Lessons to be learnt from intracervical hypervascularity

Sir,

We read with interest the article by Aryananda et al. in which the authors highlight the critical role of assessing intracervical hypervascularity in suspected cases of placenta accreta spectrum (PAS). They proposed a grading system for intracervical hypervascularity, categorizing it into three grades based on the extent of multiple tortuous anechoic spaces within the cervix: Grade 1 (<50% of cervical tissue); Grade 2 (>50% of cervical tissue), and Grade 3 (>50% of cervical tissue with loss of the clear zone between placental and cervical tissue).¹

Intracervical hypervascularity and intracervical lakes are independently associated with major postpartum hemorrhage.^{1, 2} This pathology complicates the placement of multiple colpouterine pedicle sutures, making hemorrhage control difficult and uterine reconstruction unfeasible due to insufficient healthy tissue.¹

We present a case illustrating the clinical significance of intracervical hypervascularity and its impact on surgical management. The patient had a history of two previous caesarean deliveries and a complete anterior placenta praevia, with no episodes of antepartum hemorrhage. Preoperative ultrasound revealed features highly suspicious of PAS, including uterovesical and subplacental hypervascularity, multiple placental lacunae with prominent feeder vessels, and marked intracervical hypervascularity. Magnetic resonance imaging was not performed due to the presence of a cardiac clip. A planned caesarean hysterectomy was undertaken at 35 + 6 weeks' gestation under general anesthesia.

Upon entering the abdomen, the initial primary survey did not reveal any significant pathology (Figure 1). The bladder was easily reflected; there was no apparent myometrial defect in the lower uterine segment, and only minimal bridging vessels required ligation. This appearance provided false reassurance to the surgical team, with limited experience in the significance of intracervical hypervascularity at this time. An attempt to deliver the placenta resulted in partial separation, triggering sudden, massive vaginal bleeding due to disruption of the lacunar network. A hysterectomy was promptly initiated and done within 8 min. Despite this, there was extensive and rapid vaginal hemorrhage, the full extent of which was not immediately apparent to the primary surgeon, as minimal bleeding was visualized abdominally. Hemodynamic instability was managed by experienced anesthetists and completion trachelectomy. The total weighed blood loss was 16 630 mL. The patient received 4762 mL of cell salvage blood (1762 mL from abdominal collection and 3000 mL from vaginal collection), 4 units of red blood cells, 4 packs of fresh frozen plasma, 1 unit of platelets, 2 units of cryoprecipitate, and 6 g of fibrinogen.

This case exemplifies the clinical significance of identifying intracervical hypervascularity. As illustrated in Figure 1, based on the grading system proposed by Aryananda et al.,¹ the ultrasound image confirms Grade 3 intracervical hypervascularity. Concurrently, image (a) reveals minimal uterovesical pathology, illustrating how the primary survey (image b) appeared deceptively normal. In this instance, the pathology was located low down towards the cervix rather than at the uterovesical interface, resulting in unexpected major vaginal bleeding following disruption of the placental interface during surgery. The two key issues in this case were the false reassurance provided by the primary survey—prompting an attempt at placental delivery—and the delayed recognition of the extent of vaginal hemorrhage.

Had the intracervical hypervascularity been accurately graded as Grade 3 preoperatively, a planned caesarean-hysterectomy would have been performed without attempting placental delivery, thereby minimizing blood loss. Additionally, if the extent of vaginal bleeding had been noted earlier, internal manual aortic compression (IMAC) could have been applied to significantly reduce blood loss while the hysterectomy was being performed.³

Transvaginal ultrasound has been shown to be a stronger predictor of surgical outcomes than transabdominal ultrasound.⁴ The grading system for intracervical hypervascularity may provide valuable clinical information into estimating the risk of severe PAS and intraoperative blood loss.⁵ Although Grade 3 intracervical hypervascularity is rare, its identification and appropriate management are crucial to minimizing maternal morbidity and mortality. Improved outcomes also depend on the involvement of experienced multidisciplinary teams. A strong understanding of the ultrasound features is essential for optimal surgical planning. Equally important is fostering a culture of reflective practice—learning from each case and striving for continuous improvement, rather than attributing complications solely to the complexity of the condition. Incorporating preoperative cervical grading into standard PAS screening may help guide surgical decision-making and improve patient outcomes.

SPW: Conceptualisation, Writing. ME: Reviewing and Editing.

The authors report no conflict of interest or financial disclosure of interests.