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Management of pregnancy after radical trachelectomy. Gynecol Oncol 2021; 162:220-225. [PMID: 33902946 DOI: 10.1016/j.ygyno.2021.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022]
Abstract
Radical trachelectomy (RT) is a surgery for early-stage cervical cancer treatment that preserves the childbearing ability, and its use has become increasingly common worldwide. Thus, the rate of conception in women who have undergone RT is increasing. However, pregnancy after RT is associated with a higher risk of several obstetric complications such as preterm delivery, preterm premature membrane rupture, and abnormal bleeding from varices at the site of uterovaginal anastomosis. Furthermore, since RT have a residual prophylactic cerclage, it is difficult to manage first- and second-trimester miscarriages. There is little previous data on the management of pregnancy after RT. In this review article, we summarize various management methods and experiences to provide a guide to clinicians for perinatal management after RT.
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Šimják P, Cibula D, Pařízek A, Sláma J. Management of pregnancy after fertility-sparing surgery for cervical cancer. Acta Obstet Gynecol Scand 2020; 99:830-838. [PMID: 32416616 DOI: 10.1111/aogs.13917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/17/2020] [Accepted: 05/12/2020] [Indexed: 12/14/2022]
Abstract
Cervical cancer is increasingly diagnosed in women who have not yet completed their reproductive plans. For women with early-stage disease (FIGO stage IA1-IB1), fertility-sparing procedures, such as conization, trachelectomy or radical trachelectomy, represent the treatments of choice. However, women who undergo repeated conization or trachelectomy represent a challenge for obstetricians because they are at increased risk of infertility, mid-trimester miscarriage, preterm premature rupture of membranes and preterm delivery. So far, the evidence-based guidance on the management of these pregnancies is limited. This article reviews the literature discussing pregnancy management in women after fertility-sparing surgery for early cervical cancer. Although the evidence is limited, certain measures are desirable, including screening and treatment of asymptomatic bacteriuria, screening for cervical incompetence and progressive cervical shortening by transvaginal ultrasonography, and fetal fibronectin testing. Vaginal progesterone supplementation should be primary prevention for all women after trachelectomy. Women with a history of preterm delivery or late miscarriage may benefit from cervical cerclage. Elective delivery by cesarean section in the early-term period is desirable.
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Affiliation(s)
- Patrik Šimják
- Department of Gynecology and Obstetrics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - David Cibula
- Department of Gynecology and Obstetrics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Antonín Pařízek
- Department of Gynecology and Obstetrics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jiří Sláma
- Department of Gynecology and Obstetrics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Son GH, Ham H, Park ST, Choi SY, Song JE, Lee KY. Outcomes after transabdominal cerclage in twin pregnancy with previous unsuccessful transvaginal cerclage. PLoS One 2020; 15:e0232463. [PMID: 32353024 PMCID: PMC7192486 DOI: 10.1371/journal.pone.0232463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/15/2020] [Indexed: 11/18/2022] Open
Abstract
Transabdominal cerclage (TAC) is reported to be effective for preventing preterm birth in women with unsuccessful transvaginal cerclage (TVC) history. However, TAC has rarely been performed in twin pregnancy given the lack of sufficient evidence and the technical difficulty of the operation. Thus, it is unclear whether TAC is an effective procedure for twin pregnancy in women with a history of unsuccessful TVC. The aim of this study is to compare the characteristics and pregnancy outcomes after TAC in twin pregnancy versus singleton pregnancy, to examine whether twin pregnancy is a risk factor for very preterm birth (before 32 weeks) after TAC, and to determine whether TAC is effective in preventing preterm birth in twin pregnancy. This single-center retrospective cohort study included women who underwent TAC because of unsuccessful TVC history between January 2007 and June 2018. Of 165 women who underwent TAC, 19 had twins and 146 had singletons. Our results showed that the neonatal survival rate improved dramatically when TAC was performed (15.4% (prior pregnancy) vs 94.0% (after TAC) in twins, p<0.01; 22.8% (prior pregnancy) vs 91.1% (after TAC) in singletons, p<0.01). Moreover, the risk of very preterm birth was significantly decreased after TAC in both groups (36/39 (92.3%) (prior pregnancy) vs 2/19 (10.5%) (after TAC) in twins, p<0.01; 290/337 (86.1%) (prior pregnancy) vs 17/146 (11.6%) (after TAC) in singletons, p<0.01). More advanced maternal age and history of prior preterm delivery between 26+0 and 36+6 weeks were independently associated with very preterm birth, whereas the presence of a twin pregnancy was not associated with very preterm birth on multivariate logistic regression analysis. These results suggest that TAC is associated with successful prevention of very preterm birth and improved neonatal survival rates in the absence of procedure-related major complications in women with twin pregnancy and previous unsuccessful TVC history.
