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Summary

  1. Top of page
  2. Summary
  3. Case report
  4. Discussion
  5. References

This is the first known documented case of a successful pregnancy following fertility-preserving radical trachelectomy, ovum donation and in vitro fertilisation.

Case report

  1. Top of page
  2. Summary
  3. Case report
  4. Discussion
  5. References

AB, a 45-year-old nulliparous woman was under cytological review following a cone biopsy in 1990 for cervical intraepithelial neoplasia (CIN) 3. In 2000, a severe dyskaryotic smear prompted a large loop excision of the transformation zone which showed evidence of invasive squamous cell carcinoma measuring 7 × 6 mm (stage 1B1). On more detailed histological examination, there was no apparent lymphovascular spread, and a pelvic magnetic resonance imaging scan demonstrated no evidence of parametrial or pelvic lymph node involvement. Standard treatment for this stage of malignancy would be a radical hysterectomy with bilateral pelvic lymph node dissection. As AB wished to keep the option of having a child, the alternative of fertility-sparing surgery was discussed. Referral was made to a centre offering this treatment. Following detailed counselling and a multidisciplinary team discussion, it was decided to undertake fertility-preserving surgery, and a radical vaginal trachelectomy and laparoscopic pelvic lymph node dissection were performed. During the surgery, the cervix, paracervical tissues and vaginal cuff were removed and an isthmic cerclage was inserted using 1 nylon tied around a size 6 Hagar dilator. The surgery was successful with no complications. The final histological specimen indicated residual CIN3 with glandular involvement. There was no spread to pelvic lymph nodes, of which 27 were sampled.

Prior to this, AB had a complicated obstetric history. At 39, she had a miscarriage at 9 weeks and an ectopic pregnancy 3 years later with tubal preservation. At the end of 1998, at the age of 42 during investigations for secondary infertility, AB was noted to have an increased follicle stimulating hormone level and was advised to receive ovum donation. While on the waiting list, AB had another miscarriage at 11 weeks and then in 2000, she was diagnosed with carcinoma of the cervix and underwent her radical cervical surgery.

Following her third cycle of ovum donation, AB became pregnant. Ultrasound scan at 7 weeks demonstrated dichorionic twins. She was commenced on progesterone pessaries and continued these throughout her pregnancy. At 12 weeks, only one fetus was viable and nuchal translucency screening using the egg donor’s age calculated the pregnancy to be of low risk for trisomy 21. Regular scans throughout the pregnancy identified a normal fetus, which was on all occasions appropriately grown for gestational age. Due to the lack of cervical tissue, lower uterine segment lengths were measured. At 24 weeks, this was 34 mm but by 26 weeks had reduced to 13 mm and funnelling was seen (Figure 1). AB was therefore admitted, received intramuscular betamethasone and remained an inpatient throughout the rest of her pregnancy. At 36 weeks of gestation, a healthy baby girl weighing 2720 g was delivered by classical caesarean section. Both mother and baby did well and were discharged home 2 weeks post-delivery.

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Figure 1. Transvaginal scan at 26 weeks demonstrating a lower uterine segment length of 13.3 mm (calipers) and the presence of funnelling (filled arrow).

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Discussion

  1. Top of page
  2. Summary
  3. Case report
  4. Discussion
  5. References

This is the first known documented case of a successful pregnancy following radical trachelectomy and in vitro fertilisation with ovum donation.

Fertility-preserving radical trachelectomy was first described in the literature by D’Argent in 1994 but has been performed worldwide for approximately 15 years.1 However, the number of women reported in the literature having undergone this procedure has been limited to less than 300.2 Successful pregnancies have been described following this operation for early-stage cervical carcinoma, but their numbers remain small and the management of these pregnancies remains complex.3,4

Subfertility has been described following D’Argent’s procedure. It is thought that this is secondary to decreased cervical mucous, isthmic stenosis, surgical adhesions or subclinical salpingitis.2 This woman was already known to be subfertile and awaiting ovum donation and in vitro fertilisation.

Following successful conception, the main risk to this pregnancy was the absence of a cervical canal.3 This results in a lack of mechanical support to the uterine isthmus, an absence of cervical mucous and loss of a protective barrier to ascending infection.2 Due to this, premature rupture of membranes and prematurity are significant problems in these pregnancies occurring in about 50% of cases and D’Argent noted late miscarriages and preterm labour early on in his follow up.5 Placing of permanent cervical sutures at time of radical trachelectomy was found to prevent deliveries before 30 weeks.5 Antenatally, to assess cervical competence, AB’s lower uterine/cervical length was measured regularly by transvaginal ultrasound scan from 12 weeks and at 26 weeks, this had significantly reduced. Options at this time included inserting a second suture5 but bed rest was felt to be appropriate.

In addition to cervical cerclage, natural progesterone pessaries were used throughout the pregnancy to prevent preterm labour. Evidence suggests that prophylactic vaginal progesterone reduces the frequency of uterine contractions and the rate of preterm delivery.6

If uterine contractions were to commence after radical trachelectomy, then there are serious risks of uterine rupture and haemorrhage. To avoid this, AB was delivered electively at 36 weeks of gestation. Following recommendation from the gynaecologist who performed the original cervical surgery, a classical caesarean section was undertaken. This avoids the uterine scar tissue and cervical suture that a lower transverse incision could damage. However, the presence of a vertical uterine scar would be an additional risk factor in the management of subsequent pregnancies.

This case illustrates how, even in the perimenopausal woman, radical trachelectomy in conjunction with ovum donation and in vitro fertilisation can result in a successful outcome.

References

  1. Top of page
  2. Summary
  3. Case report
  4. Discussion
  5. References