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Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and Literature Review

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Varices are common in pregnancy but cervical varices are rare and it could be a cause of massive antepartum hemorrhage. We present a case report of cervical varices, in a 31-year-old woman with placenta previa. The clinical course, imaging findings along with the outcome are being presented. In addition a literature review of published cases was done for the purpose of establishing a possible management plan.
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OPEN ACCESS EC GYNAECOLOGYEC GYNAECOLOGY
Case Report
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities
Associated with Placenta Previa. Case Report and Literature Review
Idriss Gharbi*, Alaa Al Naama, Arabo Bayo, Najah Al Janahi and Abdallah Al Ibrahim
Department of Obstetrics and Gynecology, Women Wellness and Research Center, Hamad Medical Corporation, Doha, State of Qatar
Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
*Corresponding Author: Idriss Gharbi, Department of Obstetrics and Gynecology, Women Wellness and Research Center, Hamad Medi-
cal Corporation, Doha, State of Qatar.
Received: December 25, 2020; Published: February 26, 2021
Abstract
Abbreviation
MRI: Magnetic Resonance Imaging
Introduction
The causes of antepartum hemorrhage are diverse, varied and multifactorial. Antepartum hemorrhage complicates 2 - 5% of pregnan-
cies [1]. The two most important causes of antepartum hemorrhage are placenta previa and abruptio placentae constituting more than
50% of cases. Cervical varices are rare cause of antepartum hemorrhage and only limited number of cases were reported [2-4]. In the
presence of cervical varices and placenta previa, the exact origin of bleeding in case of antepartum hemorrhage, can be uncertain. Ante-
partum hemorrhage can be severe in this situation, which can lead to serious maternal and fetal morbidity. Therefore, it is important to
report such rare case, so it will add to our understanding to the problem and the management options possible.
Case Presentation
A 31-year-old Gravida 1 Para 0 with no previous medical or surgical history, presented to emergency department in Women Wellness
and Research Center at 18 weeks of pregnancy complaining of painless unprovoked vaginal bleeding of about 50 ml. This pregnancy was
spontaneous, and its course was normal until that event. Sterile speculum examination was done and no cervical abnormality was noticed
 
lacunae with exaggerated posterior cervical and retro cervical vascularity were also noted at the time of the scan (Figure 1).
Varices are common in pregnancy but cervical varices are rare and it could be a cause of massive antepartum hemor-
rhage. We present a case report of cervical varices, in a 31-year-old woman with placenta previa. The clinical course,
   
done for the purpose of establishing a possible management plan.
Keywords: Cervix; Varices; Placenta Previa; Hemorrhage; Pregnancy
Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and
Literature Review
92
The patient was admitted for observation with the working diagnosis of threatened miscarriage. Bleeding stopped the same day. Dur-
ing her hospital stay, there was no further bleeding. She was discharged after three days with a follow up appointment to be seen in the

previa. At this stage, sterile speculum examination showed a mesh of engorged smooth woven cord like structures. The cervix appeared,
on the scan, with complex matrix blood vessels mainly venous suggestive of cervical varices (Figure 2).
Figure 1: (a) Placenta completely covering the internal cervix with multiple lacunae suggestive of blood vessels.

(a) (b)
Figure 2: (a) Complex matrix vascularity on the color Doppler, (b) Same image without Doppler.
(a) (b)
Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and
Literature Review
93
Ten days after the ultrasonography, the patient was admitted again at 21 weeks of gestation, with moderate unprovoked vaginal bleed-
ing. The clinical examination showed the same structure in the cervix but with no active bleeding. She was kept under observation in the
hospital with the diagnosis of antepartum hemorrhage, with its origin either from cervical varices or the placenta previa.
After extensive counselling of the parents, from a multidisciplinary team involving Obstetricians, Anesthesiologists, Neonatologists,
regarding the origin of bleeding and the possible outcomes for both mother and fetus, the decision was made for conservative manage-
ment unless there is bleeding enough to cause fetal or maternal compromise. The aim was to observe and stabilize the patient with blood
transfusions and to try to reach the age of fetal viability for possible delivery according to the clinical situation.
Although, careful speculum examination showed no active bleeding from varices, cervical varices were considered the most likely
cause of antepartum hemorrhage in view of the absence of abruptio or placental separation on the different scans.
During this hospital stay, the patient had frequent repeated, painless, unprovoked vaginal bleeding, leading to a drop of hemoglobin
from 10.5 to 7 g/dl. The estimation of total blood loss was about 2500 ml, and patient needed replacement by blood transfusions.
At 23 weeks of gestation, Magnetic Resonance Imaging (MRI) of the pelvis was performed but failed to clearly identify the cervical
varices (Figure 3).
Figure 3: MRI of the pelvis in T1 (a) and T2 (b). Placenta Previa type III with no MRI evidence of Placental invasion.
(a) (b)
At 24 weeks of gestation, considering the risk of preterm delivery, antenatal corticosteroids were given to accelerate fetal lung maturity.
Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and
Literature Review
94
After one month from her date of admission, at 26 weeks of gestation, the patient had recurrent severe fresh vaginal bleeding, about
2000 ml, with continuing ongoing vaginal bleeding, leading to unstable vital signs. The decision was taken for delivery by emergency

