# Massive vaginal bleeding caused by ruptured cervical varices associated with fetal loss in the second trimester of pregnancy: A report of a rare case

## TL;DR

A rare case of massive vaginal bleeding due to ruptured cervical varices during pregnancy is reported, emphasizing the importance of early diagnosis and differential diagnosis to reduce risks.

## Contribution

This paper presents a rare clinical case of cervical varices rupture in the second trimester, highlighting diagnostic and management challenges.

## Key findings

- Transvaginal Doppler ultrasonography helped identify dilated vascular structures in the endocervix.
- Cervical varices rupture was successfully managed with cesarean section and hemostatic interventions.
- Early diagnosis and differential diagnosis are crucial to prevent maternal and perinatal complications.

## Abstract

Cervical varices during pregnancy are a rare clinical entity. The rupture of cervical varices in pregnant women may be associated with fetal loss following the termination of the pregnancy or pre-term delivery, in the case that it occurs in the presence of a viable fetus. The present study describes a case of pregnancy termination by caesarean section due to massive vaginal bleeding following the rupture of cervical varices in the second trimester. A 26-year-old primigravida, with a history of placenta previa, presented to the hospital at 21 weeks of gestation, reporting significant painless vaginal bleeding. A transvaginal Doppler ultrasonography revealed elongated formations in the endocervix with increased vascularization, suggestive of dilated vascular structures. There were no obvious signs of peripheral abruption of the placenta previa. In the operating room, a thorough examination of the cervix revealed enlarged blood vessels with a variceal appearance, protruding through the cervical canal to the external cervical os, which were actively bleeding. Upon palpation of the vascular structures, torrential vaginal bleeding ensued. After temporarily controlling the bleeding with the use of several hemostatic forceps, the termination of the pregnancy was performed via cesarean section. To manage the severe intraoperative bleeding, blood transfusion was administered, and an utero-cervico-vaginal tamponade was performed using gauze packing. Blood transfusions were also required in the immediate post-operative period to stabilize the hemodynamic condition of the patient. The patient was discharged from the clinic on the 5th post-operative day. At 20 days thereafter, a clinical examination and transvaginal Doppler ultrasonography revealed normal cervical findings. On the whole, the case described herein highlights the importance of transvaginal Doppler ultrasonography in the early diagnosis of cervical varices. It also underscores the need for a differential diagnosis between bleeding from cervical varices and vaginal bleeding caused by peripheral placental abruption, with the goal of minimizing maternal and perinatal morbidity and mortality.