A 38-year-old woman at 6 weeks gestation comes to the office due to vaginal bleeding. The patient has had intermittent bleeding for the past week, which increases after intercourse. She has had no pelvic pain, nausea, or vomiting. Blood pressure is 124/68 mm Hg and pulse is 86/min. The abdomen is soft and nontender, without rebound or guarding. On pelvic examination, there is dark brown discharge pooling in the posterior vaginal vault. The cervix is closed, and there is a raised cervical mass that bleeds freely when manipulated with a swab. Ultrasound reveals a yolk sac and a 6-week intrauterine fetal pole with cardiac motion. Blood type is O, Rh positive. Which of the following is the best next step in management of this patient?

Question

A 38-year-old woman at 6 weeks gestation comes to the office due to vaginal bleeding.  The patient has had intermittent bleeding for the past week, which increases after intercourse.  She has had no pelvic pain, nausea, or vomiting.  Blood pressure is 124/68 mm Hg and pulse is 86/min.  The abdomen is soft and nontender, without rebound or guarding.  On pelvic examination, there is dark brown discharge pooling in the posterior vaginal vault.  The cervix is closed, and there is a raised cervical mass that bleeds freely when manipulated with a swab.  Ultrasound reveals a yolk sac and a 6-week intrauterine fetal pole with cardiac motion.  Blood type is O, Rh positive.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d98f_8111_bc81_bb34c1101148_MD0003_00 This patient's irregular vaginal bleeding and cervical mass are classic for invasive cervical cancer, which typically presents in patients who have not had routine Pap test screening. Other risk factors include immunosuppression, tobacco use, and multiple sexual partners. Although cervical cancer can be asymptomatic, patients typically have vaginal bleeding, particularly after intercourse (eg, postcoital) due to trauma to the cervix. Pregnancy, which increases pelvic vascularity, may increase the risk of bleeding from a cervical mass. On examination, patients typically have cervical friability (eg, bleeding with manipulation) and a raised, exophytic mass, as seen in this patient. Other features may include ulcerative lesions (due to tissue necrosis) and watery, mucoid vaginal discharge. Cervical lesions suspicious for cancer require cervical biopsy, which can be performed safely during pregnancy. Patients with cervical cancer who are pregnant (such as this patient) require specialized oncology and obstetric management, and any diagnostic delay can increase the risk of cancer progression. (Choice A) Ceftriaxone and azithromycin are empiric treatment for acute cervicitis, which can present with postcoital bleeding. However, cervicitis typically causes mucopurulent discharge, a finding not seen in this patient, and is not associated with a cervical mass. acute cervicitis (Choice C) Endometrial biopsy may be indicated in certain patients with abnormal uterine, not cervical, bleeding to exclude endometrial cancer. However, it is not performed in pregnancy due to the risk of pregnancy loss. Given her friable cervical mass with intermittent/postcoital vaginal bleeding consistent with cervical cancer, this patient should undergo cervical biopsy. Endometrial biopsy (Choice D) Expectant management is indicated for first-trimester bleeding due to threatened abortion (eg, vaginal bleeding). Although this patient has a viable intrauterine pregnancy (eg, yolk sac, intrauterine fetal pole with cardiac motion), her cervical lesion requires further evaluation. (Choice E) Kleihauer-Betke testing is required in Rh-negative patients with heavy vaginal bleeding during pregnancy to evaluate for fetomaternal hemorrhage that can lead to Rh-alloimmunization; prevention is with anti-D immunoglobulin (ie, RhoGAM). This patient is Rh-positive. Kleihauer-Betke testing Rh-alloimmunization (Choice F) Quantitative β-hCG levels are measured to evaluate for ectopic pregnancy. Once an intrauterine pregnancy with cardiac motion is identified, β-hCG levels do not change management and therefore are not measured. Educational objective: Cervical cancer typically presents with irregular vaginal bleeding (eg, postcoital) and a friable, exophytic cervical mass. Suspicious cervical lesions require biopsy, which is typically safe during pregnancy. References: Diagnosis and treatment of cervical cancer in pregnant women. (http://www.ncbi.nlm.nih.gov/pubmed/31385452) Management of cervical cancer during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26467977)

A 38-Year-Old Woman at 6 Weeks Gestation Comes to the Office