Diagnosis and Management of Cervical Pregnancy with Placental Implantation: A Case Report and Literature Review

Diagnosis and Management of Cervical Pregnancy with Placental Implantation: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Diagnosis and Management of Cervical Pregnancy with Placental Implantation: A Case Report and Literature Review Fengqing Lv, Jingyi Zhang, Xiaojie Zou, Yiyun Bai, Dan Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4657775/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Cervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) that occurs in the cervical canal. Diagnosis and treatment are particularly challenging when the lesion is large and presents without typical symptoms. We report a case of a 16+-week CP patient with placenta accreta. Case Presentation: A 39-year-old woman presented with amenorrhea for four months but no associated symptoms. Doppler ultrasound revealed an enlarged uterus and a mixed echogenic mass in the lower uterine segment extending to the cervix, accompanied by rich blood flow signals. His serum β-HCG concentration was 576.68 mIU/ml. Following multidisciplinary evaluation, exploratory laparotomy under general anesthesia revealed a significantly enlarged cervix with prominent vascular networks. The patient underwent total abdominal hysterectomy with bilateral salpingectomy, with an intraoperative blood loss of 600 ml. Pathological examination confirmed the presence of placental villi in the cervix, consistent with CP. Postoperative recovery was uneventful, with serum β-HCG levels normalizing within a week, and no abnormalities were detected in follow-up assessments over six months. Conclusion This case underscores the diagnostic and therapeutic complexities associated with CP, especially when patients present with large lesions and atypical symptoms. Comprehensive clinical history, imaging findings, and serum HCG levels are crucial for accurate diagnosis and effective clinical decision-making. The successful management of this case highlights the importance of a multidisciplinary approach in addressing such rare and challenging conditions. CP Placenta accreta Ectopic pregnancy Case report Figures Figure 1 Figure 2 Figure 3 Introduction Cervical pregnancy (CP) is an exceedingly rare form of ectopic pregnancy characterized by the implantation of a fertilized egg within the cervical canal below the internal os. The incidence of CP ranges from approximately 1 in 1,000 to 1 in 18,000 pregnancies, making it a significant clinical challenge [ 1 ]. The etiology of CP is often associated with previous uterine surgery, which may lead to alterations in uterine morphology and endometrial receptivity. The composition of the cervix, primarily fibrous connective tissue with minimal smooth muscle fibers, predisposes it to severe hemorrhage when a pregnancy occurs in this location. Rapid and profuse bleeding can result in hemorrhagic shock and even death, underscoring the importance of early detection and effective clinical management to prevent fatal outcomes [ 2 ]. Diagnosing CP is notoriously difficult due to its nonspecific clinical presentation, particularly in the early stages when symptoms are often absent. Doppler ultrasound is a useful diagnostic tool, but its features can be nonspecific, especially in advanced patients with large lesions. Consequently, CP is frequently misdiagnosed as a threatened abortion [ 3 ]. Rapid and severe vaginal bleeding should prompt clinicians to consider CP as a differential diagnosis. Current treatment modalities for CP include both surgical and medical interventions, yet there are no universally accepted guidelines, complicating the clinical decision-making process [ 4 ]. This report presents a case of a 16 + week CP with placenta accreta, an exceptionally rare condition. The patient, a 39-year-old woman, presented with amenorrhea for four months but no other symptoms. This case highlights the diagnostic challenges and complexities involved in managing CPs with large lesions and atypical presentations. Given the rarity and potential severity of this condition, our case report aims to contribute valuable insights for clinicians in diagnosing and managing similar cases. The patient provided informed consent, and the study was approved by the Ethics Committee of Ningxia Medical University General Hospital (Approval number: KYLL-2024-0752). Case Presentation A 39-year-old woman, G3P2 (with two previous cesarean sections), presented with amenorrhea for four months. Her menstrual history was irregular, with cycles of 40–50 days, and her last menstrual period (LMP) was September 25, 2023. She had no pregnancy-related gastrointestinal symptoms, abdominal pain, or vaginal bleeding. Pelvic examination revealed a smooth, enlarged cervix with a normal mucosal color and an enlarged uterus equivalent