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Affiliation(s)
- Ga-Hyun Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Heejin Ham
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sung-Taek Park
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - So-Yeon Choi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Ji-Eun Song
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Keun-Young Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
- * E-mail:
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Lee KN, Ham HJ, Whang EJ, Eun-Ji J, Seung-Hye C, Lee KY. Successful heterotopic pregnancy with prior radical trachelectomy after transabdominal cervico isthimic cerclage with methotrexate treatment. J Obstet Gynaecol Res 2020; 46:663-667. [PMID: 32028544 DOI: 10.1111/jog.14196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 12/30/2019] [Indexed: 11/30/2022]
Abstract
Heterotopic pregnancy with cervical incompetence is very uncommon. And yet there is no definite treatment for cervical incompetence occurring after radical trachelectomy. We are reporting a rare and novel case of a following in vitro fertilization combined intrauterine pregnancy and interstitial pregnancy which was successfully treated with maintenance of the pregnancy to term.
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Affiliation(s)
- Kyong-No Lee
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital of Hallym University, Seoul, Korea
| | - Hee-Jin Ham
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital of Hallym University, Seoul, Korea
| | - Eun-Jee Whang
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital of Hallym University, Seoul, Korea
| | - Jo Eun-Ji
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital of Hallym University, Seoul, Korea
| | - Choi Seung-Hye
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital of Hallym University, Seoul, Korea
| | - Keun-Young Lee
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital of Hallym University, Seoul, Korea
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Ito M, Yoneda S, Shiozaki A, Fukuta K, Yoneda N, Saito S. Multiple management strategies to prolong gestational period after radical trachelectomy. Clin Case Rep 2019; 7:1939-1944. [PMID: 31624613 PMCID: PMC6787797 DOI: 10.1002/ccr3.2400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/12/2019] [Indexed: 11/07/2022] Open
Abstract
Preterm premature rupture of membranes and massive genital bleeding in the second trimester are serious obstetrical problems in pregnancy after trachelectomy. We had managed a twin post-trachelectomy pregnancy by multiple strategies, and two healthy infants were delivered at 32+5 weeks, although the optimum management for such patients is unknown.
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Affiliation(s)
- Masami Ito
- Department of Obstetrics and GynecologyUniversity of ToyamaToyamaJapan
| | - Satoshi Yoneda
- Department of Obstetrics and GynecologyUniversity of ToyamaToyamaJapan
| | - Arihiro Shiozaki
- Department of Obstetrics and GynecologyUniversity of ToyamaToyamaJapan
| | - Kaori Fukuta
- Department of Obstetrics and GynecologyUniversity of ToyamaToyamaJapan
| | - Noriko Yoneda
- Department of Obstetrics and GynecologyUniversity of ToyamaToyamaJapan
| | - Shigeru Saito
- Department of Obstetrics and GynecologyUniversity of ToyamaToyamaJapan
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Debiève F, Joskin A, Steenhaut P, Bernard P, Hubinont C. Transabdominal cerclage for cervical insufficiency in twins: series of seven cases and literature review. J Matern Fetal Neonatal Med 2019; 33:3579-3583. [PMID: 30720374 DOI: 10.1080/14767058.2019.1579192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The diagnosis of cervical insufficiency is based on the previous history of recurrent second or early third trimester losses. Its incidence among pregnant women is 0.5-1% but can be as high as 75% among women with preterm birth. Transvaginal cerclage (TVC) is the common therapy of cervical insufficiency. However, this technique has several limits, especially in twin pregnancies. As some selected conditions, a transabdominal cerclage (TAC) is indicated, it has been offered to patients with multiple pregnancies.Aim: To evaluate the outcomes of twin pregnancies with transabdominal cerclage in terms of preterm birth rate and neonatal morbidity and mortality.Materials and methods: We conducted a retrospective study of seven patients with twin pregnancies managed with transabdominal cerclage at the end of the first trimester (12-15 weeks). We selected patients with a history of fetal loss who met the indications criteria of TAC (history of TVC failure or short cervix unable to have TVC). The antenatal and delivery data were collected and compared to those of their previous pregnancy.Outcomes: All patients carried their pregnancy throughout the second trimester and delivered during the third trimester. Mean gestational age was 34 4/7 week. All newborns were alive and neonatal morbidity rate was 50%, mostly related to preterm birth. Mean duration of neonatal intensive care stay was 32 days. There were no operative complications following TAC.Conclusions: Perinatal outcomes are considerably improved in twin pregnancies with transabdominal cerclage. Our findings corroborate those of previous case reports and support the efficacy of TAC for managing cervical insufficiency in twin pregnancies.
