Dear Editor, Cervico-isthmic pregnancy is a rare complication of pregnancy. The incidence of cervical and cervicoisthmic pregnancy ranges from 1:2400 to 1:4500 (1, 2). Appropriate early diagnosis and treatment lead to the remarkable reduction of maternal mortality from 45% to approximately zero (1). We describe the first case of a cervico-isthmic pregnancy in the first trimester that was associated with a placenta percreta and was managed surgically because of massive hemorrhage. A36-year-old woman, gravida 6 para 3, who was referred from a state hospital because attempted dilatation and curettage for 8 weeks gestation was complicated by massive vaginal bleeding. Her obstetric history was notable for three previous cesarean sections and two spontaneous abortions, both followed by curettage. She was in moderate general condition. There was marked pallor, blood pressure 90/60 mmHg and pulse 120/min. The patient's hemoglobin level was 6.0 g/dl. Pelvic examination in our center revealed that the patient's vagina was filled with a blood clot. After evacuating the vagina, severe bleeding through the cervical os was observed. The uterus was enlarged and approximately 8-9 weeks gestation. An ultrasound examination showed a cervical pregnancy with a dead fetus of 8 weeks gestation. An emergency laparotomy was performed. This pregnancy was associated with a placenta percreta that was located on the anterior wall of the servico-isthmic region, just under the posterior wall of the bladder. Bladder dissection revealed neovascularization on the anterior wall of the servix. Due to above findings, a total abdominal hysterectomy was performed with conservation of both ovaries (Fig. 1). Altogether, she was transfused with five units of blood. The postoperative course was uneventful. She was discharged 4 days later in a general good condition. The pathologist confirmed the diagnosis of cervicoisthmic placenta percreta. Although the cause of cervical and cervico-isthmic pregnancy is unclear, previous cesarean deliveries, previous curettage, Asherman's syndrome, previous cervical or uterine surgery are the likely contributing factors (1, 2). The above factors certainly contributed to development of the anormal placentation (3). Early diagnosis of cervico-isthmic pregnancy is very important due to high morbidity and mortality rates. When evaluating patients with first trimester bleeding who have predisposing factors for cervico-isthmic pregnancy, high clinical suspicion should lead to prompt imaging studies to avoid the potential catastrophic outcome associated with cervico-isthmic pregnancy. 

Dear Editor, Cervico-isthmic pregnancy is a rare complication of pregnancy. The incidence of cervical and cervicoisthmic pregnancy ranges from 1:2400 to 1:4500 (1, 2). Appropriate early diagnosis and treatment lead to the remarkable reduction of maternal mortality from 45% to approximately zero (1). We describe the first case of a cervico-isthmic pregnancy in the first trimester that was associated with a placenta percreta and was managed surgically because of massive hemorrhage. A36-year-old woman, gravida 6 para 3, who was referred from a state hospital because attempted dilatation and curettage for 8 weeks gestation was complicated by massive vaginal bleeding. Her obstetric history was notable for three previous cesarean sections and two spontaneous abortions, both followed by curettage. She was in moderate general condition. There was marked pallor, blood pressure 90/60 mmHg and pulse 120/min. The patient's hemoglobin level was 6.0 g/dl. Pelvic examination in our center revealed that the patient's vagina was filled with a blood clot. After evacuating the vagina, severe bleeding through the cervical os was observed. The uterus was enlarged and approximately 8-9 weeks gestation. An ultrasound examination showed a cervical pregnancy with a dead fetus of 8 weeks gestation. An emergency laparotomy was performed. This pregnancy was associated with a placenta percreta that was located on the anterior wall of the servico-isthmic region, just under the posterior wall of the bladder. Bladder dissection revealed neovascularization on the anterior wall of the servix. Due to above findings, a total abdominal hysterectomy was performed with conservation of both ovaries (Fig. 1). Altogether, she was transfused with five units of blood. The postoperative course was uneventful. She was discharged 4 days later in a general good condition. The pathologist confirmed the diagnosis of cervicoisthmic placenta percreta. Although the cause of cervical and cervico-isthmic pregnancy is unclear, previous cesarean deliveries, previous curettage, Asherman's syndrome, previous cervical or uterine surgery are the likely contributing factors (1, 2). The above factors certainly contributed to development of the anormal placentation (3). Early diagnosis of cervico-isthmic pregnancy is very important due to high morbidity and mortality rates. When evaluating patients with first trimester bleeding who have predisposing factors for cervico-isthmic pregnancy, high clinical suspicion should lead to prompt imaging studies to avoid the potential catastrophic outcome associated with cervico-isthmic pregnancy.