Natural conception and successful delivery after laparoscopic uterine anastomosis for traumatic cervical separation: a case report

We report the case of a 28-year-old East Asian Chinese woman with a 10-year history of secondary amenorrhea and periodic lower abdominal pain. She experienced regular menstrual cycles before the age of 18. At 18, she sustained a severe pelvic crush injury due to a motor vehicle accident, which resulted in a comminuted pelvic fracture. At that time, she underwent only pelvic internal fixation, as imaging showed no evidence of intra-abdominal bleeding and, therefore, an exploratory laparotomy was not performed. However, amenorrhea developed immediately after the injury, accompanied by progressively worsening lower abdominal pain. Specifically, she experienced persistent dull pain occurring every 30 days, lasting for 4 days each time, with a visual analog scale (VAS) score of 8–9; however, she did not have any menstrual flow. At age 25, she underwent a pelvic ultrasound at a secondary hospital for amenorrhea, which revealed the presence of fluid in the uterine cavity. Hysteroscopy was attempted but failed to pass through the cervix, raising suspicion of cervical adhesion. Her family and psychosocial histories were unremarkable. At the age of 28, she sought further medical attention at our hospital to clarify her diagnosis and develop a more effective treatment ( T 0 ). Examination revealed that vital signs were within normal limits (temperature of 36.3 ℃, heart rate of 80 beats per minute, SpO 2 of 99%, respiratory rate of 20 breaths per minute, and blood pressure of 120/77 mmHg). The systemic examination was within normal limits. Gynecological examination showed that the body of the uterus and cervix appeared discontinuous, and no other obvious abnormalities were found ( T 0 ). Ultrasound and magnetic resonance imaging (MRI) revealed the presence of uterine cavity effusion, myometrial thickening, and discontinuity between the body of the uterus and cervix. The bilateral ovaries and fallopian tubes appeared normal (Fig.  1 ) ( T 0  + 1 day). Based on these findings, uterine isthmus atresia secondary to traumatic transection was diagnosed, and surgical intervention was planned. Fig. 1 Imaging of preoperative and postoperative of uterine reconstruction. Preoperative pelvic MRI showed cervicoisthmic disjunction, with a short T1 signal in the uterine cavity and short T1 and T2 signal fluid in the cavum Douglasi. No obvious abnormalities were observed in either ovary ( 1 ). Gynecologic ultrasound showed a cervical length of 3.0 cm and a uterine body measuring 5.1 × 5.3 × 3.8 cm. Abnormal stenosis was noted at the junction of the body of the uterus and cervix, with the widest area measuring 1.2 cm. Intrauterine exploration revealed a no-echo zone with a width of 0.7 cm ( 2a , 2b ). After uterine reconstruction, ultrasound showed that the connection between the uterine cavity and cervical canal was reestablished. However, a narrowing remained at the junction of the uterine body and cervix. The thickness of the unilateral myometrium was 0.7 cm, while the adjacent side measured 1.2 cm ( 3a , 3b ) Imaging of preoperative and postoperative of uterine reconstruction. Preoperative pelvic MRI showed cervicoisthmic disjunction, with a short T1 signal in the uterine cavity and short T1 and T2 signal fluid in the cavum Douglasi. No obvious abnormalities were observed in either ovary ( 1 ). Gynecologic ultrasound showed a cervical length of 3.0 cm and a uterine body measuring 5.1 × 5.3 × 3.8 cm. Abnormal stenosis was noted at the junction of the body of the uterus and cervix, with the widest area measuring 1.2 cm. Intrauterine exploration revealed a no-echo zone with a width of 0.7 cm ( 2a , 2b ). After uterine reconstruction, ultrasound showed that the connection between the uterine cavity and cervical canal was reestablished. However, a narrowing remained at the junction of the uterine body and cervix. The thickness of the unilateral myometrium was 0.7 cm, while the adjacent side measured 1.2 cm ( 3a , 3b ) Laparoscopic surgery was performed with informed consent from the patient and her parents ( T 0  + 1 week). Intraoperatively, complete separation at the cervical isthmus was observed, with two blind ends; only fibrous adhesions connected the segments, confirming traumatic cervical separation. Coexisting peritoneal endometriosis was noted, with normal ovaries and fallopian tubes. A uterine dilator was inserted through