red blood cells were available. The outcome of the cesarean section was a delivery of a baby boy of 1020g with Apgar score of 8 and 9 at 1,

the diagnosis of placenta previa posterior type III and no placental separation was found. The estimated blood loss during cesarean sec-
tion was 500 ml, but active vaginal bleeding continued after completing the cesarean section. Vaginal examination under anesthesia was
performed. Cervix was hyper vascular with multiple varices noted all around with active bleeding. Hemostasis was achieved by ligation

about 3000 ml coming from cervical varices. Patient received seven units of blood transfusion.
     
post-cesarean section. She was seen six weeks later in the outpatient clinic with a normal postpartum course and normal looking cervix
on vaginal examination. Transvaginal ultrasonography was performed and cervical varices have disappeared completely (Figure 4). Baby
was discharged from hospital 6 weeks after cesarean section in good condition.
Figure 4: (a) Aspect of the cervix in transvaginal ultrasonography showing absence of varices and (b) same image with color Doppler.
(a) (b)
Discussion
Varicose veins, in general, are common in pregnancy with a prevalence of up to 40% [5]. However, cervical varicosities are quite rare
in pregnancy with only 22 cases reported in the literature [2-4,6,8-12].
In normal pregnancy, vaginal and uterine veins form vaginal and uterine venous plexuses along the sides of the vagina and cervix, and
tributaries drain into the internal iliac veins. The exact mechanism of formation of cervical varices is unknown, however few theories
were given.
Firstly, compression of the internal iliac veins by the gravid uterus could cause formation of dilated vessels similar to the mechanism of
lower limb varicosities, vulvar varicosities or hemorrhoidal plexus. This could explain the formation of cervical varices in twins pregnancy
and polyhydramnios cases. However, out of the 22 cases reported in the literature, only one was associated with polyhydramnios and one

Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and
Literature Review
95
Secondly, in cases of placenta previa, increased blood drainage of the placental bed locally could result in greater venous pressure and
formation of varicosities as explained by Sammour., et al [6]. Out of the 22 cases reported in the literature, 16 were associated with pla-
centa previa [13]. In cases of placenta previa, specially abnormally adherent ones, neovascularization can occur and lead to the formation
of new vessels as mentioned by Chou., et al [7]. In the case we presented, placenta previa was present.
Finally, Diethylstilbestrol exposure in utero is said to be a possible cause leading to the formation of cervical varices [13]. Out of the 22
reported cases, four had this exposure in utero [13]. In our case, patient had no exposure to Diethylstilbestrol as mentioned in the history
of the patient.
The presence of cervical varicosities along with placenta previa can lead to severe antepartum hemorrhage and preterm delivery as

ml [14]. The need for blood products is also increased with transfusion rate of 45.5% [14]. There is one reported case of hysterectomy for
ruptured cervical varices associated with severe hemorrhage [9].
Severe antepartum bleeding can lead to iatrogenic preterm delivery, which can increase the fetal morbidity and mortality. The average
gestational age at delivery, as reported by Peng., et al. is 33 weeks [14].
In cases of antepartum hemorrhage, physicians should consider the differential diagnosis of cervical varices specially in presence of
any of the risk factors such as: placenta previa, uterine overdistention or Diethylstilbestrol exposure.
In assessing the differential diagnosis, speculum vaginal examination in early gestational age can miss the diagnosis of cervical varices

a mesh of engorged smooth woven cord like structures.
In a context of sever antepartum hemorrhage along with the presence of placenta previa, the exact origin of bleeding, either from cervi-

theater, as it was shown in our case.
Also, cervical varices can emerge either from the endocervix or from the external part of the cervix as mentioned by Tanaka., et al [15].

