A 39-year-old woman (gravida 6, para 3-0-3-3) underwent a standard protocol of artificial cycle FET and had been transferred two in vitro fertilization-derived embryos at a fertility clinic. Detailed information about the transferred embryos was not available for this case. The patient had episodes of spontaneous and artificial abortions and a salpingectomy for an ectopic pregnancy, but had no history of a cesarean section. She became pregnant by FET and was treated with progesterone agents, an estrogen patch, and aspirin.
At 5-2/7 weeks of gestation, she presented to our hospital with hemorrhagic shock due to persistent genital bleeding. A transvaginal ultrasonography detected an intrauterine gestational sac of age-appropriate size and a squashed cystic lesion in the cervix. A blood examination indicated a hemoglobin level of 4.8 g/dL. Blood coagulum from the genitalia contained decidual tissues. Her genital bleeding was successfully controlled by manual compression of the external cervical os and the blood pressure and heart rate were stabilized after transfusing four units of red cell concentrates. She was diagnosed with a cervical heterotopic pregnancy. All the medications that had been prescribed at the fertility clinic were withdrawn, with the intention to terminate the pregnancy. However, despite the discontinuation of progesterone supplementation, the gestational sacs in the cervix and uterus continued to develop and formed yolk sacs (Figs 1a and 1b).
At 8 weeks of gestation, the patient expressed her desire to maintain the intrauterine pregnancy, despite being fully informed of the risk of hemorrhage and other complications. As there was growth discordancy in the two pregnancies and the fetal heartbeat was not observed in the gestational sac in the cervical canal,7 the gestational sac was manually removed with forceps under ultrasound guidance, instead of local potassium chloride injection. The cervical bleeding was controlled by astriction. Histological analyses of the removed specimen confirmed the presence of fetal tissues.
The subsequent course of the pregnancy was uneventful until delivery, except for a vasa previa that was detected at 28 weeks of gestation (Figs 1c and 1d). In order to avoid the rupture of the vasa previa, a cesarean section was performed at 36 weeks of gestation, which resulted in the birth of a healthy female infant. However, at the delivery, massive bleeding occurred from the region around the internal cervical os. A total hysterectomy was performed because the placenta was not able to be manually separated from the uterus. A histological examination of the uterus indicated a total placenta accreta; placental villi had invaded the myometrium (Figs 2a and 2b). There was no histological abnormality in the cervix or in the region around the internal os.