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ABSTRACT Introduction the Management and Maternal Outcomes of Cervical Varicosities in Pregnancy: Spontaneous Vaginal Delivery I

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ABSTRACT Introduction the Management and Maternal Outcomes of Cervical Varicosities in Pregnancy: Spontaneous Vaginal Delivery I The Management and Maternal Outcomes of Cervical Varicosities in Pregnancy: Spontaneous Vaginal Delivery in the Setting of Cervical Varicosities KA Whitsell, MD, MJ McKuen MD, PhD, and VB Mello, DO Department of Obstetrics and Gynecology, Central Michigan University, Saginaw, MI ABSTRACT CASE PRESENTATION CONCLUSIONS Postpartum hemorrhage is one of the most common maternal A Caucasian 18-year-old G2P0101 at 30w2d presented to labor • There is a great need to establish management guidelines morbidities, which has increased by greater than fifty percent from and delivery at a outlying facility with pelvic pressure and vaginal for cervical varicosities in pregnancy to minimize 1993 to 2014 [2]. Although cervical varicosities are rare in spotting. A transvaginal ultrasound (TVUS) revealed a hypoechoic pregnancy, they have been associated with placenta previas and structure in the posterior cervix that was suspicious for an antepartum and postpartum hemorrhages. low-lying placentas as well as significant antepartum and arteriovenous malformation. She was found to be anemic with a • The mode of delivery in the absence of abnormal postpartum hemorrhage[1-3,8-9,11-13,15]. Cervical varicosities are hemoglobin of 7.7 and received a blood transfusion. A few weeks placental implantation should be decided based on the thought to be the result of inferior vena cava compression by the later, she returned with preterm contractions. She was initiated on location of the cervical varicosities. expanding uterus in pregnancy [6]. In the literature, only 17 cases of nifedipine and received betamethasone for fetal lung maturity. A cervical varicosities have been reported. Due to the rare nature of repeat TVUS performed by Maternal Fetal Medicine (MFM) at 33w3d • Cesarean section for cervical varicosities in the setting of cervical varicosities in pregnancy, proper management has not been confirmed cervical varicosities on the posterior wall of the cervix and abnormal placental implantation, especially placenta established. Management of antepartum bleeding has required in the cul-de-sac measuring 3.0x2.1x2.8 cm. According to MFM, the previa, may ensure control of postpartum hemorrhage. blood transfusions and placement of vaginal packings, cerclages, passage of the fetal head would compress the cervical varicosities on and Bakri balloons [1-3, 7-17]. Reported maternal and neonatal the posterior wall and minimize intrapartum bleeding. Therefore, MFM ▪ In our case, the cervical varicosities were in the posterior outcomes include preterm delivery, emergency cesarean sections, recommended a vaginal delivery in contrast to a cesarean section. cervix, which likely contributed to a successful and hysterectomy [7-8,10,12,15]. This is the rare case of a She was induced at 38w0d utilizing oxytocin. In preparation for a spontaneous vaginal delivery without a postpartum Caucasian 18-year-old G2P0101 diagnosed with cervical postpartum hemorrhage, 4 units of packed RBCs were prepared, and varicosities. Despite experiencing vaginal bleeding and contractions an interventional radiology consult was placed for possible hemorrhage due to compression by the fetal head. requiring a blood transfusion and tocolytics, she underwent a embolization. She underwent a spontaneous vaginal delivery. One ▪ Spontaneous vaginal deliveries in cases of cervical spontaneous vaginal delivery with no complications. This rare case small posterior vaginal wall laceration was repaired. No cervical varicosities without abnormal placenta implantation may of cervical varicosities emphasizes the need to establish lacerations or continuous active bleeding from the cervix were management guidelines for cervical varicosities in pregnancy. visualized. There was no postpartum hemorrhage. Her total calculated decrease the occurrence of postpartum hemorrhages. blood loss at delivery was 400 cc and there was no significant vaginal bleeding in the postpartum period. Her hemoglobin dropped Introduction appropriately from 9.7 to 8.8 upon discharge. REFERENCES Brown III JV, Mills MM, Wong H, Goldstein BH. Large volume cervical varix bleeding in a gravid patient. Gynecologic Oncology Reports Though rare, the majority of