{"paper_id":"b44d5c1f-755f-4e74-ab55-ec7d4cef2408","body_text":"Journal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 75–78. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):75–78. \nwww.ijcriog.com\nZayat et al. 75\nCASE REPORT  OPEN ACCESS  \nCervical endometriosis in pregnancy: A rare cause of  \nbleeding in pregnancy\nNawras Zayat, Ariane M Chabanne, Ishola Adeyemo\nABSTRACT\nIntroduction: Cervical endometriosis is a very rare site \nfor endometriosis, with a reported incidence of 0.11–\n2.4%.\nCase Report: We present a histologically proven case of \ncervical endometriosis in a 33-year-old pregnant woman \nwho presented with post-coital bleeding during the first \ntrimester of her pregnancy, with subsequent spontaneous \nregression, and successful vaginal delivery.\nConclusion: This case emphasizes the importance of a \nthorough pelvic examination in patients presenting with \nbleeding in early pregnancy and biopsy of any lesions \nas long as it is safe. Cervical endometriosis should be \nadded to the list of differential diagnoses of bleeding \nin pregnancy after the more common causes have been \nexcluded.\nKeywords: Cervical endometriosis, Cervical mass, Preg-\nnancy, Vaginal bleeding\nHow to cite this article\nZayat N, Chabanne AM, Adeyemo I. Cervical \nendometriosis in pregnancy: A rare cause of bleeding \nin pregnancy. J Case Rep Images Obstet Gynecol \n2023;9(1):75–78.\nNawras Zayat 1, Ariane M Chabanne 2, Ishola Adeyemo 1\nAffiliations: 1Department of Obstetrics and Gynecology, State \nUniversity of New York, Downstate Health Sciences Universi-\nty, Brooklyn, New York, USA; 2St. George’s University School \nof Medicine, West Indies, Grenada.\nCorresponding Author: Nawras Zayat, MD, Department of \nObstetrics and Gynecology, State University of New York, \nDownstate Health Sciences University, 450 Clarkson Avenue, \nBrooklyn, NY 11203, USA; Email Address: Nawras2mk@out-\nlook.com\nReceived: 09 April 2023\nAccepted: 19 May 2023\nPublished: 07 June 2023\nArticle ID: 100151Z08NZ2023\n*********\ndoi: 10.5348/100151Z08NZ2023CR\nINTRODUCTION\nEndometriosis is one of the most common benign \ngynecological conditions and occurs in approximately \n15% of women of reproductive age [1]. Cervical \nendometriosis is a very rare site for endometriosis, \nwith a reported incidence of 0.11–2.4% [1, 2]. Its rarity \nmay be due to the limited awareness of the clinical \nappearance of the disease [2]. Cervical endometriosis has \nbeen reported to be related to previous cervical injuries, \nfor example, conization and pregnancy. Some cases, \nhowever, do not have any identifiable cause [1]. Although \nit is usually asymptomatic and diagnosed retrospectively \nin histopathologic reports, it can rarely present with \ngynecological symptoms such as hemorrhage, post-\ncoital bleeding, irregular intermenstrual bleeding, and \neven life-threatening hemorrhage [1, 3–5]. Cervical \nendometriosis has been defined in two histopathological \nforms, superficial and deep [1]. Superficial cervical \nendometriosis involves the cervical stroma adjacent to the \nepithelium [1]. Deep cervical endometriosis involves the \nouter third of the cervical wall, the recto-vaginal septum \nor serosal surface of the supra-vaginal portion of the \ncervix [1]. Massive hemorrhage has been reported in rare \ncases and malignancy of deep infiltrating endometriosis \nhas also been remissive [1, 6].\nCASE REPORT\nWe report a case of a 33-year-old para 1021 who \npresented for her initial prenatal visit at a gestational age \nof 12 weeks and six days. She was initially evaluated by \na midwife, who then called the obstetrician due to the \nfinding of significant bleeding from a mass in the vagina \nduring the speculum exam. The patient admitted a history \nCASE REPORT  PEER REVIEWED | OPEN ACCESS \n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 75–78. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):75–78. \nwww.ijcriog.com\nZayat et al. 76\nof frequent post-coital bleeding since the beginning of the \npregnancy. However, she denied any post-coital bleeding \nprior to pregnancy, dysmenorrhea, or dyspareunia. \nOn evaluation, there was 6 cm × 5 cm soft, friable mass \nprotruding from the cervical os, which completely occluded \nit (Figure 1). The majority of the cervix was not visible. No \nother lesions were seen. Due to significant bleeding from \nthe mass, vaginal packing was done and the gynecologic \noncologist was consulted who arrived within minutes. The \npacking was removed, and the bleeding subsided slightly. \nAfter obtaining consent from the patient, biopsies were \nperformed, after which Monsel solution (Ferric subsulfate \nsolution, a hemostatic agent) was applied for hemostasis. \nThe patient was observed for an hour and was discharged \nwhen the bleeding subsided significantly. The patient \nwas advised against sexual intercourse. Pathological \nexamination of the biopsy revealed endometriosis. She \nwas informed of the diagnosis and was advised that further \nmanagement, including possible surgical excision, might \nbe necessary if significant bleeding recurred.\nThe patient continued to report recurrent vaginal \nspotting until about 20 weeks gestation. After 20 weeks \ngestation, the patient reported no further episodes of \nvaginal bleeding. Subsequent speculum examination \nrevealed a significant regression of the mass, more of the \ncervix was visible, and the mass became restricted to the \nright side of the cervix. There was no bleeding with the \nspeculum exams.\nThe patient presented twice to the labor and delivery \ntriage at 33- and 36-weeks’ gestation with complaints \nof uterine contractions. Gentle vaginal exams were \ndone to determine cervical dilatation and there was no \nbleeding associated with the pelvic exam. The patient \nwas discharged on both occasions with recommendations \nto abstain from having sexual intercourse, avoid putting \nanything deep in the vagina, and restricting any heavy \nexercises that may strain the pelvic floor. The Maternal-\nFetal Medicine specialist was consulted and advised that \nthe patient could attempt a vaginal delivery. The patient \npresented in spontaneous labor at 39 weeks’ gestation and \nhad a successful vaginal delivery with no bleeding from the \nmass.\nDuring a 6-week postpartum visit, the patient reported \nfeeling well and had returned to her daily activities. The \npelvic examination revealed complete resolution of the \nendometriosis.\nDISCUSSION\nCervical endometriosis causing bleeding is very \nrarely documented in pregnancy. An extensive literature \nsearch yielded no case reports. The majority of cervical \nendometriosis are bluish, bluish-black, or red nodules \nthat are 0.2–1.5 cm lesions [1]. Other findings include \npolyploid lesions, e.g., cystic red masses of 3–6 cm in \nsize, which was the presentation in our case, myoma-like \nmasses of about 4 cm, or retrocervical masses [6, 7]. In \n2020, Ayala et al. reported a case of a pregnant patient \nat 13 weeks’ gestation who presented with disabling \npain at 13 weeks gestation [8]. She was diagnosed with a \nlarge, rapidly growing retrocervical endometriosis nodule \nencompassing a uterine artery pseudo-aneurysm [8]. \nFrederic Richard et al. also reported a case of a 32-year-\nold woman with suspected malignant deep infiltrating \nendometriosis fistulized to the cervix, who became \npregnant while being worked up for radical hysterectomy \n[9]. However, she did not present with any bleeding. That \npatient had a cesarean delivery at 34 weeks followed by full \nexamination and biopsies which revealed endometriosis \nwithout malignancy [9]. Although our patient did well with \nconservative management and spontaneous shrinkage of \nthe cervical mass, allowing for a vaginal delivery, massive \nhemorrhage could potentially require termination of the \npregnancy and even hysterectomy.\nCONCLUSION\nCervical endometriosis as a cause of bleeding in \npregnancy is extremely rare. This case underscores the \nimportance of a thorough pelvic examination in patients \npresenting with bleeding in early pregnancy and biopsy \nof any lesions as long as it is safe. Persistent symptomatic \ncervical endometriosis could potentially preclude vaginal \ndelivery. Clinicians should add cervical endometriosis to \ntheir differential diagnoses of bleeding in pregnancy once \nthe more common causes have been ruled out.\nFigure 1: Speculum pelvic examination showing a large cervical \nmass in a pregnant patient with cervical endometriosis.\n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 75–78. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):75–78. \nwww.ijcriog.com\nZayat et al. 77\nREFERENCES\n1. Seval MM, Cavkaytar S, Atak Z, Guresci S. Postcoital \nbleeding due to cervical endometriosis. BMJ Case Rep \n2013;2013:bcr2012008209.