to a 4 + month pregnancy with a distended lower segment. Laboratory tests, including complete blood count (HGB 144 g/L), coagulation profile, and liver and kidney function tests, were normal. Special tests revealed a serum β-HCG concentration of 576.68 mIU/ml. Ultrasound revealed a 9.8 x 7.4 cm mixed echogenic mass in the lower uterine segment, partially invading the anterior and posterior uterine wall myometrium, with a 4.5 x 2.1 cm area resembling a gestational sac and rich blood flow signals within the myometrium (Fig. 1 ). Enhanced pelvic MR image indicated a significantly enlarged uterus with diffuse soft tissue beneath the endometrium and multiple tortuous blood vessels between the lesion and myometrium (Fig. 2 ). After multidisciplinary team (MDT) discussion, the most likely diagnosis was a retained placenta with accreta, but a trophoblastic tumor could not be ruled out. The patient and her family were fully informed of the treatment options. After completing the preoperative preparations and ensuring sufficient blood supply, an exploratory laparotomy was performed on February 6, 2024. During surgery, dense pelvic adhesions were noted. After adhesiolysis, a gourd-shaped enlarged uterus with a significantly distended lower segment extending to the vaginal part was observed, with prominent vascular networks on both sides of the uterus and the lower segment. The bladder peritoneum was incised, revealing a bulging cervix with rich vascularization and congested bladder mucosa with unclear anatomical structures. Total hysterectomy with bilateral salpingectomy was performed successfully, with 600 ml of blood lost. Examination of the excised uterus revealed an empty uterine cavity, a cystic lesion resembling a gestational sac within the cervical canal, and no formed fetus, with pregnancy tissue invading the cervical myometrium (Fig. 3 , left). Postoperative pathology confirmed that the placental villi in the cervix were consistent with those in the CP (Fig. 3 , right). Her serum β-HCG concentration was 51.57 mIU/ml on the first postoperative day and decreased to 3.340 mIU/ml (< 5 mIU/ml) on the seventh postoperative day. Follow-up Doppler, chest X-ray, and serum HCG within six months showed no abnormalities. Discussion 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: The MRI diagnosis lacked specificity and should be combined with the patient's history, clinical presentation, and auxiliary examinations. 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 Declarations Ethics approval and consent to participate The patient provided informed consent, and the study was approved by the Ethics Committee of Ningxia Medical University General Hospital (Approval number: KYLL-2024-0752). Consent for publication All the authors listed have approved the enclosed manuscript. Availability of data and material The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing Interests The authors declare that no competing interests exist. Funding Not applicable for that section. Authors' contributions LFQ collected basic information from the patient and image data and wrote the main content of the manuscript; ZJY, ZXJ, and BYY performed the clinical work and follow-up; and LD promptly discovered the first case of cervical pregnancy, revised the language of the manuscript and helped write it. Acknowledgments The authors thank all members of the Liu Dan team from Ningxia Medical University General Hospital for their assistance in our work. Ethics approval and consent to participate The Ethics Committee of Ningxia Medical University General Hospital approved the study with the Ethics Approval number: KYLL-2024-0752. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. All authors contributed equally to the study. References Ishibashi H, Miyamoto M, Shinnmoto H, et al. Cervical varicosities may predict placenta accreta in posterior placenta previa: a magnetic resonance imaging study. Arch Gynecol Obstet. 2017;296(4):731-736. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/28710549/) Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006;107(4):927-941. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/16582134/) Altraigey A, Ellaithy M, Barakat E, et al. Cervical length should be measured for women with placenta previa: cohort study. J Matern Fetal Neonatal Med. 2021;34(13):2124-2131. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/31434519/) Vintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. Am J Obstet Gynecol. 2015;213(4 Suppl):S70-77. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/26428505/) Leeman LM, Wendland CL. Cervical ectopic pregnancy. Diagnosis with endovaginal ultrasound examination and successful treatment with methotrexate. Arch Fam Med. 2000;9(1):72-7. