Radical vaginal trachelectomy now affords a fertility-sparing procedure for the treatment of early-stage cervical cancer in young women. Subsequent obstetric management within this group of women remains a challenge to the obstetrician, with risks of premature labour a continuing probability throughout pregnancy. Here we describe four cases of successful pregnancy following radical vaginal trachelectomy within our unit. The merits of early antenatal intervention, regular lower uterine segment length monitoring and use of daily progesterone pessaries are discussed, alongside the current supportive evidence. We conclude with a discussion of proposed recommendations for obstetric management of pregnancy in women post-radical vaginal trachelectomy.
Please cite this paper as: Kay T, Renninson J, Shepherd J, Taylor M. Successful pregnancy following radical trachelectomy and in vitro fertilisation with ovum donation. BJOG 2006; 113:965-966. SummaryThis is the first known documented case of a successful pregnancy following fertility-preserving radical trachelectomy, ovum donation and in vitro fertilisation. Case reportAB, 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 1B 1 ). 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 intramuscula...
Background Preterm birth may result in short- and long-term health problems for the child. Accurate diagnoses of preterm births could prevent unnecessary (or ensure appropriate) admissions into hospitals or transfers to specialist units. Objectives The purpose of this report is to assess the test accuracy, clinical effectiveness and cost-effectiveness of the diagnostic tests PartoSure™ (Parsagen Diagnostics Inc., Boston, MA, USA), Actim® Partus (Medix Biochemica, Espoo, Finland) and the Rapid Fetal Fibronectin (fFN)® 10Q Cassette Kit (Hologic, Inc., Marlborough, MA, USA) at thresholds ≠50 ng/ml [quantitative fFN (qfFN)] for women presenting with signs and symptoms of preterm labour relative to fFN at 50 ng/ml. Methods Systematic reviews of the published literature were conducted for diagnostic test accuracy (DTA) studies of PartoSure, Actim Partus and qfFN for predicting preterm birth, the clinical effectiveness following treatment decisions informed by test results and economic evaluations of the tests. A model-based economic evaluation was also conducted to extrapolate long-term outcomes from the results of the diagnostic tests. The model followed the structure of the model that informed the 2015 National Institute for Health and Care Excellence guidelines on preterm labour diagnosis and treatment, but with antenatal steroids use, as opposed to tocolysis, driving health outcomes. Results Twenty studies were identified evaluating DTA against the reference standard of delivery within 7 days and seven studies were identified evaluating DTA against the reference standard of delivery within 48 hours. Two studies assessed two of the index tests within the same population. One study demonstrated that depending on the threshold used, qfFN was more or less accurate than Actim Partus, whereas the other indicated little difference between PartoSure and Actim Partus. No study assessing qfFN and PartoSure in the same population was identified. The test accuracy results from the other included studies revealed a high level of uncertainty, primarily attributable to substantial methodological, clinical and statistical heterogeneity between studies. No study compared all three tests simultaneously. No clinical effectiveness studies evaluating any of the three biomarker tests were identified. One partial economic evaluation was identified for predicting preterm birth. It assessed the number needed to treat to prevent a respiratory distress syndrome case with a ‘treat-all’ strategy, relative to testing with qualitative fFN. Because of the lack of data, our de novo model involved the assumption that management of pregnant women fully adhered to the results of the tests. In the base-case analysis for a woman at 30 weeks’ gestation, Actim Partus had lower health-care costs and fewer quality-adjusted life-years (QALYs) than qfFN at 50 ng/ml, reducing costs at a rate of £56,030 per QALY lost compared with qfFN at 50 ng/ml. PartoSure is less costly than Actim Partus while being equally effective, but this is based on diagnostic accuracy data from a small study. Treatment with qfFN at 200 ng/ml and 500 ng/ml resulted in lower cost savings per QALY lost relative to fFN at 50 ng/ml than treatment with Actim Partus. In contrast, qfFN at 10 ng/ml increased QALYs, by 0.002, and had a cost per QALY gained of £140,267 relative to fFN at 50 ng/ml. Similar qualitative results were obtained for women presenting at different gestational ages. Conclusion There is a high degree of uncertainty surrounding the test accuracy and cost-effectiveness results. We are aware of four ongoing UK trials, two of which plan to enrol > 1000 participants. The results of these trials may significantly alter the findings presented here. Study registration The study is registered as PROSPERO CRD42017072696. Funding The National Institute for Health Research Health Technology Assessment programme.
SummaryThis is a case report of a 49-year-old Key words endometrial carcinoma, IUDCase Report A 49 year old woman, para 2 + 1, presented to her general practitioner (GP) with a 2 month history of a clear, offensive vaginal discharge 3 years following her menopause. She had not used hormone replacement therapy. Cervical cytology 10 years earlier had shown moderate dyskaryosis leading to colposcopy and large loop excision of the transformation zone for CIN1. Subsequent cytology had been negative. She offered no other gynaecological or medical history of relevance.Examination revealed a normal appearing lower genital tract with a healthy cervix, but intra-uterine contraceptive device (IUD) threads were noted at the external os. The uterus was mobile and not enlarged. No adenexal masses were palpable. The patient had forgotten that an IUD had been inserted nearly 20 years previously. Bacteriological swabs were taken, but no organism was cultured.A Lippes loop IUD was removed. The IUD looked abnormal, with mucoid material adherent to it. Unsure of its nature, her GP sent it for histology. The tissue was reported as moderately to poorly differentiated adenocarcinoma (grade II -III).Following referral to the gynaecological oncology clinic, a hysteroscopy was carried out under general anaesthesia. Operative findings were of a raised area measuring 0.5 x 0.5 cm on the left uterine wall. This was biopsied and endometrial curretings were obtained. Histology was inconclusive, showing blood clots and scanty disintegrated endometrial fragments. The initial pathology specimen from the patient was reviewed in the joint gynaecological
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