Prenatal care for woman after fertility-sparing surgery for cervical cancer

Czech version

Authors: P. Šimják; A. Pařízek; J. Sláma
Authors‘ workplace: Gynekologicko‑porodnická klinika 1. LF UK a VFN, Praha, přednosta prof. MUDr. A. Martan, DrSc.
Published in: Ceska Gynekol 2020; 85(6): 422-429
Category: Review Article

Overview

Aim: To summarize the current knowledge about the care of pregnant women after fertility-preserving operations for cervical cancer.

Study type: Review article.

Setting: Department of Gynecology and Obstetrics, 1st Faculty of Medicine, Charles University and General University Hospital, Prague.

Methodology: Search of published literature on a given topic using the PubMed database.

Results: Pregnant women after fertility-sparing surgery for cervical cancer can benefit from screening and treatment for asymptomatic bacteriuria, cervical incompetence screening, and progressive cervical shortening by transvaginal ultrasonography. Tests to determine the presence of biomarkers of preterm birth in cervicovaginal fluid improve the prediction of preterm birth. Vaginal progesterone supplementation should be the primary prevention of preterm birth in all women after trachelectomy. Women with a history of preterm birth or late abortion may benefit from cerclage. The preferred mode of delivery is the cesarean section after 37 weeks of gestation.

Conclusion: Due to the lack of data, pregnancy management in women who have undergone fertility-sparing surgery for early cervical cancer is inconsistent. An increasing number of pregnancies after fertility-sparing surgery will likely prompt clinical research in this field.

Keywords:

fertility-sparing surgery – trachelectomy – Preterm birth – preterm premature rupture of membranes – cerclage – fetal fibronectin

Sources

1. Abbott, DS., Radford, SK., Seed, PT., et al. Evaluation of a quantitative fetal fibronectin test for spontaneous preterm birth in symptomatic women. Am J Obstet Gynecol, 2013, 208, 122, e1–6.

2. Aleman, A., Althabe, F., Belizan, J., Bergel, E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev, 2005, CD003576.

3. Alfirevic, Z., Stampalija, T., Roberts, D., Jorgensen, AL. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database Syst Rev, 2012, CD008991.

4. Alvarez, RM, Biliatis, I., Rockall, A., et al. MRI measurement of residual cervical length after radical trachelectomy for cervical cancer and the risk of adverse pregnancy outcomes: a blinded imaging analysis. BJOG, 2018, 125, 13, p. 1726-1733.

5. Balayla, J., Wo, BL., Bedard, MJ. A late-preterm, early-term stratified analysis of neonatal outcomes by gestational age in placenta previa: defining the optimal timing for delivery. J Matern Fetal Neonatal Med, 2015, 28, p. 1756–1761.

6. Beiner, ME., Covens, A. Surgery insight: radical vaginal trachelectomy as a method of fertility preservation for cervical cancer. Nat Clin Pract Oncol, 2007, 4, p. 353–361.

7. Bentivegna, E., Maulard, A., Pautier, P., et al. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: a systematic review of the literature. Fertil Steril, 2016, 106, p. 1195–1211.e5.

8. Berghella, V., Pereira, L., Gariepy, A., Simonazzi, G. Prior cone biopsy: prediction of preterm birth by cervical ultrasound. Am J Obstet Gynecol, 2004, 191, p. 1393–1397.

9. Berghella, V., Rafael, TJ., Szychowski, JM., et al. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis. Obstet Gynecol, 2011, 117, p. 663–671.

10. Bernardini, M., Barrett, J., Seaward, G., Covens, A. Pregnancy outcomes in patients after radical trachelectomy. Am J Obstet Gynecol, 2003, 189, p. 1378–1382.

11. Bhatla, N., Aoki, D., Sharma, DN., Sankaranarayanan, R.Cancer of the cervix uteri. Int J Gynaecol Obstet, 2018, 143, Suppl., p. 22–36.

12. Boss, EA., van Golde, RJT., Beerendonk, CCM., Massuger, LFAG. Pregnancy after radical trachelectomy: a real option? Gynecol Oncol, 2005, 99, S152-156.

13. Cibula, D., Potter, R., Planchamp, F., et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer, 2018, 28, p. 641–655.

14. Crane, JMG., Delaney, T., Hutchens, D. Transvaginal ultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia. Obstet Gynecol, 2006, 107, p. 37–44.