part and four cases from the endocervix. In cases where cervical varices are emerging from the endocervix, speculum vaginal examination
will show no abnormalities and could eventually miss the diagnosis.
On the other hand, the review of reported cases suggests to avoid any vaginal examination such as speculum examination, Papanico-
laou smear, cervical biopsies or intercourse [14].
In view of all this, the best way to establish the diagnosis of cervical varices is by transvaginal ultrasonography with color and pulse
Doppler [3,12-14]. In presence of placenta previa, physicians should localize the placenta precisely and look for any vessels in the sur-
roundings such as vasa previa, and they should also screen the cervix to look for any cervical varices in the cervix or around it. This map-
ping of the placenta and cervix is best done by transvaginal ultrasonography, but it can also be done by abdominal probe [3].
Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and
Literature Review
96
-
ocal cases or suspicion of abnormally adherent placenta [12]. Sagittal T2 views may be useful in imaging vascular dilatation in the cervix
     
Resonance Imaging failed to identify vessels or varices in or around the cervix, maybe because of focusing on looking for an abnormally
invasive placenta.
 
plan of management or guidelines. The majority of authors agree on bed rest, pelvic rest (avoid intercourse, minimize speculum examina-
tion) and antenatal corticosteroids when fetal viability is achieved [2,8-10]. If cervical varices are discovered early in pregnancy and are
et al. in a case report, proposed emergency cervical cerclage in association with bed and
pelvic rest [13]. In their case, cervical varices were discovered at 15 weeks of gestation and emergency cervical Mac Donald cerclage was
placed. Delivery was achieved at 39 weeks.
However, the risk of severe hemorrhage, due to iatrogenic rupture of cervical varices during the cervical cerclage, and the absence of

More studies are required to recommend any antenatal interventions and weigh pros and cons.
In our case, active bleeding continued after completing the cesarean section and was only stopped once the ligation of varices was
performed vaginally. It is possible that this ligation could be the treatment of active bleeding from cervical varices in case of antepartum

hands, could stop the bleeding, as demonstrated in our case, and probably allow pregnancy to continue till term. The major challenge in
a context of cervical varices along with the presence of placenta previa is to clearly identify the origin of bleeding, from the placenta or
the cervical varices.
In the review by Tanaka., et al. of nine case of cervical varices associated with placenta previa, the delivery was 37 weeks in three cases,
36 weeks in one case, 34 weeks in one case, 32 weeks in two cases and 27 weeks in one case [15]. The high incidence of preterm delivery
in these cases is explained by the risk of severe antepartum hemorrhage leading to emergency cesarean section as reported in our case.
The role of the physician is to optimize the time of delivery whilst avoiding fetal or maternal compromise. Multidisciplinary meetings
involving obstetricians, anesthesiologists, pediatricians, hematologists and even interventional radiologists is of high importance. Patient
should be aware of all risks (preterm birth, emergency cesarean section, multiple blood transfusions) and the responsible treating team
should be ready for intervention at appropriate time.
Among the 22 cases described in the literature, one case delivered vaginally at 31 weeks [8] and one had second trimester abortion
at 17 weeks [16]. All the other cases had either elective or emergency cesarean section. Emergency cesarean section was also performed
in our case. Cesarean section is the preferred mode of delivery in case of cervical varices in order to minimize vaginal manipulations and
avoid any rupture of varices during the vaginal delivery.
Other modalities to control bleeding, such as uterine artery embolization, have been reported in the literature in certain conditions. In
situation where termination of pregnancy is indicated in a non-viable fetus, Lesko., et al. used prophylactic uterine artery embolization in
Citation: Idriss Gharbi., et al. “Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case
Report and Literature Review”. EC Gynaecology 10.3 (2021): 91-98.
Uncommon Cause of Ante Partum Hemorrhage: Cervical Varicosities Associated with Placenta Previa. Case Report and
Literature Review
97
-
tion of pregnancy and uterine evacuation was performed after uterine artery embolization. According to the authors, it helped to prevent

