The management of pregnancy after trachelectomy for early cervical cancer

Abstract

Key content Cervical cancer continues to affect many women in the UK with over half under the age of 45 years at the time of diagnosis; with a trend towards starting families later in life this raises fertility concerns. While the standard treatment for stage IA2 or IB1 cervical cancer is a radical hysterectomy, radical trachelectomy has been shown to have equivalent 5‐year survival and is a surgical option if there is a wish to preserve fertility. Although trachelectomies are performed by gynaecological oncologists, the management of any subsequent pregnancies falls under the remit of obstetricians who therefore require a sound knowledge of the procedure and potential obstetric sequelae. Pregnancies following trachelectomy are high risk because of the increased rate of mid‐trimester miscarriage and preterm delivery, often as a consequence of preterm prelabour rupture of membranes. Delivery is by caesarean section, traditionally by classical section as a permanent isthmic suture is placed at the time of trachelectomy, but nowadays a transverse incision may be used to reduce morbidity and the implications on future fertility. Learning objectives Management of a pregnancy following radical trachelectomy. Intrapartum care of post‐radical trachelectomy pregnancy and complication risks. Impact of trachelectomy and subsequent pregnancy on the woman. Ethical issues Informed consent surrounding trachelectomy and future pregnancies.

Successful Term Pregnancy Following Radical Trachelectomy and Laparoscopic Lymphadenectomy in a Patient with Invasive Cervical Squamous Cell Carcinoma: The First Case Reported from Iran

“…The second important finding in the patient was the interval between surgery and pregnancy. Four months was suggested for stopping the contraception, as she had no postsurgical complication and normal test results at each postoperative visit, while a minimum of 6 months is recommended for sufficient wound healing and preparedness of the uterus for conception (10). Thirdly, previous studies have reported a high risk of miscarriage, preterm delivery, and premature rupture of membranes (11,12), which were not observed in the patient presented here she experienced a full-term pregnancy with live and healthy fetus.…”

“…Cervical cancer is an important cancer among women and fertility-sparing procedures are becoming more common with the recent development for earlier detection of cervical cancer, decreased age of cervical cancer in women, increased age of conception, and willingness of women to preserve their fertility (6). Here we reported our experience in order to draw the researcher's attention to the fact that the issue of the fertility-sparing procedure is not only important for oncologists and gynecologic surgeons, but also for obstetricians, due to the incomparable conditions of pregnancy in the post-trachelectomy patient (10).…”

Pregnancies after vaginal radical trachelectomy (RT) in patients with early invasive uterine cervical cancer: results from a single institute

“…We still use long term administration (> 72 h) of ritodrine hydrochloride and/or magnesium sulfate for them, but most western countries do not undergo long term tocolysis for them. Tocolytic agents are usually used for at most 72 h. Instead, progesterone gels or pessaries will be used for preterm uterine contraction as described in a review by Tirlapur et al [24]. Ritodrine hydrochloride has not been used in western countries except Japan due to its complications anymore.…”

“Will It Affect Our Chances of Having Children?” and Feeling “Like a Ticking Bomb” —The Fertility Concerns and Fears of Cancer Progression and Recurrence in Cancer Treatment Decision-Making Among Young Women Diagnosed With Gynaecological or Breast Cancer

“…As the literature seems to suggest that it is women's subjective perception of, rather than the objective fertility status that affect's women's well-being (Sobota and Ozakinci, 2014), we decided to include women who had any treatment with the potential to affect fertility. This included women who had chemotherapy for breast cancer as it is associated with uncertainty regarding individual fertility which may be difficult to predict (Wallace et al, 2005;Knobf, 2006;Duffy and Allen, 2009); women with early stage cervical cancer who underwent a cone biopsy or trachelectomy because while both treatments preserve fertility, they can be associated with adverse obstetric outcomes such as second trimester miscarriage (with a rate nearly twice as high as for the general population), and pre-term birth (Tirlapur et al, 2017). Also, according to the recent review, up to 61% of women who had a trachelectomy need artificial reproductive technologies to conceive (Tirlapur et al, 2017) which can be associated with uncertainty about one's fertility.…”

“…This included women who had chemotherapy for breast cancer as it is associated with uncertainty regarding individual fertility which may be difficult to predict (Wallace et al, 2005;Knobf, 2006;Duffy and Allen, 2009); women with early stage cervical cancer who underwent a cone biopsy or trachelectomy because while both treatments preserve fertility, they can be associated with adverse obstetric outcomes such as second trimester miscarriage (with a rate nearly twice as high as for the general population), and pre-term birth (Tirlapur et al, 2017). Also, according to the recent review, up to 61% of women who had a trachelectomy need artificial reproductive technologies to conceive (Tirlapur et al, 2017) which can be associated with uncertainty about one's fertility. Both atypical hyperplasia and early stage endometrial cancer (often grouped together), can be treated with progestogens, however, fertility outcomes are poorer than in the general population (Wei et al, 2017).…”