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/10664646/) Yoshimatsu K, Sekiya T, Ishihara K, et al. Detection of the cervical gland area in threatened preterm labor using transvaginal sonography in the assessment of cervical maturation and the outcome of pregnancy. Gynecol Obstet Invest. 2002;53(3):149-56. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/12053099/) Hiersch L, Rosen H, Okby R, et al. The greater risk of preterm birth in triplets is mirrored by a more rapid cervical shortening along gestation. Am J Obstet Gynecol. 2016;215(3):357.e1-6. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/26996985/) Prorocic M, Vasiljevic M. Treatment of heterotopic cervical pregnancy after in vitro fertilization-embryo transfer by using transvaginal ultrasound-guided aspiration and instillation of hypertonic solution of sodium chloride. Fertil Steril. 2007;88(4):969.e3-5. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/17412333/) Sheng S, Zhang H, Pan Z, et al. Treatment of heterotopic cervical pregnancy by ultrasound-guided hysteroscopy: A case report and literature review. Medicine (Baltimore). 2022;101(48):e32177. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/36482618/) Starita A, Di Miscia A, Evangelista S, et al. Cervical ectopic pregnancy: clinical review. Clin Exp Obstet Gynecol. 2006;33(1):47-9. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/16761540/) Auger N, Marcoux S, Paradis G, et al. Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study. Arch Gynecol Obstet. 2021;304(4):943-950. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/33817754/) Vintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. Am J Obstet Gynecol. 2015;213(4 Suppl):S70-77. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/26428505/) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4657775","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":335860639,"identity":"349cceef-677b-4fd2-a28b-8ebd024b1ac8","order_by":0,"name":"Fengqing Lv","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fengqing","middleName":"","lastName":"Lv","suffix":""},{"id":335860640,"identity":"9aeeb813-e13f-4f9b-931b-42fb543b7df0","order_by":1,"name":"Jingyi Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACNvbmAwc+/pHgYWxvPvggoaKGsBY+nmOJD2c2WMgx9xxLNnhw5hhhLXISOcbGvA0VxuwzfMwkH7YwE+EwngNm0rw7JBJ7Z/CYVSQ2sDHwt3cnEPBLQ5rk3DMSiTNnt5XdSNwhwyBx5uwGQrYck3jDJpG4cc7hbTcSz7AxGEjkEtAikdgmwQMk999IMCtIbGMmRksysyFvm4Qx44wUMwbitPAcY3w444yEHCMwkCUSzhzjIegX+fb+Dwc+VNSBo/Ljj4oaOf72XvxaMAAPacpHwSgYBaNgFGAFADruTxu6k0seAAAAAElFTkSuQmCC","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jingyi","middleName":"","lastName":"Zhang","suffix":""},{"id":335860641,"identity":"53d87d9e-c0fd-4401-96fc-6e616998f39d","order_by":2,"name":"Xiaojie Zou","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaojie","middleName":"","lastName":"Zou","suffix":""},{"id":335860642,"identity":"b68b23de-b1ca-4512-b734-07708a1675a3","order_by":3,"name":"Yiyun Bai","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yiyun","middleName":"","lastName":"Bai","suffix":""},{"id":335860643,"identity":"1b11a5b5-1351-4d38-a652-4c299d71c2ae","order_by":4,"name":"Dan Liu","email":"","orcid":"","institution":"General Hospital of Ningxia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-06-29 06:14:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4657775/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4657775/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62216804,"identity":"27437cc9-50ce-453b-94fd-6c5d7844a379","added_by":"auto","created_at":"2024-08-11 11:47:58","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":365911,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound Image of CP with Placenta Accreta\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4657775/v1/7d766f144a98a43f21fa4ac7.jpeg"},{"id":62216803,"identity":"e851966e-5745-4948-9d63-61189755081c","added_by":"auto","created_at":"2024-08-11 11:47:58","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":471871,"visible":true,"origin":"","legend":"\u003cp\u003ePelvic MR image of the CP with placenta accreta. Sagittal view (left) and axial view (right) T2WI showing an abnormal echogenic mass protruding from the cervix into the lower uterine segment with rich parametrium vascularity\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4657775/v1/654b0d8015446d8863ef793b.jpeg"},{"id":62217719,"identity":"fa60ab08-30b7-495c-8865-8f502d4faf91","added_by":"auto","created_at":"2024-08-11 11:55:58","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":827996,"visible":true,"origin":"","legend":"\u003cp\u003eCP with placenta accreta. (Left) Gross specimen. (Right) Pathology (the arrows show the myometrium, villi, and placenta).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4657775/v1/d6031833e7f62dab6b5902d7.jpeg"},{"id":67879514,"identity":"e5625853-d325-4f22-a61e-a3791f37a6ff","added_by":"auto","created_at":"2024-10-30 16:47:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1922394,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4657775/v1/5b34bf15-e833-49ca-aba2-0ba56d964bee.