the vagina to guide the repair. Adhesions at the vesicouterine and rectouterine spaces were carefully released. Incisions were made in the upper cervical canal and the lower body of the uterus, and the dilator was advanced into the uterine cavity. End-to-end anastomosis was achieved using interrupted full-thickness absorbable sutures (Vicryl 1). After anastomosis, the dilator was removed and a 14-Fr Foley catheter was placed through the vagina at the uterine isthmus to prevent postoperative stenosis (Fig.  2 ). Fig. 2 Laparoscopic cervical-uterine anastomosis. After opening the cystoperitoneal fold and broad ligaments on both sides of the uterus, complete separation of the corpus uteri (◎) from the cervix (❉) at the cervical isthmus was revealed. Two blind ends were present, adhered to each other by a film-like intermediate structure ( 1 ). A uterus-lifting apparatus was placed inside the cervix as a guide, and the upper blind end of the cervical canal was opened to communicate with the external end of the cervical canal ( 2 ). A small incision was made at the uterine fundus, and exploration from top to bottom revealed a small uterine cavity and the presence of hematocele ( 3 ). A belt was then passed through the uterine cavity to assist in turning the corpus uteri ( 4 ). The blind ends of the cervix (❉) and uterus (◎) were exposed ( 5 ). Scar tissue at the broken ends of the cervix and corpus uteri was trimmed, and the uterine cavity was expanded ( 6 ). The posterior aspects of the cervix and corpus uteri were sutured together in full thickness ( 7 , 8 ). A drainage catheter was inserted from the uterine fundus incision into the uterine cavity and cervix to act as a stent and maintain the patency of the anastomotic tract ( 9 ). The fundus incision was then closed with full-thickness sutures ( 10 ). Finally, the anterior and lateral aspects of the cervix and corpus uteri were sutured together ( 11 ) Laparoscopic cervical-uterine anastomosis. After opening the cystoperitoneal fold and broad ligaments on both sides of the uterus, complete separation of the corpus uteri (◎) from the cervix (❉) at the cervical isthmus was revealed. Two blind ends were present, adhered to each other by a film-like intermediate structure ( 1 ). A uterus-lifting apparatus was placed inside the cervix as a guide, and the upper blind end of the cervical canal was opened to communicate with the external end of the cervical canal ( 2 ). A small incision was made at the uterine fundus, and exploration from top to bottom revealed a small uterine cavity and the presence of hematocele ( 3 ). A belt was then passed through the uterine cavity to assist in turning the corpus uteri ( 4 ). The blind ends of the cervix (❉) and uterus (◎) were exposed ( 5 ). Scar tissue at the broken ends of the cervix and corpus uteri was trimmed, and the uterine cavity was expanded ( 6 ). The posterior aspects of the cervix and corpus uteri were sutured together in full thickness ( 7 , 8 ). A drainage catheter was inserted from the uterine fundus incision into the uterine cavity and cervix to act as a stent and maintain the patency of the anastomotic tract ( 9 ). The fundus incision was then closed with full-thickness sutures ( 10 ). Finally, the anterior and lateral aspects of the cervix and corpus uteri were sutured together ( 11 ) The patient recovered well and was discharged 3 days postoperatively ( T 0  + 1 week and 3 days). Menstruation resumed 23 days after surgery, and the Foley catheter was removed ( T 0  + 2 months). She subsequently experienced regular, painless periods. Ultrasound every 3 months for a year confirmed a re-established, although slightly narrowed, connection between the uterine cavity and cervical canal; the muscle thickness on one side was 0.7 cm, compared with 1.2 cm on the adjacent side (Fig.  1 ) ( T 0  + 1 year). The patient was thoroughly informed that the risks of placenta percreta (PP) and hysterectomy were significantly increased in the event of pregnancy, necessitating careful evaluation. Three years postoperatively, the patient conceived naturally ( T 0  + 3 years). Early ultrasound showed the gestational sac implanted at the anastomosis site, with the lower myometrial thickness reduced to 0.2 cm (Fig.  3 ). Obstetric counseling outlined risks including uterine rupture, PP, severe hemorrhage, potential need for hysterectomy, and possible life-threatening complications. After thorough discussion, the patient chose to continue the pregnancy. Serial