Cord Prolapse in Pregnancy—A Rare Complication of LEEP and Cervical Conization

Introduction: Loop Electrosurgical Excision Procedure (LEEP) and cervical conization are surgical procedures performed for management of high grade cervical intraepithelial lesion. Common complications associated with these procedures are bleeding, infection and cervical stenosis. It is also associated with increased rates of preterm delivery and perinatal mortality. Literature has reports on uncommon complications such as rectovaginal and vesicovaginal fistula.

Case Report: Thirty-year-old Gravida 1 Para 0010 at 23 weeks and 1 day presented with preterm premature rupture of membranes (PPROM). Following Maternal Fetal Medicine and NICU consults, patient desired all measures to resuscitate fetus and was admitted for administering latency antibiotics and steroid for fetal lung maturity. Her surgical history was significant for LEEP and cone biopsy for high grade cervical lesion. At 16 weeks of gestation, she was diagnosed with cervical length of 1.8cm. A McDonald cerclage was placed for short cervix and prior history of fetal loss at 20 weeks secondary to cervical incompetence. At 21 weeks funneling of membranes was noted in sonogram ([Fig. 1]). Patient opted for a revision cerclage. During the procedure, previous cerclage stitch was noted to be in place. However, at the 7–8 o'clock region a defect of ~1 cm was noted in the posterior fornix where the cervix abuts the uterus. This defect was completely sealed with a new cerclage stitch ([Fig. 2]).

On the second day of admission, patient had a cord prolapse. Quick sonogram was performed to confirm fetal heart beat given that it is a peri-viable pregnancy. A hand was placed in vagina to reduce the cord while preparing for a classical cesarean section. Interestingly, the cervix was noted to be completely closed with sutures in place. Following the c section, a speculum and vaginal examination revealed a closed cervix with sutures intact and a 2 cm defect in the posterior fornix at the junction of the cervix and uterus. Cord prolapse was likely secondary to uterovaginal fistula. Baby of 525 g was born with APGAR 4 and 6 and admitted in NICU for further care.

Conclusion: Defect at cervico-uterine junction causing a fistulous communication between endometrial cavity and vagina led to a cord prolapse. This is attributed as a complication of LEEP and cone biopsy. To the best knowledge of the authors, this defect and fistula leading to a cord prolapse during pregnancy has not been reported in literature before.

Fig. 1 Ultrasound at 21 weeks showing funneling of membranes. Note: Blue arrow: Closed cervix. Orange arrow: Defect posterior to cervix with funneling of membranes into vagina.

Fig. 2 Ultrasound image of closed cervix and intact sutures post revision cerclage. Note: Blue arrow: Cerclage stitch in place.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
17 September 2021