Introduction

Cervical pregnancy is one of the rarest forms of ectopic gestation, which should be considered in differential diagnosis of abnormally low gestational sacs in Transvaginal ultrasound (1). Placenta percreta, with incidence rate of 1 in 9000 deliveries, is a complication of pregnancy that can be life threatening for both mother and fetus (2).

The incidence of placenta accreta in cervical pregnancy is rare (1 in 93,000 pregnancies) (3). The etiology of cervical ectopic pregnancy is uncertain; however, the contributing factors could be curettage, history of cesarean delivery, Asherman’s syndrome, in-vitro fertilization, and history of cervical or uterine surgery (4).

Delayed diagnosis and progression of cervical ectopic pregnancy are associated with life-threatening hemorrhage (5, 6). Considering the features of cervical tissue, placenta may invade through the full thickness of the cervix. The incidence rate of placenta percreta is on a growing trend. Cesarean section is a risk factor for hematuria, which is a sign of abnormal placental adhesion (7).

 Patients with advanced ectopic pregnancy and placenta percreta are difficult to manage, and surgical intervention is associated with high rates of morbidity and mortality (8). Cervical pregnancy is rarely diagnosed before 20 weeks gestation. Accurate early diagnosis and critical decision-making are of great importance in management of this condition, since they allow treatment with minimal intervention and attenuate the overall rates of morbidity and mortality. Bladder involvement of percreta is an uncommon complication (6, 9), and it is mostly diagnosed after hysterectomy and massive hemorrhage.

Conservative management of cervical ectopic pregnancy aims at fertility preservation, which includes systemic or local ultrasound guided intraamniotic methotrexate injection, local potassium chloride injection, dilatation and curettage, and amputation of the cervix or partial trachelectomy (8).

Very few cases of this condition were reported in the literature worldwide (5-8), for instance, in a study by Jaswal (6) a case of ectopic pregnancy with hematuria and vaginal bleeding was reported. The patient died two hours following the surgery. The current study describes a rare case of placenta percreta with gross hematuria in cervical ectopic pregnancy.

Case Presentation

In this study, we present the case of a 32 -year-old (gravid: 4, parity: 3, death: 1) woman with spontaneous conception and history of two previous cesarean sections admitted to Qaem Hospital, affiliated to Mashhad University of Medical Sciences, in 10 February 2014. The patient was at 19 weeks of gestation and presented to the hospital with gross hematuria and stable vital signs.Abdominal ultrasonography revealed an intrauterine, 19-week, viable fetus and placenta percreta. After two days (12 February), color Doppler ultrasonography demonstrated blood flow in the placenta extending to the bladder dome. Magnetic resonance imaging (MRI) revealed reduced thickness of the myometrium in the lower part of the placenta and penetration of the vessels into the wall of the bladder dome, which indicate percreta (Figure 1).

Evidence of intravesical hematoma was observed in the bladder due to hematuria secondary to bladder invasion. After four days of admission, due to aggravation of hematuria, cystoscopy was performed, and areas with active bleeding were detected. Hemoglobin and hematocrit levels fell. On this day (14 February), a multi-disciplinary meeting was held in the presence of an anesthesiologist, gynecologic oncologist, vascular surgeon, and urologist for planning management of the patient. Finally, surgery was planned due to severe hematuria.

On 14 February, during the operation, there was an empty large uterus and fetus and placenta had engaged the entire length of the cervix (Figure 2).After ligation of the internal iliac artery on both sides, hysterectomy and partial cystectomy were carried out and 3-way Foley catheter was placed. Due to oozing from the pelvic floor, pelvic packing was performed with six surgical long gazes, and then the patient was transferred to intensive care unit.