imaging throughout pregnancy revealed progressive placental invasion. By 12 weeks of gestational age, ultrasound showed placenta covering the cervical internal os with near-complete loss of myometrial echo at the attachment site. Later imaging confirmed complete placenta previa with invasion into the left parametrium (Fig.  4 ). At 30 weeks of gestational age, cesarean section was performed due to PP. Dense bladder adhesions and external placental protrusion were noted. A longitudinal uterine incision 5 cm above the vesicoperitoneal reflection avoided the placenta, and a healthy female infant was delivered. Hemostasis was achieved by tamponade and uterine incision closure, followed by hysterectomy (Fig.  5 ). Estimated blood loss was 1,200 mL. The patient and her infant were discharged in good condition 1 week postpartum. Annual telephone follow-ups have been conducted to date, during which the patient reported no relevant abnormal symptoms, and the offspring exhibited normal growth and development ( T 0  = 7 years). Table 1 presents a comprehensive summary of the timeline of clinical events. Fig. 3 Ultrasound and pelvic MRI in early pregnancy. At 6 weeks, ultrasound showed that the intrauterine gestational sac measured 4.7 × 2.0 × 1.8 cm, with its lower edge reaching the internal os of the cervix. The thinnest part of the myometrium at the lower uterine wall measured 0.2 cm ( 1a , 1b ). At 10 weeks, MRI revealed significant thinning of the anterior and posterior walls of the lower uterus, widening of the uterine cavity, and the lower edge of the gestational sac reaching and covering the internal os of the cervix ( 2 , 3 ) Fig. 4 Ultrasound and pelvic MRI in the middle and late pregnancy. At 12 weeks, the placenta was located on the left anterior and posterior walls, with its lower edge covering the internal os of the cervix. Abundant blood flow signals were detected in the left uterine wall and at the site of placental attachment to the cervix, presenting as a “boiling water” sign. The myometrial echo was interrupted, and the boundary between the anterior uterine wall and bladder was unclear ( 1a ). At 15 weeks, MRI suggested that the left posterior portion of the placenta appeared to invade the myometrium ( 1b ). At 24 weeks, the placenta was attached to the lower segment of the left anterior and posterior walls, with the muscular layer at the internal cervical orifice nearly absent. Blood sinus echoes were detected near the cervix in the placental parenchyma attached to the posterior wall ( 2a ). MRI showed that the posterior lower edge of the placenta was suspected to involve the posterior lip of the cervix, which was thickened with internal blood sinuses. The placenta showed uneven signal thickening, with empty blood vessels in the left lower region, an indistinct signal in the left lower myometrium, and abnormal swelling of the lateral contour of the placental serosa ( 2b ). At 29 weeks, the lower edge of the placenta involved the posterior lip of the cervix and formed a blood sinus. The left lower part of the placenta protruded significantly into the parauterine area, and the placental blood sinus was markedly more enlarged compared with a month earlier ( 3a , 3b ) Fig. 5 Intraoperative condition and corresponding preoperative ultrasound images. Transabdominal ultrasound ( 1a ) showed an anastomotic scar (yellow arrow) and protruding placental tissue (blue arrow) in the lower segment of the left uterine wall. Doppler imaging revealed a blood sinus echo ( 1b ). Transvaginal ultrasound ( 2a ) showed that the placenta on the posterior wall of the uterus involved the posterior lip of the cervix, with a blood sinus developing in the posterior lip ( 2b ). Intraoperatively, the lower segment of the anterior uterine wall was exposed, revealing a surface with dilated and tortuous vessels ( 3 ). The left posterior wall of the uterus was also exposed, showing a 5.0 × 6.0 cm protrusion where the myometrium was almost completely absent and under high tension ( 4 ). On the posterior aspect of the uterus, there was a prominent protrusion in the area of placenta accreta on the left posterior wall, measuring approximately 5.0 × 6.0 cm, with only the serosal layer remaining (blue arrow). In addition, placental tissue was found protruding outward through the posterior wall of the lower uterine segment and the posterior lip of the cervix (black arrow) ( 5 ). Viewed from the anterior aspect of the uterus, an external protrusion measuring 4.0 × 5.0 cm