The usual presentation of cervical pregnancy is like threatened abortion in almost all cases. Clinically, the findings of a soft enlarged cervix with open external os which usually results in profuse vaginal bleeding when manipulated during examination and may need an emergency hysterectomy [1, 3]. However, these signs are not always diagnostic, and imaging is essential to confirm the diagnosis if cervical pregnancy is suspected. Radiologically, one needs to differentiate between a cervical pregnancy, cervical abortion, and early intrauterine pregnancy. As proposed by Raskin  there are 4 criteria by ultrasound for diagnosing cervical pregnancy: cervix and enlargement of the uterus, diffuse intrauterine echoes, and absence of intrauterine pregnancy. This was followed by more stringent criteria by Timor-Tritsch et al : the placenta and entire chorionic sac containing the live pregnancy must be below the internal os and cervical canal must be dilated and barrel-shaped. The role of color doppler for the demonstration of peri-trophoblastic blood flow remains controversial. Routine use of magnetic resonance imaging does not improve the diagnostic benefit. The causes of cervical pregnancy remain elusive, but instrumentation and manipulation of the endocervical canal, intrauterine device insertion, di-ethyl stilbesterol (DES) exposure, in-vitro fertilization (IVF) conception  have been commonly cited. Although in a study , the authors have reported that only 4% of cervical pregnancies were a consequence of IVF while the majority (96%) were because of spontaneous conception, as was in our patient also who had spontaneous cervical pregnancy thrice, though she had predisposing risk factor as well such as repeated cervical dilatation and curettage. Serum beta hCG as high as 1,28,700 IU, with fetal cardiac activity is found in 80% cases. Day 1 Beta hCG of our patient was 1,31,438 IU.
Currently, there are no clear treatment protocols for this entity. Management of this rare but potentially life-threatening complication is usually a combination of systemic therapy with MTX alone or injecting potassium chloride (KCL) locally. As it occurs in relatively young women, the uterine preserving mode of treatment is the preferred one compared to the traditional teaching of total abdominal hysterectomy . Non-surgical management with MTX has now become an effective alternative . Early diagnosis is crucial for the management of cervical pregnancy to preserve fertility. Surgical evacuation with tamponade has a success rate of 62.5% but is associated with blood loss. Procedures to reduce hemorrhage include ligation of cervical branches of uterine arteries – as was done for previous cervical pregnancy in the index case, or uterine artery ligation or embolization, as was also done in our patient in the present pregnancy. Although Mitrani , Pisarski  have reported live births in cervical pregnancy, but hysterectomy was done for control of bleeding. Hysterectomy leads to loss of future reproductive potential. Hysterectomy may be considered if the patient does not desire fertility, has intractable hemorrhage or gestational age is > 12 weeks .
Fertility preserving options consists of use of systemic MTX, Injection KCl into fetal heart with USG alone, or, in combination with UAE to decrease risk of bleeding. MTX alone or combined with KCl was successfully used by the authors for the management of cervical pregnancies [2, 10]. Intracardiac injection of feticidal agents under ultrasound- guidance may be considered superior maternal chemotherapeutic agents alone . Similarly for control of hemorrhage, irrigation of uterine cavity with 3.5% H2O2 through transcervical foley’s catheter followed by successful hysteroscopic removal of cervical gestation has also been described . Bilateral uterine artery ligation laparoscopically combined with intraamniotic MTX helps reduce the blood loss and therefore preserve fertility . Another fertility preserving option for early gestation cervical pregnancy described is uterine artery embolization before dilation and curettage.Non-surgical management should be undertaken only after informed written consent in the settings where advanced medical facilities for resuscitation and emergency surgery are available.
In our patient, a viable fetus of 8 weeks gestation was noticed in the cervical canal on ultrasonography which looked ballooned out on speculum examination. The uterine cavity was empty which differentiated this condition from a miscarriage in the process of expulsion. Three-dimensional ultrasonography may aid in confirming the diagnosis  Spontaneous recurring cervical pregnancy is even rare, with two case reports only with a mean gestational age of 7.5 weeks at diagnosis, bleeding as the chief presenting feature in 80%, as was seen in our patient also, but with a higher Beta hCG value. Previous curettage and previous cesarean delivery were the commonly identified risk factors, both of which were also present in our patient .
In another case report of recurrent cervical pregnancy, cervical pregnancy was erroneously diagnosed as a spontaneous abortion, for completion of which curettage led to brisk hemorrhage. The clinical diagnosis of cervical pregnancy was made. Cervical and vaginal packing for local pressure had to be resorted to for control of bleeding. Pressure tamponade with locally inflated foley’s balloon tamponade was shown to be the most effective local treatment for hemorrhage as was done in second consecutive cervical pregnancy , while the first cervical pregnancy, in the same patient was successfully treated with MTX and UAE. Both these treatment modalities were also found to be of help in our patient in our patient.