Also, uterine artery embolization was used immediately post cesarean section in the two cases presented by Chyjek., et al [13]. The
blood loss in these two cases was 1000 ml.
We did consider prophylactic uterine artery catheter placement before planned cesarean section and planned to be discussed in future
multidisciplinary meetings, but pregnancy was terminated at 26 weeks in a life threatening situation.
The evolution of cervical varices in the post-natal period seems to be good as varices tend to completely disappear. In the review of
nine cases presented by Tanaka., et al. seven cervical varices have disappeared immediately after delivery, one after three days and an-
other one after uterine artery embolization [15].

could be explained by the sudden drop of the venous pressure generated from the placental bed after delivery, and the collapse of cervical
varices after ligation.
Conclusion
Cervical varices associated with placenta previa are rare and could be potentially life threatening. In these circumstances physicians
should be aware of this association and they should diagnose cervical varices in order to avoid iatrogenic rupture or misleading diagnosis
of bleeding placenta previa. Cervical mapping by transvaginal sonography is important in such cases to establish the origin of bleeding.
Multidisciplinary team involvements are also of high importance and the treating team should be ready for massive hemorrhage or pre-
term delivery.
Elective cervical varices ligation could be an option in skilled hands in order to prolong the pregnancy, if diagnosis is made early.


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Volume 10 Issue 3 March 2021
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Article
Full-text available
Objective Ruptured cervical varicose veins can cause significant vaginal bleeding during the third trimester of pregnancy. The etiology is not uncommon, yet receives little discussion in current literature. We here report such a case with complete evaluations, managements and follow ups; while analyzing similar cases published. Case report A 34-year-old pregnant woman, gravida 1, presented with sudden onset of painless antepartum hemorrhage at 31⁺⁵ weeks of gestation. Speculum examination revealed ruptured cervical varicose veins; further evaluations with transvaginal sonography and magnetic resonance imaging were done to study the extensiveness and characteristics of the lesion. The cervical varices spontaneously regressed by postpartum day 4 and no recurrence was observed in the immediate postpartum follow-up period or in the subsequent pregnancy. Conclusion The case is unique for the lack of association with placenta previa. Cervical varicose veins rupture should be considered for painless vaginal bleeding during the third trimester pregnancy.
Chapter
In addition to unacceptably high perinatal mortality [1], antepartum hemorrhage (APH) is an important contributory cause of maternal mortality and morbidity in the developing countries. Although it is not preventable, an early diagnosis and treatment can improve maternal and perinatal outcome to a large extent.
Article
Uterine cervical varix is rare, and its clinical course is poorly understood. Therefore, we present a case report of cervical varix complicating placenta previa before describing our findings in the context of an electronic database search of relevant reports. In the case report, we describe the clinical course and imaging results of a 35-year-old woman who was diagnosed with cervical varix complicated by placenta previa. Investigation by magnetic resonance imaging, serial ultrasonography, and speculum confirmed the diagnosis, and a healthy baby was successfully delivered at 36 weeks of gestation by cesarean section. An electronic search identified nine previous cases of cervical varix complicated by placenta previa in the literature. Clinicians should be aware of cervical varices when managing placenta previa to avoid iatrogenic rupture or misdiagnosis of placenta accreta by magnetic resonance imaging.
Article
Cervical varicosities (CVs) have been reported infrequently in pregnancy and have been associated with significant antepartum and postpartum haemorrhage. The most common association with CVs in pregnancy in the literature is placenta praevia. To further investigate the association between placenta praevia and CVs. A retrospective audit of all cases of placenta praevia that had an ultrasound in the Feto-Maternal Unit at Liverpool Hospital over the period January 2001 to January 2012. Patient outcomes were obtained from the hospital paper and electronic medical records, including mode of delivery and blood loss. Eighty-four cases of placenta praevia were identified, and 78 had saved images that were reviewed. 51 of these 78 cases had transvaginal ultrasound (TVUS) images, which identified nine further cases of cervical varicosities. All cases of CVs were complicated by APH and delivered by caesarean section. There was no significant difference in the blood loss at delivery between the placenta praevia with CVs and those without (925 vs 870 mLs P = 0.3877). Cervical varicosities are not as rare as the literature would suggest. The clinical relevance of the additional finding of CV on TVUS in cases of placenta praevia is questionable.
Article