was visible on the left side, with only the serosal layer remaining ( 6 ) Table 1 Timeline of clinical events Time point Event description T 0 Initial presentation: A 28-year-old woman with secondary amenorrhea and intermittent lower abdominal pain for the past 10 years Clinical history review (a history of severe pelvic trauma at 18 years old), vital signs, gynecological examination T 0 + 1 day Ultrasound and magnetic resonance imaging (MRI) revealed traumatic separation of the cervix from the body of the uterus T 0 + 1 week Surgical procedure: laparoscopic anastomosis between the body of the uterus and the cervix, with a 14-Fr Foley catheter placed through the vagina at the uterine isthmus to prevent stenosis T 0 + 1 week and 3 days The patient made a smooth recovery and was subsequently discharged T 0 + 2 months Menstruation resumed, and the Foley catheter was removed T 0 + 1 year Ultrasounds performed every three months for a year confirmed the effectiveness of the re-establishment T 0 + 3 years The patient conceived naturally. At 30 weeks of gestational age, the cesarean section and hysterectomy were performed due to placenta percreta (PP) T 0 + 7 years During annual follow-ups to date, the patient reported no significant abnormal symptoms, and the offspring demonstrated normal growth and development Ultrasound and pelvic MRI in early pregnancy. At 6 weeks, ultrasound showed that the intrauterine gestational sac measured 4.7 × 2.0 × 1.8 cm, with its lower edge reaching the internal os of the cervix. The thinnest part of the myometrium at the lower uterine wall measured 0.2 cm ( 1a , 1b ). At 10 weeks, MRI revealed significant thinning of the anterior and posterior walls of the lower uterus, widening of the uterine cavity, and the lower edge of the gestational sac reaching and covering the internal os of the cervix ( 2 , 3 ) Ultrasound and pelvic MRI in the middle and late pregnancy. At 12 weeks, the placenta was located on the left anterior and posterior walls, with its lower edge covering the internal os of the cervix. Abundant blood flow signals were detected in the left uterine wall and at the site of placental attachment to the cervix, presenting as a “boiling water” sign. The myometrial echo was interrupted, and the boundary between the anterior uterine wall and bladder was unclear ( 1a ). At 15 weeks, MRI suggested that the left posterior portion of the placenta appeared to invade the myometrium ( 1b ). At 24 weeks, the placenta was attached to the lower segment of the left anterior and posterior walls, with the muscular layer at the internal cervical orifice nearly absent. Blood sinus echoes were detected near the cervix in the placental parenchyma attached to the posterior wall ( 2a ). MRI showed that the posterior lower edge of the placenta was suspected to involve the posterior lip of the cervix, which was thickened with internal blood sinuses. The placenta showed uneven signal thickening, with empty blood vessels in the left lower region, an indistinct signal in the left lower myometrium, and abnormal swelling of the lateral contour of the placental serosa ( 2b ). At 29 weeks, the lower edge of the placenta involved the posterior lip of the cervix and formed a blood sinus. The left lower part of the placenta protruded significantly into the parauterine area, and the placental blood sinus was markedly more enlarged compared with a month earlier ( 3a , 3b ) Intraoperative condition and corresponding preoperative ultrasound images. Transabdominal ultrasound ( 1a ) showed an anastomotic scar (yellow arrow) and protruding placental tissue (blue arrow) in the lower segment of the left uterine wall. Doppler imaging revealed a blood sinus echo ( 1b ). Transvaginal ultrasound ( 2a ) showed that the placenta on the posterior wall of the uterus involved the posterior lip of the cervix, with a blood sinus developing in the posterior lip ( 2b ). Intraoperatively, the lower segment of the anterior uterine wall was exposed, revealing a surface with dilated and tortuous vessels ( 3 ). The left posterior wall of the uterus was also exposed, showing a 5.0 × 6.0 cm protrusion where the myometrium was almost completely absent and under high tension ( 4 ). On the posterior aspect of the uterus, there was a prominent protrusion in the area of placenta accreta on the left posterior wall, measuring approximately 5.0 × 6.0 cm, with only the serosal layer remaining (blue arrow). In addition, placental tissue was found protruding outward through the posterior wall of the lower uterine segment and the posterior lip of the cervix (black arrow) ( 5 ). Viewed from the anterior aspect of the uterus, an external protrusion measuring 4.0 × 5.0 cm was visible on the left side, with only the serosal layer remaining ( 6 ) Timeline of clinical events Initial presentation: A 28-year-old woman with secondary amenorrhea and intermittent lower abdominal pain for the past 10 years Clinical history review (a history of severe pelvic trauma at 18 years old), vital signs, gynecological examination

