Most patients diagnosed with cervical dysplasia are asymptomatic. Invasive cervical cancer typically presents in patients who have not had routine Pap test screening and can be asymptomatic. However, the most common presenting features of invasive cervical cancer are irregular vaginal bleeding and a friable, exophytic cervical mass. Other features of cervical cancer include postcoital bleeding; watery, mucoid vaginal discharge; and ulcerative cervical lesions. Suspicious cervical lesions require a cervical biopsy to evaluate for cancer. Additional risk factors for cervical cancer include tobacco use, prior sexually transmitted infection, and multiple sexual partners. cervical cancer (Choice A) Azithromycin plus ceftriaxone is indicated for empiric treatment of acute cervicitis. Although cervicitis can present with irregular vaginal bleeding, it also presents with a mucopurulent cervical discharge (not seen in this patient). acute cervicitis (Choice B) Trichloroacetic acid is indicated in the treatment of condyloma acuminata. Condyloma acuminata can present as cervical lesions, although they typically present on the external genitalia as soft, nonfriable lesions. (Choice D) Suction curettage can be used for a termination of pregnancy or spontaneous abortion. Treatment of cervical cancer typically includes chemoradiation; pregnancy termination is recommended when cancer is diagnosed early in pregnancy due to the risk of teratogenicity associated with treatment. However, other treatment options are available for patients who desire to continue their pregnancy. Suction curettage is indicated if the patient decides to terminate the pregnancy after the diagnosis of cancer is confirmed via cervical biopsy. Suction curettage (Choice E) Repeating the β-hCG levels in 48 hours is indicated in patients with a pregnancy of undetermined location (ie, pregnancy that cannot be visualized on ultrasound at a β-hCG level below the discriminatory zone [<1,500 IU/L]). This patient has an intrauterine gestation. Educational objective: Cervical cancer can present with vaginal bleeding and a friable, exophytic cervical lesion. Diagnosis is with a biopsy of the lesion. In patients who are HIV positive, invasive cervical cancer is an AIDS-defining illness. References: Invasive carcinoma of cervix during pregnancy--a case report and review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/22482324) Gynaecological cancers in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/22325661) Malignancies in women with HIV infection. (http://www.ncbi.nlm.nih.gov/pubmed/27849632)

A 39-Year-Old Woman, Gravida 3 Para 2, at 7 Weeks