Introduction: Cervical varicosity is a rare complication of pregnancy. They present as painless vaginal bleeding, mostly during the second or third trimester, potentially leading to maternal and fetal morbidity and mortality. There have only been 18 cases reported in the English literature with varying presentation, and there has been no consensus on the optimal approach to manage cervical varices. Cervical cerclage was placed in three cases, however there were other concurrent indications for them rather than the bleeding cervical varices. We present a case of cervical varix presenting with vaginal bleeding starting in first trimester and directly managed with McDonald cerclage.

Case Presentation: Patient was a 29 year-old G1 woman with no known exposure to diethylstilbestrol (DES). Patient experienced two episodes of vaginal spotting at 9 weeks gestation and was advised to practice pelvic rest. Speculum exam at 12 weeks gestation noted non-bleeding cervical varices. Patient continued to experience intermittent spotting the following weeks, though she did not practice pelvic rest. At 14 weeks gestation patient experienced heavy vaginal bleeding which resolved. Patient was subsequently referred for evaluation by Maternal Fetal Medicine (MFM) specialists.

Final Diagnosis: Cervical varicose was confirmed as well as varicosity of the lower uterine segment.

Management/ Outcome/ Follow-up: Decision was made to perform McDonald cerclage under spinal anesthesia. A persistently bleeding point was successfully tamponade with a single chromic suture. Patient continued to follow up regularly with her primary physician as well as MFM throughout her pregnancy. She was also advised to practice strict pelvic rest. At 19 weeks gestation, transvaginal ultrasound revealed short cervix and cerclage in situ. There was no evidence of low-lying placenta or placenta previa. The patient was started on vaginal progesterone. The cervical length remained short but stable throughout the remainder of her pregnancy. At 32 weeks gestation, patient experienced preterm contractions after vaginal intercourse which resolved with tocolysis. She completed a course of antenatal corticosteroid. The patient did not experience further vaginal bleeding through the remainder of her pregnancy. Cesarean delivery was planned at 37 weeks 6 days gestation. The cerclage was removed at the end of the Cesarean delivery. Cervical varicosity was noted to have resolved at time of cerclage removal.

Our case does not only report a rare obstetric occurrence being cervical varicosity, but our case is also significant in several aspects. Firstly, while most cases of cervical varices were diagnosed with second or third trimester bleeding, our patient presented with painless vaginal bleeding since first trimester. She also does not have other risk factors that have been documented such as DES exposure, placenta previa or increased uterine size. She received a McDonald cerclage as the management method which successfully prevented further bleeding episodes during her pregnancy. The patient was followed closely and regularly throughout her pregnancy with ultrasonography. They patient was delivered at term via planned Cesarean delivery with birth of a healthy infant. Our case report is the first in which cervical cerclage was used to manage bleeding cervical varices during pregnancy without complications and with good maternal and fetal outcomes.