15. Davis, G., Berghella, V., Talucci, M., Wapner, RJ. Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. Am J Obstet Gynecol, 2000, 183, p. 836–839.

16. DiGiulio, DB., Romero, R., Kusanovic, JP., et al. Prevalence and diversity of microbes in the amniotic fluid, the fetal inflammatory response, and pregnancy outcome in women with preterm pre-labor rupture of membranes. Am J Reprod Immunol, 2010, 64, p. 38–57.

17. Enakpene, CA., DiGiovanni, L., Jones, TN., et al. Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening. Am J Obstet Gynecol, 2018, 219, 4, 397.e1–397.e10.

18. Epstein, E., Testa, A., Gaurilcikas, A., et al. Early-stage cervical cancer: tumor delineation by magnetic resonance imaging and ultrasound – a European multicenter trial. Gynecol Oncol, 2013, 128, p. 449–453.

19. Grazzini, E., Guillon, G., Mouillac, B., Zingg, HH. Inhibition of oxytocin receptor function by direct binding of progesterone. Nature, 1998, 392, p. 509–512.

20. Grobman, WA., Gilbert, SA., Iams, JD., et al. Activity restriction among women with a short cervix. Obstet Gynecol, 2013, 121, p. 1181–1186.

21. Haahr, T., Ersboll, AS., Karlsen, MA., et al. Treatment of bacterial vaginosis in pregnancy in order to reduce the risk of spontaneous preterm delivery – a clinical recommendation. Acta Obstet Gynecol Scand, 2016, p. 850–860.

22. Hume, H., Rebarber, A., Saltzman, DH., et al. Ultrasound-indicated cerclage: Shirodkar vs. McDonald. J Matern Fetal Neonatal Med, 2012, 25, p. 2690–2692.

23. Ishioka, S., Endo, T., Hayashi, T., et al. Pregnancy-related complications after vaginal radical trachelectomy for early-stage invasive uterine cervical cancer. Int J Clin Oncol, 2007, 12, p. 350–355.

24. Ishioka, S., Kim, M, Mizugaki, Y., et al. Transabdominal cerclage (TAC) for patients with ultra-short uterine cervix after uterine cervix surgery and its impact on pregnancy. J Obstet Gynaecol Res, 2018, 44, p. 61–66.

25. Jolley, JA., Wing, DA. Pregnancy management after cervical surgery. Curr Opin Obstet Gynecol, 2008, 20, p. 528–533.

26. Kasuga, Y., Miyakoshi, K., Nishio, H., et al. Mid-trimester residual cervical length and the risk of preterm birth in pregnancies after abdominal radical trachelectomy: a retrospective analysis. BJOG, 2017, 124, p. 1729–1735.

27. Kim, M., Ishioka, S., Endo, T., et al. Importance of uterine cervical cerclage to maintain a successful pregnancy for patients who undergo vaginal radical trachelectomy. Int J Clin Oncol, 2014, 19, p. 906–911.

28. Knight, LJ., Acheson, N., Kay, TA., et al. Obstetric management following fertility-sparing radical vaginal trachelectomy for cervical cancer. J Obstet Gynecol, 2010, 30, p. 784–789.

29. Kyrgiou, M., Athanasiou, A., Kalliala, IEJ., et al. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. Cochrane Database Syst Rev, 2017, 11, CD012847.

30. Lee, KN., Whang, EJ., Chang, KHJ., et al. History-indicated cerclage: the association between previous preterm history and cerclage outcome. Obstet Gynecol Sci, 2018, 61, p. 23–29.

31. Lee, KY., Jun, HA., Roh, JW., Song, JE. Successful twin pregnancy after vaginal radical trachelectomy using transabdominal cervicoisthmic cerclage. Am J Obstet Gynecol, 2007, 197, p. 5–6.

32. Ma, LK., Cao, DY., Yang, JX., et al. Pregnancy outcome and obstetric management after vaginal radical trachelectomy. Eur Rev Med Pharmacol Sci, 2014, 18, 3019–3024.

33. Maher, MA., Abdelaziz, A., Ellaithy, M., Bazeed, MF. Prevention of preterm birth: a randomized trial of vaginal compared with intramuscular progesterone. Acta Obstet Gynecol Scand, 2013, 92, p. 215–222.

