Case Report: Post-Partum SARS-CoV-2 Infection After the First French Uterus Transplantation

Abstract

Absolute uterus factor infertility, whether congenital or acquired, renders the woman unable to carry a child. Although uterus transplantation (UTx) is being increasingly performed as a non-vital procedure to address this unfortunate condition, the immunosuppression required presents risks that are further compounded by pregnancy and during the puerperium period. These vulnerabilities require avoidance of SARS-CoV-2 infection in pregnant UTx recipients especially during the third trimester, as accumulating evidence reveals increased risks of morbidity and mortality. Here we describe a successful UTx case with delivery of a healthy child, but in which both mother and neonate developed asymptomatic SARS-CoV-2 infection seven days after RNA vaccination, on day 35 post-partum. Although the patient was successfully treated with a combination therapy comprised of two monoclonal antibodies, this case highlights the challenges associated with performing UTx in the era of Covid-19. More broadly, the risks of performing non-vital organ transplantation during a pandemic should be discussed among team members and prospective patients, weighing the risks against the benefits in improving the quality of life, which were considerable for our patient who achieved motherhood with the birth of a healthy child.

Miracles of science: Birth after uterus transplantation

“…In January 2019, an open‐label, nonrandomized, French UTx trial (NCT‐03689842) was conducted in 10 women who were infertile because of MRKH syndrome or hysterectomy for cervical cancer 25 . A 34‐year‐old woman with MRKH gave birth to the first infant by UTx in France 26 . The pregnancy was complicated by vaginal bleeding, uterine contractions at 30 weeks, PE, and elevated kidney function indices.…”

“…70 Seven SARS-CoV-2 infections have been reported in five UTx recipients in the United States with no/mild symptoms (treated with casirivimab/ imdevimab), 71 in an Italian woman who gave birth to a 1.7-kg infant after COVID-19 fever, 40 and in an asymptomatic French mother and her infant on postpartum day 35 after RNA vaccination (the mother was treated with two monoclonal antibodies in addition to Aza cessation). 26 Although hospitalization is more frequent in SOT recipients, the incidence of infection and SARS-CoV-2-related mortality are similar to those in the general population. 72,73 All recipients with SARS-CoV-2 infection recovered without complications; however, any assumptions about SARS-CoV-2 and UTx pregnancy should be made with caution because, regardless of the transplantation and adverse effects of immunosuppression, the pregnancy itself carries an additional risk of severe infection.…”

“…25 A 34-year-old woman with MRKH gave birth to the first infant by UTx in France. 26 The pregnancy was complicated by vaginal bleeding, uterine contractions at 30 weeks, PE, and elevated kidney function indices. Fetal ultrasound revealed an 18-mm adrenal anechoic cyst at 32 weeks.…”

“…A 1845-g female infant (42 cm in height) was delivered at 32 4/7 weeks with Apgar scores of 7, 8, and 10 at 1, 5, and 10 min, respectively. 26 She received NICU care for 48 days and was generally in good health. On postpartum day 35, although asymptomatic, she and her mother tested positive for SARS-CoV-2 at 7 days after receiving mRNA vaccination (her mother was treated with two monoclonal antibodies in addition to Aza cessation).…”

Transgender Males as Potential Donors for Uterus Transplantation: A Survey

“…In France, transgender patients are treated in specialized units, such as that in our hospital, which has been operational for 32 years. Our center also has a uterus transplantation program, having performed the first uterus transplantation in France [ 14 ], resulting in a healthy live birth. We therefore have a special interest in determining the viewpoints of transgender males who undergo hysterectomy in their gender-affirming surgery.…”