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnosis and Management of Cervical Pregnancy with Placental Implantation: A Case Report and Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical pregnancy (CP) is an exceedingly rare form of ectopic pregnancy characterized by the implantation of a fertilized egg within the cervical canal below the internal os. The incidence of CP ranges from approximately 1 in 1,000 to 1 in 18,000 pregnancies, making it a significant clinical challenge [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The etiology of CP is often associated with previous uterine surgery, which may lead to alterations in uterine morphology and endometrial receptivity. The composition of the cervix, primarily fibrous connective tissue with minimal smooth muscle fibers, predisposes it to severe hemorrhage when a pregnancy occurs in this location. Rapid and profuse bleeding can result in hemorrhagic shock and even death, underscoring the importance of early detection and effective clinical management to prevent fatal outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiagnosing CP is notoriously difficult due to its nonspecific clinical presentation, particularly in the early stages when symptoms are often absent. Doppler ultrasound is a useful diagnostic tool, but its features can be nonspecific, especially in advanced patients with large lesions. Consequently, CP is frequently misdiagnosed as a threatened abortion [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Rapid and severe vaginal bleeding should prompt clinicians to consider CP as a differential diagnosis. Current treatment modalities for CP include both surgical and medical interventions, yet there are no universally accepted guidelines, complicating the clinical decision-making process [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis report presents a case of a 16\u0026thinsp;+\u0026thinsp;week CP with placenta accreta, an exceptionally rare condition. The patient, a 39-year-old woman, presented with amenorrhea for four months but no other symptoms. This case highlights the diagnostic challenges and complexities involved in managing CPs with large lesions and atypical presentations. Given the rarity and potential severity of this condition, our case report aims to contribute valuable insights for clinicians in diagnosing and managing similar cases. The patient provided informed consent, and the study was approved by the Ethics Committee of Ningxia Medical University General Hospital (Approval number: KYLL-2024-0752).\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 39-year-old woman, G3P2 (with two previous cesarean sections), presented with amenorrhea for four months. Her menstrual history was irregular, with cycles of 40\u0026ndash;50 days, and her last menstrual period (LMP) was September 25, 2023. She had no pregnancy-related gastrointestinal symptoms, abdominal pain, or vaginal bleeding. Pelvic examination revealed a smooth, enlarged cervix with a normal mucosal color and an enlarged uterus equivalent to a 4\u0026thinsp;+\u0026thinsp;month pregnancy with a distended lower segment. Laboratory tests, including complete blood count (HGB 144 g/L), coagulation profile, and liver and kidney function tests, were normal. Special tests revealed a serum β-HCG concentration of 576.68 mIU/ml. Ultrasound revealed a 9.8 x 7.4 cm mixed echogenic mass in the lower uterine segment, partially invading the anterior and posterior uterine wall myometrium, with a 4.5 x 2.1 cm area resembling a gestational sac and rich blood flow signals within the myometrium (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Enhanced pelvic MR image indicated a significantly enlarged uterus with diffuse soft tissue beneath the endometrium and multiple tortuous blood vessels between the lesion and myometrium (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter multidisciplinary team (MDT) discussion, the most likely diagnosis was a retained placenta with accreta, but a trophoblastic tumor could not be ruled out. The patient and her family were fully informed of the treatment options. After completing the preoperative preparations and ensuring sufficient blood supply, an exploratory laparotomy was performed on February 6, 2024. During surgery, dense pelvic adhesions were noted. After adhesiolysis, a gourd-shaped enlarged uterus with a significantly distended lower segment extending to the vaginal part was observed, with prominent vascular networks on both sides of the uterus and the lower segment. The bladder peritoneum was incised, revealing a bulging cervix with rich vascularization and congested bladder mucosa with unclear anatomical structures. Total