Cervical pregnancy (CP) with placenta accreta, as reported in this case, is an exceedingly rare and complex clinical scenario. The rarity of CP, compounded by the presence of placenta accreta, underscores the importance of this case in the medical literature. This case contributes to the limited pool of documented cases and provides valuable insights into the diagnosis and management of such conditions.
The rarity of CP with placenta accreta necessitates a thorough understanding of its risk factors and diagnostic criteria. The etiology of CP often involves previous uterine surgeries, such as cesarean section, which can alter uterine morphology and endometrial receptivity [5]. In our case, the patient had a history of two cesarean sections and uterine fibroids, which likely contributed to the development of CP.
The diagnosis of CP is challenging, particularly in the absence of typical symptoms such as vaginal bleeding or abdominal pain. Doppler ultrasound is the primary diagnostic tool, often revealing a gestational sac within the cervical canal with rich blood flow signals [6]. However, in cases where the lesion is large or atypical, as in our patient, additional imaging modalities such as pelvic MRI can provide more detailed information on the extent and characteristics of the pregnancy [7]. In this case, MRI revealed a significantly enlarged uterus with diffuse soft tissue signals and multiple tortuous blood vessels, although it lacked some typical CP features.
Management of CP with placenta accreta requires a multidisciplinary approach. The literature suggests various treatment modalities, including conservative medical management with methotrexate, surgical interventions such as cervical cerclage, and, in severe cases, hysterectomy [8, 9]. In our patient, a total abdominal hysterectomy with bilateral salpingectomy was performed due to the extensive invasion of pregnancy tissue into the cervical myometrium and the prominent vascular networks observed intraoperatively.
The postoperative course in our patient was uneventful, with serum β-HCG levels returning to normal within one week, and no abnormalities were detected on follow-up imaging. This outcome aligns with other reports suggesting that timely surgical intervention can result in favorable outcomes even in complex cases of CP [10].
According to the literature, the diagnosis and management of CP remain complex. A study by Ishibashi et al. highlighted the predictive value of MRI in diagnosing placenta accreta in patients with posterior placenta previa, emphasizing the importance of imaging in clinical decision-making [11]. Another report by Sheiner et al. discussed the challenges in managing CP with placenta accreta, noting that early diagnosis and surgical intervention are crucial for favorable outcomes [12].
Our MDT team reviewed and reflected on this case, noting the following shortcomings in the diagnostic and treatment process:
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The MRI diagnosis lacked specificity and should be combined with the patient's history, clinical presentation, and auxiliary examinations.
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Preoperative UAE was not performed, and intraoperative attempts to ligate the internal iliac artery were hampered by the excessively enlarged lower uterine segment, making pelvic vessel identification and dissection difficult. The patient experienced 600 ml of intraoperative blood loss, which might have been better managed with preoperative UAE.
In summary, this case highlights the diagnostic and therapeutic challenges associated with CP complicated by placenta accreta. Early and accurate diagnosis facilitated by advanced imaging techniques is crucial for effective management. Surgical intervention remains a viable option in cases where conservative management is insufficient or when the patient's condition necessitates it. This case reinforces the need for heightened clinical awareness and a multidisciplinary approach to manage such rare and complex pregnancies effectively.
CP = Cervical pregnancy, EP = ectopic pregnancy, LMP = last menstrual
period: MDT = multidisciplinary team