occurrences of cervical varicosities in 4(2013) 20-22 CDC. Severe Maternal Morbidity in the United. Division of Reproductive Health, National Center for Chronic Disease Prevention and pregnancy led to postpartum hemorrhages [1,3,7,9,11-12,15]. Many Health Promotion. Pregnancy complications. Stated. maternal physiologic changes in pregnancy contribute to the https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html Chjek K, Hutz C, Marci C, Berger J. Cervical Varices Presenting as Vaginal Bleeding: A Description of Two Cases and A Management development of cervical varicosities, including increased blood A B Plan. Obstet Gynecol cases Rev 2015,2:053 volume, hormonal changes, and the compression of the IVC by the Fleming AD, Anderson TL. Cervical AV malformation with in utero DES exposure. Nebr MED j. 1993;78:138-9 expanding uterus in pregnancy [6]. Abnormal placenta implantations Follen MM, Fox HE, Levine RU. Cervical vascular malformation as a cause of antepartum and intrapartum bleeding in three diethylstilbestrol-exposed progeny. Am J Obstet Gynecol. 1985;153:890-1 such as placenta previas and low-lying placentas are associated with Gabbe S. Obstetrics-Normal and Problem Pregnancy. (7th edn) Elsevier: 2015 half of the reported cervical varicosity cases [3, 8-13,15]. Upon Hurton T, Morril H, Mascola M, York C, Bromely B. Cervical varices; an unusual etiology for third trimester bleeding. J Clin Ultrasound literature review, only 17 cases of cervical varicosities in pregnancy Med. 2006;25:545-9 Idelson A, Mashiach R, Meizner I. Venous cervical varix presenting as a late cause of obstetric hemorrhage have been reported. Antepartum bleeding and preterm contractions Kumazawa Y. Shimizu D, Hosoya N, Hirano H, Ishiyama K, Tanaka T. Cervical Varix with placenta previa totalis. J Obstet Gynaecol Res. are the major complications of cervical varicosities in pregnancy [1- 2007;33:536-8 Kusanovic ,J, Soto E, Espinoza J. Stites S, Goncalves L. Cervical Varix as a Cause of Vaginal Bleeding During Pregnancy Prenatal 3,8-9,11-13,15]. Although cervical varicosities in pregnancy have Diagnosis by Color Doppler Ultrasound resulted in blood transfusions, preterm deliveries, and postpartum C Kurihara Y, Tachibana D, Teramae M, Matsumoto, M. Pregnancy Complicated by Cervical Varix and Low-lying Placenta: Case Report. Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine. Japanese Clinical Medicine 2013;4 21- hemorrhages, guidelines for the management, treatment, and mode 24. Doi: 10.4137/jcms11276 of delivery have not been established [1-3, 7-17]. In previous reported Matsuzaki S, Kakigano A, Mimura K, Kimura T. Letter to “Cervical varices unrelated to placenta previa as an unusual cause of antepartum hemorrhage; A case report and literature review,” Successful management of postpartum hemorrhage due to cervical varix: case reports antepartum bleeding was managed with vaginal Modified Matsubara Nelaton method using Bakri balloon. Taiwanese Journal of Obstetrics & Gynecology 58 (2019)721-722 O’brien B, Smolemeic. Cervical varicosities and placenta previa. Australian and New Zealand Journal of Obstetrics and Gynecology packing, blood transfusions, cerclages, Gelfoam, thrombin, and 2013;53:451-454 emergency cesarean sections [1-3,7-17]. Preterm contractions were Park J, Kim MJ, Kim MK, Kim, HM. Cervical varix with thrombosis diagnosed in the first trimester of pregnancy. Obstet Gynecol Sci managed with magnesium sulfate, indomethacin, and bed rest [7,10]. 2019;62(1):65-68 Sammour RN, Gonen r, Ohel G, and Leibovitz Z. Cervical Varices complicated by thrombosis in pregnancy. Ultrasound Obstet Gynecol Sixteen out of 17 reported cervical varicosities in pregnancy resulted 2011; 37:614-616 in cesarean sections. One third of the cervical varicosity cases Sukur YE, Yalcin I, Kahraman K, Soylemez F. Cervical varix complicating marginal placenta previa: a unique coexistence. J. Obstet Gynaecol Res. 2011; 37:1515-Sammour RN, Gonen R, Ohel G, Leibovitz Z. Cervical varices complicated by thrombosis in pregnancy. resulted in postpartum hemorrhages [1-3. 7-17]. Ultrasound Obstet Gynaecol Res.2007; 33;536-8 Yoshimura K, Hirsch E, Kitano R, Kashimura M. Cervical Varix accompanied by placenta previa in twin pregnancy , J Obstet Gynaecol Res. 2004;30:323-5 FIG 1: Transvaginal ultrasound demonstrating cervical varicosities in the posterior cervix in (A) Sagittal and (B) transverse orientation. The probe tip (Pr), fetal head (FH), cervix (Cx), uterus (Ut), and cervical varicosities (CV)..
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