hysterectomy with bilateral salpingectomy was performed successfully, with 600 ml of blood lost. Examination of the excised uterus revealed an empty uterine cavity, a cystic lesion resembling a gestational sac within the cervical canal, and no formed fetus, with pregnancy tissue invading the cervical myometrium (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, left). Postoperative pathology confirmed that the placental villi in the cervix were consistent with those in the CP (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, right). Her serum β-HCG concentration was 51.57 mIU/ml on the first postoperative day and decreased to 3.340 mIU/ml (\u0026lt;\u0026thinsp;5 mIU/ml) on the seventh postoperative day. Follow-up Doppler, chest X-ray, and serum HCG within six months showed no abnormalities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCervical 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.\u003c/p\u003e \u003cp\u003eThe 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 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our case, the patient had a history of two cesarean sections and uterine fibroids, which likely contributed to the development of CP.\u003c/p\u003e \u003cp\u003eThe 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 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eManagement 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 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eThe 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 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording 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 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur MDT team reviewed and reflected on this case, noting the following shortcomings in the diagnostic and treatment process:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe MRI diagnosis lacked specificity and should be combined with the patient's history, clinical presentation, and auxiliary examinations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePreoperative 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.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eIn 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.\u003c/p\u003e \u003cp\u003eCP\u0026thinsp;=\u0026thinsp;Cervical pregnancy, EP\u0026thinsp;=\u0026thinsp;ectopic pregnancy, LMP\u0026thinsp;=\u0026thinsp;last menstrual\u003c/p\u003e \u003cp\u003eperiod: MDT\u0026thinsp;=\u0026thinsp;multidisciplinary team\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe patient provided informed consent, and the study was approved by the Ethics Committee of Ningxia Medical University General Hospital (Approval number: KYLL-2024-0752).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors listed have approved the enclosed\u0026nbsp;manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors\u0026nbsp;declare\u0026nbsp;that no competing\u0026nbsp;interests exist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot\u0026nbsp;applicable\u0026nbsp;for that section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLFQ collected basic information from the patient and image data and wrote the main content of the manuscript;\u0026nbsp;ZJY,\u0026nbsp;ZXJ,\u0026nbsp;and\u0026nbsp;BYY\u0026nbsp;performed\u0026nbsp;the clinical work and follow-up;\u0026nbsp;and\u0026nbsp;LD\u0026nbsp;promptly\u0026nbsp;discovered the first case of cervical pregnancy,\u0026nbsp;revised the language of the manuscript and helped write it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all members of\u0026nbsp;the\u0026nbsp;Liu Dan team from Ningxia Medical University General Hospital for their assistance in our work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;Ethics Committee of Ningxia Medical University General Hospital\u0026nbsp;approved the study with the Ethics Approval number:\u0026nbsp;KYLL-2024-0752.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors contributed equally to the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIshibashi H, Miyamoto M, Shinnmoto H, et al. Cervical varicosities may predict placenta accreta in posterior placenta previa: a magnetic resonance imaging study. Arch Gynecol Obstet. 2017;296(4):731-736. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/28710549/)\u003c/li\u003e\n\u003cli\u003eOyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006;107(4):927-941. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/16582134/)\u003c/li\u003e\n\u003cli\u003eAltraigey A, Ellaithy M, Barakat E, et al. Cervical length should be measured for women with placenta previa: cohort study. J Matern Fetal Neonatal Med. 2021;34(13):2124-2131. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/31434519/)\u003c/li\u003e\n\u003cli\u003eVintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. Am J Obstet Gynecol. 2015;213(4 Suppl):S70-77. