J Womens Med 2011;4(1):31-33 doi: 10.5468/jwm.2011.4.1.31 pISSN 2005-0321⋅ eISSN 2233-6222
Case Report
Cervical pregnancy with placenta accreta Jin Young Kang, MD, Hong Bae Kim, MD, PhD, and Sung Ho Park, MD Department of Obstetrics and Gynecology, Hallym University College of Medicine, Seoul, Korea
Cervical pregnancy, resulting from implantation of the blastocyst within the cervical canal, is a rare condition that could previously only be diagnosed after uncontrollable hemorrhage and hysterectomy. However, ultrasonography now permits the early diagnosis, but some limits still exist. This paper reports the case of a patient initially suspected of an inevitable abortion in the preoperative ultrasonography, but was finally diagnosed as having a cervical pregnancy with placenta accreta. If we are able to distinguish cervical pregnancy from early spontaneous abortion, we can preserve the patient’s reproductive function. Successful treatment requires not only an early diagnosis but also prompt intervention and the control of bleeding. Key words: Cervical pregnancy; Placenta accreta; Ultrasonography
Introduction Cervical pregnancy is a life threatening condition that is associated with uncontrollable hemorrhage. Placenta accreta further complicates the situation. The incidence of cervical pregnancy is approximately 1 in 16,000 pregnancies 1 and placenta accreta is even rarer (1 in 93,000 pregnancies). Until the introduction of ultrasonography, diagnosis of cervical pregnancy was difficult. It could be made only after 2 uncontrollable hemorrhage and hysterectomy. Now the use of ultrasonography permits early diagnosis of cervical pregnancy, but there are some limits still exist. Early in pregnancy, ultrasonography is unable to distinguish between the cervical canal and isthmus. Also cervical pregnancy may be confused with the cervical phase of a spontaneous abortion.
Received: 2010. 11. 22. Revised : 2011. 2. 7. Accepted: 2011. 2. 9. Corresponding author: Sung Ho Park, MD Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1 Daerim 1-dong, Yeongdeungpo-gu, Seoul 150-950, Korea Tel: +82-2-829-5163, Fax: +82-2-833-5323 E-mail:
[email protected] Copyright ⓒ 2011. Korean Society of Obstetrics and Gynecology
Appropriate early diagnosis and treatment lead to the remarkable reduction of maternal mortality. We report the case of a patient who was suspected inevitable abortion in preoperative ultrasonography, but finally diagnosed as cervical pregnancy with placenta accreta.
Case Report A 32-year-old woman visited her local obstetrics clinic complaining of continuous vaginal bleeding and mild abdominal pain. The amount of bleeding was massive, with the patient changing around 10 pads per day. Her last menstruation was over about 9 weeks previously, and her urine human chorionic gonadotropin (hCG) was positive. Given an early diagnosis of missed abortion, she was transferred our hospital for further evaluation and treatment. Her obstetric history was remarkable including one previous cesarean section, and two artificial abortions, both followed by curettage. She experienced her first menstruation at 16-years of age and her cycle was irregular, 25-30 days. An ultrasonography examination showed a mass of 6.2×4.0 cm with honeycomb appearance in the endometrium, which was connected to the cesarean section scar. There was no gestational sac like shadow in the uterus, and both adnexa were intact. Her vagina was filled with a blood clot. After evacuating the vagina, further brisk bleeding was observed from the parous os. On physical examina-
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Fig. 1. The gross specimen shows cervical pregnany with placenta accreta on cerivcal isthmic area.