Uterine cervical varix (CV) is a very rare condition during pregnancy and may cause moderate to severe hemorrhage. We present the third reported case of huge CV coexisting with placenta previa in the English literature. A 40-year-old chronic hypertensive patient with marginal placenta previa also had cervical varix causing hemorrhage. At the 38th gestational week emergent cesarean section was performed because of placental abruption. Placenta previa is a risk factor for CV and patients with placenta previa who have moderate bleeding should be examined for this coexistence. The choice of management is close follow-up and cesarean section close to term.
Article
Adverse pregnancy outcome in diethylstilbestrol-exposed progeny has been described by many authors. These three cases demonstrate many of the features discussed in the literature as well as a previously unreported cause of antepartum and intrapartum bleeding: a cervical vascular malformation.
Article
The prevalence of reflux in the deep and superficial venous systems in the Edinburgh population and the relationship between patterns of reflux and the presence of venous disease on clinical examination were studied. A cross-sectional survey was done on men and women ranging in age from 18 to 64 years, randomly selected from 12 general practices. The presence of varicose veins and chronic venous insufficiency was noted on clinical examination, as was the duration of venous reflux by means of duplex scanning in 8 vein segments on each leg. Results were compared using cut-off points for reflux duration (RD) of 0.5 seconds or more (RD >/= 0.5) and more than 1.0 second (RD > 1.0) to define reflux. There were 1566 study participants, 867 women and 699 men. The prevalence of reflux was similar in the right and left legs. The proportion of participants with reflux was highest in the lower thigh long saphenous vein (LSV) segment (18.6% in the right leg and 17.5% in the left leg for RD >/= 0.5), followed by the above knee popliteal segments (12.3% in the right leg and 11.0% in the left leg for RD >/= 0.5), the below knee popliteal (11.3% in the right leg and 9.5% in the left leg for RD >/= 0.5), upper LSV (10.0% in the right leg and 10.8% in the left leg for RD >/= 0.5) segments, the common femoral vein segments (7.8% in the right leg and 8.0% in the left leg for RD >/= 0.5), the lower superficial femoral vein (SFV) segments (6.6% in the right leg and 6.4% in the left leg for RD >/= 0.5), and the upper SFV (5.2% in the right leg and 4.7% in the left leg for RD >/= 0.5) and short saphenous vein (SSV) (4.6% in the right leg and 5.6% in the left leg for an RD >/= 0.5) segments. In the superficial vein segments, there was little difference in the occurrence of reflux whether RD >/= 0.5 or RD > 1.0 was used; but in the different deep vein segments, the prevalence of reflux was 2 to 4 times greater for RD >/= 0.5 rather than RD > 1.0. Men had a higher prevalence of reflux in the deep vein segments than women, reaching statistical significance (P </=.01) in 4 of 5 segments for RD >/= 0.5. In general, the prevalence of reflux increased with age. Those with "venous disease" had a significantly higher prevalence of reflux in all vein segments than those with "no disease" (P </=.001). The prevalence of venous reflux in the general population was related to the presence of "venous disease," although it was also present in those without clinically apparent disease. There was a higher prevalence of reflux in the deep veins in men than the deep veins in women. Follow-up study of the population will determine the extent to which reflux is a predictor of future disease and complications.
Article
A case of placenta previa increta/percreta was diagnosed at 18 weeks' gestation with the 3-dimensional color power Doppler imaging technique. Unusually extensive uteroplacental vascular network architecture was seen on the 3-dimensional angiohistogram. After appropriate counseling, the patient chose to terminate the pregnancy. A hysterectomy was performed with prophylactic preoperative embolization of internal iliac arteries at 21 weeks' gestation, and histopathologic examination revealed placenta previa increta/percreta. This new 3-dimensional angiohistogram technique allowed us to visualize all 3 orthogonal planes of the angioarchitectural information. It appears to be a useful complementary tool and is likely to play a more defining and clarifying role in assessing the quantification of abnormal uteroplacental neovascularization for patients with placenta previa increta/percreta.
Article
Uterine cervical varix is a rare complication in pregnant women and can be the cause of obstetric hemorrhage in the vagina resulting in adverse events for both the mother and fetus. A 34-year-old Japanese woman was hospitalized at 18 weeks gestation because of cervical varix and placenta previa. Prophylactic tocolysis successfully controlled the obstetric hemorrhage. At 27 weeks gestation, emergent cesarean section was performed because of intractable hemorrhage from the marginal placenta previa. Intraabdominal findings revealed no vascular malformation of the uterus, and the operation was performed uneventfully. A speculum examination of the vagina and cervix at 1 month postpartum were unremarkable. It is important to recognize the clinical features and available treatments for cervical varix.