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Publicly Available Published by De Gruyter June 3, 2017

Placenta increta complicating a second trimester cervical pregnancy: a case report

  • Nupur Tamhane EMAIL logo , Aditi Parikh and Vivek M. Joshi

Abstract

Cervical ectopic pregnancy is defined as implantation of the embryo in the endocervical canal below the level of the internal os. It is a rare condition that accounts for 0.15% of all ectopic pregnancies. As it can lead to complications such as uncontrolled hemorrhage, it is associated with high morbidity and mortality. This paper illustrates a rare case of a 2nd trimester cervical pregnancy with failed conservative management due to the limitations of ultrasonography. Successful conservative management requires not only early diagnosis but also usage of other sophisticated techniques such as magnetic resonance imaging (MRI) that can help in detecting adherent placenta.

Introduction

The association of cervical pregnancy with placenta increta is a life-threatening condition as it can lead to uncontrollable hemorrhage. Statistically, the incidence of a morbidly adherent placenta in cervical pregnancy is 1 in 93,000 pregnancies [1]. Ultrasonography (USG) is the primary tool in the diagnosis of cervical pregnancy but with limitations that can be overcome by magnetic resonance imaging (MRI) [2]. In patients with a cervical pregnancy, successful conservative management depends on early and accurate diagnosis. Conservative management options include intraamniotic methotrexate injection, local potassium chloride injection, dilatation and curettage and amputation of the cervix [3]. Failure of early detection of placental invasiveness could cause excessive and uncontrolled bleeding, leading to hysterectomy. The current case report describes a rare case of 2nd trimester cervical pregnancy with failed conservative management due to the limitations of USG to detect placenta increta, leading to hysterectomy.

Case report

A 26-year-old woman, G2P1L1, presented with complaints of per-vaginal spotting for a period of 3 weeks. She complained of 12 weeks amenorrhea and had positive urine pregnancy test. Her first pregnancy was an uneventful full-term primary lower segment cesarean section with a healthy 1-year-old female child. On admission, the patient’s vitals were stable. On per-abdominal examination, the abdomen was soft with no guarding, rigidity or tenderness. Ultrasound examination showed a ballooned cervical canal and a gestational sac with crown-rump length (CRL) measuring 50 mm (Figure 1). Fetal Cardiac activity was present. On admission, the serum β HCG level was 43,200 U. Conservative management was considered as the patient desired to retain fertility. Five doses of 1 mg/kg intramuscular methotrexate alternating with 0.1 mg/kg leucovorin were administered. A cross-matched blood bag was available in case of emergency. β HCG levels were monitored serially to a minimal decline of 38,988 U, and a repeat ultrasound showed persistent fetal cardiac activity. Furthermore, at 13 weeks, the patient had profuse vaginal bleeding with tachycardia and hypotension. The patient was then transferred to the operation room. A total abdominal hysterectomy was performed and the ovaries were preserved. Intraoperative findings showed the anterior walls of the cervix thinned out with placenta increta (Figure 2). Three units of packed cell volume and two units of fresh-frozen plasma were given intraoperatively. The bladder was adherent to the uterine wall. The bladder was dissected and pushed downwards. An abgel was placed in the abdomen. A Foley catheter was kept for 1 week. The histopathological report suggested placenta increta and cervical pregnancy (Figure 3). The patient made a good recovery and was discharged 1 week following surgery without any complications.

Figure 1: 
Ultrasound showing cerival ectopic pregnancy at 12 weeks of gestation.
Figure 1:

Ultrasound showing cerival ectopic pregnancy at 12 weeks of gestation.

Figure 2: 
Intraoperative image during hysterectomy.
Figure 2:

Intraoperative image during hysterectomy.

Figure 3: 
Cut-section of uterus showing cervical ectopic pregnancy.
Figure 3:

Cut-section of uterus showing cervical ectopic pregnancy.

Discussion

Cervical pregnancy is the rarest among ectopic pregnancies. Previous reports show that it accounts for approximately 0.15% of all ectopic pregnancies [4]. Additional factors such as placenta increta make this case unique and rare. An invasive placenta is characterized by attachment or invasion of the placenta into the wall of the uterus. Additionally, infiltration by the trophoblastic tissue occurring in the cervical canal could lead to a potential risk of catastrophic bleeding [5].

Previous cesarean section scar poses a major risk factor for morbidly adherent placenta. [6]. Our patient presented with such a risk factor. Additionally, one must consider differential diagnosis of ectopic scar pregnancy in such a case. The primary diagnostic modality used in diagnosing these conditions is ultrasound. Ultrasound can detect the presence of a gestational sac in the lower uterine segment with the presence or absence of cardiac activity. However, it can fail to detect placental invasiveness, especially in the early weeks of gestation. MRI is a better imaging tool to detect these limitations of ultrasound [2]. MRI can also diagnose and rule out the possibility of a scar pregnancy, an important differential in any similar case.

In cases of cervical pregnancy at any gestational age, one of the approaches includes conservative management [7], [8]. This aids in preserving fertility. However, failure of early and accurate diagnosis of this condition could lead to the likelihood of life-threatening complications and death.

The present case was successfully managed with prompt intervention and a multidisciplinary approach to control bleeding. The patient underwent an emergency hysterectomy as a life-saving measure. Hence, in any similar emergent situation, the presence of anesthesiologists, gynecologists and sufficient blood and blood products are necessary to reduce mortality.

Conclusions

Clinicians should have high suspicion to rule out the possibility of adherent placenta in patients with previous cesarean pregnancies. If facilities are available, MRI should be used as an additional diagnostic tool along with sonography. In addition, early and complete diagnosis is critically important for the successful management of cervical pregnancy with adherent placenta by avoiding an episode of uncontrolled bleeding.

Author’s Statement

  1. Conflict of interest: Authors state no conflict of interest.

Material and methods

  1. Informed consent: Informed consent has been obtained from all individuals included in this study.

  2. Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

References

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Received: 2017-02-26
Accepted: 2017-03-22
Published Online: 2017-06-03

©2017 Walter de Gruyter GmbH, Berlin/Boston

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