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/26428505/)\u003c/li\u003e\n\u003cli\u003eLeeman LM, Wendland CL. Cervical ectopic pregnancy. Diagnosis with endovaginal ultrasound examination and successful treatment with methotrexate. Arch Fam Med. 2000;9(1):72-7. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/10664646/)\u003c/li\u003e\n\u003cli\u003eYoshimatsu K, Sekiya T, Ishihara K, et al. Detection of the cervical gland area in threatened preterm labor using transvaginal sonography in the assessment of cervical maturation and the outcome of pregnancy. Gynecol Obstet Invest. 2002;53(3):149-56. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/12053099/)\u003c/li\u003e\n\u003cli\u003eHiersch L, Rosen H, Okby R, et al. The greater risk of preterm birth in triplets is mirrored by a more rapid cervical shortening along gestation. Am J Obstet Gynecol. 2016;215(3):357.e1-6. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/26996985/)\u003c/li\u003e\n\u003cli\u003eProrocic M, Vasiljevic M. Treatment of heterotopic cervical pregnancy after in vitro fertilization-embryo transfer by using transvaginal ultrasound-guided aspiration and instillation of hypertonic solution of sodium chloride. Fertil Steril. 2007;88(4):969.e3-5. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/17412333/)\u003c/li\u003e\n\u003cli\u003eSheng S, Zhang H, Pan Z, et al. Treatment of heterotopic cervical pregnancy by ultrasound-guided hysteroscopy: A case report and literature review. Medicine (Baltimore). 2022;101(48):e32177. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/36482618/)\u003c/li\u003e\n\u003cli\u003eStarita A, Di Miscia A, Evangelista S, et al. Cervical ectopic pregnancy: clinical review. Clin Exp Obstet Gynecol. 2006;33(1):47-9. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/16761540/)\u003c/li\u003e\n\u003cli\u003eAuger N, Marcoux S, Paradis G, et al. Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study. Arch Gynecol Obstet. 2021;304(4):943-950. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/33817754/)\u003c/li\u003e\n\u003cli\u003eVintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. Am J Obstet Gynecol. 2015;213(4 Suppl):S70-77. [Hyperlink](https://pubmed.ncbi.nlm.nih.gov/26428505/)\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"CP, Placenta accreta, Ectopic pregnancy, Case report","lastPublishedDoi":"10.21203/rs.3.rs-4657775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4657775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eCervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) that occurs in the cervical canal. Diagnosis and treatment are particularly challenging when the lesion is large and presents without typical symptoms. We report a case of a 16+-week CP patient with placenta accreta.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 39-year-old woman presented with amenorrhea for four months but no associated symptoms. Doppler ultrasound revealed an enlarged uterus and a mixed echogenic mass in the lower uterine segment extending to the cervix, accompanied by rich blood flow signals. His serum β-HCG concentration was 576.68 mIU/ml. Following multidisciplinary evaluation, exploratory laparotomy under general anesthesia revealed a significantly enlarged cervix with prominent vascular networks. The patient underwent total abdominal hysterectomy with bilateral salpingectomy, with an intraoperative blood loss of 600 ml. Pathological examination confirmed the presence of placental villi in the cervix, consistent with CP. Postoperative recovery was uneventful, with serum β-HCG levels normalizing within a week, and no abnormalities were detected in follow-up assessments over six months.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case underscores the diagnostic and therapeutic complexities associated with CP, especially when patients present with large lesions and atypical symptoms. Comprehensive clinical history, imaging findings, and serum HCG levels are crucial for accurate diagnosis and effective clinical decision-making. The successful management of this case highlights the importance of a multidisciplinary approach in addressing such rare and challenging conditions.\u003c/p\u003e","manuscriptTitle":"Diagnosis and Management of Cervical Pregnancy with Placental Implantation: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-11 11:47:53","doi":"10.21203/rs.3.rs-4657775/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cbb938e5-7e8b-4d30-93c9-dbf4dac0e63b","owner":[],"postedDate":"August 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-30T16:39:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-11 11:47:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4657775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4657775","identity":"rs-4657775","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}