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Affiliation(s)
- Frédéric Debiève
- Obstetrics Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Aude Joskin
- Obstetrics Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Patricia Steenhaut
- Obstetrics Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Pierre Bernard
- Obstetrics Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Corinne Hubinont
- Obstetrics Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
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Ishioka S. First case of twin pregnancy after vaginal radical trachelectomy in a Japanese woman. Surg Case Rep 2018. [DOI: 10.31487/j.scr.2018.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Twin pregnancy after radical trachelectomy (RT) for uterine cervical cancer involves an extremely high risk of preterm premature rupture of the membrane (pPROM) and the following occurrence of preterm birth. Herein we report the first case of twin pregnancy after vaginal RT in a Japanese woman. The patient was a 36-year-old nulliparous woman. She became pregnant with twins one year after vaginal RT with laparoscopic lymphadenectomy and the following treatment with the use of in vitro fertilization/embryo transfer. Her pregnancy course was favorable with vaginal disinfection, bed rest, and administration of progesterone, ritodrine, and an ulinastatin vaginal suppository. At 31 weeks + 4 days of pregnancy, a scheduled cesarean section was performed. One baby weighed 1000g, with Apgar scores of 7/8, and the other 1100g, with Apgar scores of 8/9. Her postpartum course was also favorable. The mother remains without evidence of recurrence of the cancer at the time of this report.
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Ishioka S, Kim M, Mizugaki Y, Kon S, Isoyama K, Mizuuchi M, Morishita M, Baba T, Sekiya T, Saito T. Transabdominal cerclage (TAC) for patients with ultra-short uterine cervix after uterine cervix surgery and its impact on pregnancy. J Obstet Gynaecol Res 2017; 44:61-66. [DOI: 10.1111/jog.13487] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/17/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Shinichi Ishioka
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Miseon Kim
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Yuko Mizugaki
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Saori Kon
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Kyoko Isoyama
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Masahito Mizuuchi
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Miyuki Morishita
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Tsuyoshi Baba
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
| | - Takao Sekiya
- Department of Obstetrics and Gynecology; Fujita Health University; Toyoake Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology; Sapporo Medical University; Sapporo Japan
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Bentivegna E, Maulard A, Pautier P, Chargari C, Gouy S, Morice P. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: a systematic review of the literature. Fertil Steril 2016; 106:1195-1211.e5. [DOI: 10.1016/j.fertnstert.2016.06.032] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/09/2016] [Accepted: 06/20/2016] [Indexed: 01/17/2023]
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Abdominal cerclage in twin pregnancy after radical surgical conization. Case Rep Obstet Gynecol 2014; 2014:519826. [PMID: 24592341 PMCID: PMC3926403 DOI: 10.1155/2014/519826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/19/2013] [Indexed: 01/25/2023] Open
Abstract
Radical and repeated cone biopsies are associated with a high risk of spontaneous preterm birth. A 30-year-old gravida 1 presented with a spontaneous dichorionic twin pregnancy. She had a history of two radical surgical conizations. By speculum examination, no cervical tissue was detected. A history-indicated transabdominal cervicoisthmic cerclage was performed at 12 + 4/7 gestational weeks because of assumed cervicoisthmic insufficiency. The pregnancy continued until 34 + 3/7 weeks when the patient developed preeclampsia indicating Cesarean delivery. Transabdominal cerclage in twin pregnancy has rarely been described, but it may be considered in case of extreme cervical shortening after radical cervical surgery, as it would in singleton pregnancy.
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Kim M, Ishioka SI, Endo T, Baba T, Akashi Y, Morishita M, Adachi H, Saito T. Importance of uterine cervical cerclage to maintain a successful pregnancy for patients who undergo vaginal radical trachelectomy. Int J Clin Oncol 2013; 19:906-11. [DOI: 10.1007/s10147-013-0631-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/14/2013] [Indexed: 11/30/2022]
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Chun KC, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Neoadjuvant chemotherapy with paclitaxel plus platinum followed by radical surgery in early cervical cancer during pregnancy: three case reports. Jpn J Clin Oncol 2010; 40:694-8. [PMID: 20427545 DOI: 10.1093/jjco/hyq039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
To date, only seven women with Stage Ib1 to IIb cervical cancer during pregnancy treated with neoadjuvant chemotherapy followed by radical surgery have been reported. We describe three cases of pregnant women with Stage Ib1 to IIa cervical cancer who were treated with paclitaxel plus platinum neoadjuvant chemotherapy followed by radical surgery. The first patient had a Stage Ib1 small cell neuroendocrine carcinoma of the cervix, the second had a Stage IIa, 8 cm squamous cell carcinoma of the cervix and the third had a Stage Ib2 squamous cell carcinoma and positive lymph nodes. The three patients and their newborns were followed up. All patients had a partial or complete response to neoadjuvant chemotherapy. Two of these patients developed recurrences and one died due to progressive disease at 49 months. All neonates were healthy and had no abnormalities. In conclusion, neoadjuvant chemotherapy with paclitaxel and platinum followed by radical surgery may be an option for pregnant women with invasive cervical cancer.
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Affiliation(s)
- Kyoung-Chul Chun
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Current world literature. Curr Opin Obstet Gynecol 2008; 20:602-7. [PMID: 18989138 DOI: 10.1097/gco.0b013e32831ceeb3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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