Complete cervical separation from the uterus due to pelvic fracture is extremely rare, with a very low incidence [ 1 ]. Delayed diagnosis and treatment can result in permanent loss of fertility. Because the injury is often concealed deep in the pelvis and may lack obvious bleeding, it is frequently missed until symptoms such as amenorrhea or infertility appear. This report describes a case in which laparoscopic uterine reconstruction restored normal menstruation and enabled successful natural conception and delivery in a patient with cervical separation following pelvic trauma.

This case demonstrates that minimally invasive uterine reconstruction can restore both anatomy and function, enabling natural conception and delivery. Timely treatment can provide an opportunity for fertility; however, a significantly high risk of pregnancy-related complications persists, necessitating individualized assessment.

We present a rare case of laparoscopic uterine anastomosis for traumatic cervical separation in a patient with a history of pelvic fracture, resulting in natural conception and successful delivery. Complete cervical separation due to pelvic trauma is extremely rare, owing to the protection provided by pelvic tissues. However, high-impact injuries can cause cervical isthmus transection, especially in younger patients, as this region is anatomically vulnerable [ 1 ]. Diagnosis is often delayed because the injury may lack overt symptoms such as bleeding or hemodynamic instability, leading to missed or late identification. Long-term complications include amenorrhea, endometriosis, and infertility, with delayed surgery further complicated by pelvic and cervical adhesions. Management options include repair and reconstruction or hysterectomy, with fertility preservation prioritized in young patients. End-to-end uterine-cervical anastomosis restores reproductive anatomy and resolves symptoms such as amenorrhea and dysmenorrhea. A review of the literature since 2000 identified only seven similar cases [ 2 – 8 ], most involving adolescents aged 15–18 who sustained pelvic fractures from motor vehicle accidents. The primary clinical manifestations were amenorrhea and periodic lower abdominal pain, with some cases also reporting infertility and endometriosis. Surgical intervention was often delayed after trauma. Notably, only Mankus [ 8 ] reported a case with acute abdominal pain and imaging evidence of intraperitoneal hemorrhage, where exploratory laparotomy revealed uterine transection, but the patient’s circulation remained stable and end-to-end anastomosis was performed. Among the reported cases, six underwent laparotomy, and only one [ 6 ] was managed laparoscopically. Intraoperative endometriosis was common, likely due to menstrual blood reflux. Among all cases, only one patient [ 2 ] conceived through assisted reproductive technology and delivered via cesarean section. Our case highlights the advantages of laparoscopy, including faster recovery and fewer perioperative complications. Scar contracture and tract obstruction remain short-term risks, but maintaining postoperative patency with a uterine catheter is effective. Full-thickness suturing is essential for structural integrity. Furthermore, long-term pregnancy risks should be a concern. The weakening of the myometrium at the site of uterine incision may increase the risk of placental percreta. The loss of normal uterine vascularity and the remodeling of the scar area expose the placental villi to abnormally high-velocity and high-pressure blood flow from the large-diameter deep uterine arteries. In addition, the absence of decidua allows the placental villi to come into direct contact with the myometrium, contributing to the invasive growth of the placenta into the uterine muscle [ 9 ]. Patients should be counseled regarding risks of uterine rupture, PP, and hysterectomy in future pregnancies.

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