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Case Report

Pregnancy after trachelectomy: a high-risk condition of preterm delivery.

Report of a case and review of the literature

Patrick Petignat,a,* Catalin Stan,a Eric Megevand,a and Daniel Dargentb

aGynecologic Oncology Service, University Hospitals of Geneva, Geneva, SwitzerlandbDepartment of Gynecologic Surgery, Hospital Edouard Herriot, Lyons, France

Received 4 August 2003

Available online 2 July 2004

Abstract

Background. Trachelectomy is a conservative but locally radical procedure associated with a high risk of preterm delivery.

Case. A 28-year-old patient with cervical cancer FIGO stage IB1 was treated with laparoscopic pelvic lymphadenectomy followed by

trachelectomy. Three years later, she conceived spontaneously. In consideration of the high risk of preterm delivery, the cervical status was

evaluated by transvaginal ultrasonography. At 16 weeks gestation, we observed the cerclage suture correctly placed at the level of the

internal cervical os and a neo-cervical segment length of 1.5 cm. Thereafter, serial ultrasound measurements showed preservation of the

cervical competence. The patient achieved an uneventful pregnancy and delivered by elective cesarean section at 37 weeks.

Conclusion. Transvaginal scans to evaluate the competence of the neo-cervix may contribute to the management and counseling of

patients after trachelectomy.

D 2004 Elsevier Inc. All rights reserved.

Keywords: Cervical cancer; Fertility; Laparoscopic lymphadenectomy; Pregnancy; Trachelectomy

Introduction

Women with early stage cervical cancers are usually

managed by radical hysterectomy and have to forego

their desire for future fertility. The issue of having

children after cervical cancer is important as the disease

affects primarily young women and many of them before

childbearing is completed. Vaginal trachelectomy is a

locally radical procedure which allows preservation of

the body of the uterus, but is associated with a high risk

of preterm delivery in pregnancy (Table 1) [110].

In a woman with a stage IB1 cervical cancer who

desired to preserve her childbearing potential, we per-

formed laparoscopic pelvic lymph node dissection fol-

lowed by a radical trachelectomy. Three years later, the

patient had a successful pregnancy and term delivery.

Case report

A 28-year-old woman, gravida 3, para 1, with no medical

or surgical history apart from one normal pregnancy and

delivery, presented to our colposcopic clinic for evaluation

of a high-grade squamous intraepithelial lesion identified on

her Papanicolaou smear. A cervical biopsy showed a cervi-

cal intraepithelial neoplasia (CIN) III, and the patient was

treated with large loop electrosurgical excision of the trans-

formation zone. Histologic examination showed invasive,

well-differentiated squamous cell carcinoma measuring 9

mm laterally and infiltrated to a depth of 7 mm, without the

presence of lymph vascular space involvement.

The patient was assessed by magnetic resonance imag-

ing of the pelvis and abdomen and examination under

anesthesia to determine the extension of the disease and

was staged FIGO IB1. She was informed of the standard

management in this situation, including radical hysterecto-

my. However, because the patient strongly desired to

preserve her fertility, she was counseled as to the possi-

bility of radical trachelectomy and informed of the known

risks and complications of the procedure, including the

possibility of compromised fertility.

0090-8258/$ - see front matterD 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.ygyno.2004.05.039

* Corresponding author. Department of Gynecology and Obstetrics,

University Hospitals of Geneva, Boulevard de la Cluse 30, 1211 Geneva,

14 Switzerland. Fax: +41-22-382-42-24.

E-mail address: patrick-petignat@hcuge.ch (P. Petignat).

www.elsevier.com/locate/ygyno

Gynecologic Oncology 94 (2004) 575 577

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Laparoscopic pelvic lymphadenectomy was performed

which revealed no lymph node metastases. We then pro-

ceeded with radical vaginal trachelectomy, as previously

described [4]. In addition, a single monofilament non-ab-sorbable (1 nylon) suture was inserted into the lower segment

of the uterus to form a cerclage; the knot was hidden in the

isthmo-vaginal suture after a Sturmdorf closure. The vaginal

mucosa was approximated to the isthmic mucosa (squamo-

columnar junction) to leave a permeable cervical canal. At the

end of the procedure, the cervical canal was measured and

showed a neo-cervix of 1.2 cm length below the isthmus.

The patient then resumed normal menses; follow-up by

colposcopy and Papanicolaou smear repeatedly tested neg-

ative. Three years later, she conceived spontaneously. Trans-

vaginal ultrasound measurement of cervical length was

performed at 16, 20, 24, 28, and 34 weeks of gestation to

assess the stability and competence of the cervix (Fig. 1).The cerclage placement was located at the internal os with a

cervical length of 1.5 cm throughout the pregnancy.