\n2. Ata B, Ates U, Usta T, Attar E. Cervical endometriosis, a \ncase presenting with intractable spotting. MedGenMed \n2005;7(2):64.\n3. Phadnis SV, Doshi JS, Ogunnaike O, Coady A, Padwick \nM, Sanusi FA. Cervical endometriosis: A diagnostic \nand management dilemma. Arch Gynecol Obstet \n2005;272(4):289–93.\n4. Wong FWS, Lim CED, Karia S, Santos L. Cervical \nendometriosis: Case series and review of literature. J \nObstet Gynaecol Res 2010;36(4):916–19.\n5. Selo-Ojeme D, Freeman-Wang T, Khan NH. Post-coital \nbleeding: A rare and unusual presentation of cervical \nendometriosis. Arch Gynecol Obstet 2006;273(6):370–\n3.\n6. Matoba Y, Tsuji K, Morisada T, et al. Massive \nhemorrhage due to cervical endometriotic cyst rupture: \nTwo case reports and a literature review. Am J Case \nRep 2021;22:e934120.\n7. Wang S, Li XC, Lang JH. Cervical endometriosis: \nClinical character and management experience in a 27-\nyear span. Am J Obstet Gynecol 2011;205(5):452.e1-5.\n8. Zilberman A, Eisenberg V, Yoeli R, et al. Uterine \nartery pseudoaneurysm in a pregnant patient with \nretrocervical endometriosis. J Minim Invasive Gynecol \n2020;27(5):1209–13.\n9. Richard F, Canlorbe G, Bazot M, Daraï E. Management \nof pregnancy in woman with suspected malignant \ndeep infiltrating endometriosis fistulised to the uterine \ncervix. BMJ Case Rep 2014;2014:bcr2014204978.\n*********\nAcknowledgments\nWe would like to acknowledge and thank the patient who \ngraciously allowed us to share her story in this article so \nthat it may inform future obstetrical and gynecologic care.\nAuthor Contributions\nNawras Zayat – Conception of the work, Design of the \nwork, Acquisition of data, Analysis of data, Interpretation \nof data, Drafting the work, Revising the work critically \nfor important intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nAriane M Chabanne – Conception of the work, Design of \nthe work, Drafting the work, Final approval of the version \nto be published, Agree to be accountable for all aspects of \nthe work in ensuring that questions related to the accuracy \nor integrity of any part of the work are appropriately \ninvestigated and resolved\nIshola Adeyemo – Conception of the work, Design of the \nwork, Acquisition of data, Interpretation of data, Drafting \nthe work, Final approval of the version to be published, \nAgree to be accountable for all aspects of the work in \nensuring that questions related to the accuracy or integrity \nof any part of the work are appropriately investigated and \nresolved\nGuarantor of Submission\nThe corresponding author is the guarantor of submission.\nSource of Support\nNone.\nConsent Statement\nWritten informed consent was obtained from the patient \nfor publication of this article.\nConflict of Interest\nAuthors declare no conflict of interest.\nData Availability\nAll relevant data are within the paper and its Supporting \nInformation files.\nCopyright\n© 2023 Nawras Zayat et al. This article is distributed under \nthe terms of Creative Commons Attribution License which \npermits unrestricted use, distribution and reproduction in \nany medium provided the original author(s) and original \npublisher are properly credited. Please see the copyright \npolicy on the journal website for more information.\nABOUT THE AUTHOR\nArticle citation:  Zayat N, Chabanne AM, Adeyemo I. Cervical endometriosis in pregnancy: A rare cause of \nbleeding in pregnancy. J Case Rep Images Obstet Gynecol 2023;9(1):75–78.\nNawras Zayat is a resident physician in obstetrics and gynecology at State University of New York \nDownstate. He is currently in his last year of residency and plans on pursuing a maternal fetal medicine \nfellowship at Montefiore Medical Center/Albert Einstein College of Medicine. His primary research \ninterests include women’s health, preterm birth, and infectious diseases in pregnancy.\nEmail: Nawras2mk@outlook.com\n\n\nJournal of Case Reports and Images in Obstetrics and Gynecology, Volume 9, Issue 1, 2023; Pages 75–78. ISSN: 2582-0249\nJ Case Rep Images Obstet Gynecol 2023;9(1):75–78. \nwww.ijcriog.com\nZayat et al. 78\nAccess full text article on\nother devices\nAccess PDF of article on\nother devices\n\nSubmit your manuscripts at\nwww.edoriumjournals.com","source_license":"CC0","license_restricted":false}