tion, the abdomen was soft, and tenderness was noted above the previous operation scar. The uterus was enlarged to approximately 8-9 weeks of gestation. She was then suspected of having an inevitable abortion or cesarean section scar pregnancy. Her vital signs were stable and initial lab findings were normal including hemoglobin 11.3 g/dL, and serum beta-human chorionic gonadotropin (β-hCG) 961.3 mIU/mL. Under general anesthesia, we attempted dilatation and curettage, however she suddenly developed uncontrollable massive vaginal bleeding and hemorrhagic shock with no detectable pulse or blood pressure. We performed an emergent total abdominal hysterectomy after explained the life-threatening condition to her husband. We found that massive bleeding was emanating from the placental site. She was transfused with 5 units of packed red blood cells and 2 units of fresh frozen plasma because of intra-operative hemoglobin 7.6 g/dL. She was transferred to the intensive care unit for close observation. Post-operative hemoglobin was 10.4 g/dL, and prothrombin time (PT) 14.2 seconds, activated prothrombin time (aPTT) 24.0 seconds were checked. Post-operative β-hCG decreased to 86.1 mIU/mL. The patient made good recovery and was di scharged without complications on operation day 8. The pathology report revealed a cervical pregnancy with placenta accreta and curettage material that was the product of conception (Fig. 1).
Discussion True cervical ectopic pregnancy is a very rare form
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among ectopic pregnancies. Frates et al. reported that it accounts for approximately 0.15% of all ectopic pregnancies. The present case is even rarer in nature due to the presence of placenta accreta. Furthermore cervical pregnancy is lethal because of the likelihood of massive hemorrhage and complications at advanced gestation, often requiring a hysterectomy. This case shows both the difficulty of dianosis and management of cervical pregnancy especially when complicated by placenta accreta. The cause of cervical ectopic pregnancy is unclear. 3 Curettage, previous cesarean delivery, Asherman’s syndrome, in vitro fertilization and previous cervical or uterine 4 surgery could all be contributing factors. Our patient had one previous cesarean delivery and two artificial abortions, both by curettage. The differential diagnoses that must be considered in this condition include inevitable, incomplete, complete abortions, cervical malignancy, advanced uterine malignancy, trophoblastic tumor and degenerative cervical leiomyoma. Although the cervical ectopic pregnancy is traditionally treated by an abdominal hysterectomy, the recent trend is toward conservative therapy, which supports the preservation of reproductive function, since transvaginal ultra5,6 sonography has been used. Delayed diagnosis and surgical management of cervical ectopic pregnancy are associated with serious complications and death, because the 7 trophoblastic tissue infiltrates deep into the cervical wall. However if an accurate diagnosis is made early, the condition can be treated conservatively, resulting in fewer complications and the preservation of the reproductive function. Many methods have been used to control cervical bleeding by direct pressure, foley or Blakemore tube balloons, hemostatic or mattress sutures, hemostatic clamping of ves8 sel, packs, cervical cerclage, or an intracervical obturator. Endometrial ablation with a rollerball and injection of vasoconstrictive agents have also been used to control cervical bleeding. Abdominal methods to control bleeding include embolization of the hypogastric or uterine arteries, ligation of the hypogastric arteries, or ingection of the hypogastric arteries with vasopressin. Local injections of methotrexate and prostaglandin F2 alpha have been used to treat cervical pregnancies. Methotrexate and potassium chloride have been injected into the gestational sac to treat cervical 9 pregnancies. Modern successful treatment of cervical pregnancies usually involves more than one therapeutic approach to
Jin Young Kang, et al. Cervical pregnancy with placenta accreta
minimize risks of catastrophic bleeding and preserve reproductive function. Such measures include dilatation and curettage followed by a foley catheter balloon to compress the placental bed, embolization of the uterine or hypogastric arteries followed by dilatation and curettage, or methotrexate 9 followed by dilatation and curettage. But ultrasonography has some limits. Early in pregnancy, ultrasonography is unable to distinguish the cervical canal from isthmus. Magnetic resonance imaging may be useful in distinguishing 10 between a cervical and cervico-isthmic pregnancy if available. Cervical pregnancies may be confused with the cervical phase of a spontaneous abortion as in our case. Therefore diagnosis is made by history and clinical presentation. A high index of suspicion can save the patient.
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