At 37 weeks gestation, a low transverse cesarean section

was performed under rachis anesthesia, and a live healthy

female child weighing 2700 g was delivered. The mother

and child were discharged 6 days post delivery.

Discussion

The most important issue for the patient and her physi-

cian following a treatment for cancer is the cure rate. The

available data in terms of survival after trachelectomy are

scant because the number of patients treated by this proce-

dure remains small. However, it seems that the control of the

disease and survival are comparable to traditional surgicalprocedures for early-stage cervical cancer[3,4,6,10].

The second important issue is the fertility and pregnancy

outcome. Even if the body of the uterus is preserved, this

therapeutic approach may alter the reproductive function

and expose those women to a high risk of preterm labor. To

the best of our knowledge, 10 reports regrouping 40 women

and 55 pregnancies have been published in the literature to

date (Medline search: 1966 to April 2003). Among those

women with a pregnancy of more than 20 weeks gestation,

42% delivered z36 weeks gestation(Table 1).

Preterm delivery may occur as a result of lack of

mechanical support of the residual cervix or ascending

infection followed by chorioamnionitis. Given the largeamount of cervix surgically removed, most authors rec-

ommend the insertion of a prophylactic cerclage to

provide sufficient mechanical support. A second poten-

tially effective prevention strategy (not performed in our

case) is a total cervico-vaginal occlusion using the Saling

technique, which should be performed between 12 and 14

weeks of pregnancy in an effort to reduce the risk of

chorioamnionitis [4,11].

To date, no data exist in the literature on the cervical

status and competence during pregnancy following trache-

lectomy. However, it can be assumed that early detection of

preterm labor in these women might be difficult given the

Table 1

Pregnancy outcome and gestational age at delivery after radical trachelectomy

Authors (years) Number

of patients

Number of

pregnancies

Gestational age

at delivery (weeks)

N(%) deliveries at

z36 weeks gestation

Roy et al. [1] 4 5 25; 34; 38; 39 2 (50%)

Martin et al.[2] 1 1 27 0

Covens et al.[3] 4 5 2 miscarriages; 28; 2 at z36 2 (66%)*

Dargent et al.[4] 13 20 10 miscarriages or fetal deaths; 10 at z36 10 (NA)*Burnham et al. [5] 1 1 37 1

Shepherd et al.[6] 8 14 4 miscarriages; 25; 26; 28; 31; 35; 35; 4 at z36 4 (40%)*

Alexopoulos et al. [7] 1 1 25 0

Rodriguez et al. [8] 1 1 39 1

Schlaerth et al.[9] 4 4 24; 26; 32; 38 1 (25%)

Burnett et al. [10] 3 3 20; 24; >36 1 (33%)

Total 40 55 38* 22 (58%)*

Miscarriage (

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risk of painless and progressive dilation of their residual

uterine cervix. Usual approaches used to detect preterm

delivery are regular digital cervical examinations, sterile

speculum examinations or ultrasonographic examination.

After trachelectomy, digital cervical and speculum exami-

nations have a limited reliability due to the markedly

modified anatomy caused by the suture of the vaginalmucosa to the neo-cervix, except in cases presenting with

advanced cervical dilatation or prolapsed of the membranes.

Transvaginal ultrasonographic follow-up may present a

significant advantage over digital or speculum examination

to evaluate the neo-cervix and the endocervical canal, and

to identify women truly at risk of preterm delivery. The

clinician performing the scan should be aware of the

anatomical modifications induced by the surgery, as the

narrowing of the upper part of the vagina due to its

approximation to the isthmic mucosa and should avoid an

excessive pressure on the vaginal probe which could poten-

tially disturb the neo-cervix. In our case, we inserted the

probe slightly into the vagina until it met resistance, visu-

alized the cerclage in the sagittal plane and manipulated the

probe until the entire cervical canal has been visualized.

Neither suture displacement nor significant cervical short-

ening was observed during the complete pregnancy.

What is the appropriate management if an ultrasono-

graphic diagnosis of cervical incompetence is established?

First and foremost, antenatal interventions should be per-

formed such as a transfer to a facility with a neonatal

intensive unit and the administration of corticosteroids to

the mother to hasten lung maturation. Other approaches

such as the Saling procedure or a second vaginal cerclage

performed in an emergency status would seem to us to beconsidered as perilous.

We conclude that serial vaginal ultrasound assessment

of the neo-cervix in patients after trachelectomy allows

the determination of its competence and subsequently

contributes to the management and counseling of the

patient. The effective benefit of this procedure has not

yet been established by evidence-based scientific proof

because of the rarity of these cases, but this attitude may

be considered as a likely contributing factor to the efficient

clinical care of these patients.

Acknowledgment

We thank Mrs. Rosemary Sudan for editorial assistance.

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