34. Nam, KH., Kwon, JY., Kim, YH., Park, YW. Pregnancy outcome after cervical conization: risk factors for preterm delivery and the efficacy of prophylactic cerclage. J Gynecol Oncol, 2010, 21, p. 225–229.

35. Nishio, H., Fujii, T., Sugiyama, J., et al. Reproductive and obstetric outcomes after radical abdominal trachelectomy for early-stage cervical cancer in a series of 31 pregnancies. Hum Reprod, 2013, 28, p. 1793–1798.

36. Oh, KJ., Lee, SE., Jung, H., et al. Detection of ureaplasmas by the polymerase chain reaction in the amniotic fluid of patients with cervical insufficiency. J Perinat Med, 2010, 38, p. 261–268.

37. Pils, S., Eppel, W., Seemann, R., et al. Sequential cervical length screening in pregnancies after loop excision of the transformation zone conisation: a retrospective analysis. BJOG, 2014, 121, p. 457–462.

38. Plante, M. Vaginal radical trachelectomy: an update. Gynecol Oncol, 2008, 111, S105-110.

39. Plante, M., Roy, M. Fertility-preserving options for cervical cancer. Oncology, 2006, 20, p. 473–479.

40. Rob, L., Skapa, P., Robova, H. Fertility-sparing surgery in patients with cervical cancer. Lancet Oncol, 2011, 12, p. 192–200.

41. Rodriguez, PA., Fylstra, D., Newman, R., Nino, JM. Shirodkar cerclage is more effective than McDonald for the prevention of preterm birth. Obstet Gynecol, 2018, 131, 161S-162S.

42. Romero, R., Conde-Agudelo, A., Da Fonseca, E., et al. Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix: a meta-analysis of individual patient data. Am J Obstet Gynecol, 2018, 218, p. 161–180.

43. Romero, R., Dey, SK., Fisher, SJ. Preterm labor: one syndrome, many causes. Science, 2014, 345, p. 760–765.

44. Romero, R., Espinoza, J., Goncalves, LF., et al. The role of inflammation and infection in preterm birth. Semin Reprod Med, 2007, 25, p. 21–39.

45. Schneider, A., Erdemoglu, E., Chiantera, V., et al. Clinical recommendation radical trachelectomy for fertility preservation in patients with early-stage cervical cancer. Int J Gynecol Cancer, 2012, 22, p. 659–666.

46. Shah, JS., Jooya, ND., Woodard, TL., et al. Reproductive counseling and pregnancy outcomes after radical trachelectomy for early stage cervical cancer. J Gynecol Oncol, 2019, 30, e45.

47. Shepherd, JH., Milliken, DA. Conservative surgery for carcinoma of the cervix. Clin Oncol, 2008, 20, p. 395–400.

48. Shepherd, JH., Mould, T., Oram, DH. Radical trachelectomy in early stage carcinoma of the cervix: outcome as judged by recurrence and fertility rates. BJOG, 2001, 108, p. 882–885.

49. Shepherd, JH., Spencer, C., Herod, J., Ind, TEJ. Radical vaginal trachelectomy as a fertility-sparing procedure in women with early-stage cervical cancer-cumulative pregnancy rate in a series of 123 women. BJOG, 2006, 113, p. 719–724.

50. Smaill, FM., Vazquez, JC. Antibiotics for asymptomatic bacteriuria in pregnancy., Cochrane Database Syst Rev, 2015, CD000490.

51. Son, M., Miller, ES. Predicting preterm birth: Cervical length and fetal fibronectin. Semin Perinatol, 2017, 41, p. 445–451.

52. Šimják, P., Cibula, D., Pařízek, A., Sláma J. Management of pregnancy after fertility-sparing surgery for cervical cancer. Acta Obstet Gynecol Scand, 2020, 99, 7, 830-838.

53. Sosa, CG., Althabe, F., Belizan, JM., Bergel, E. Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database Syst Rev, 2015, CD003581.

54. Vandermolen, BI., Hezelgrave, NL., Smout, EM., et al. Quantitative fetal fibronectin and cervical length to predict preterm birth in asymptomatic women with previous cervical surgery. Am J Obstet Gynecol, 2016, 215, 480.e1–480.e10.

55. Wing, DA., Haeri, S., Silber, AC., et al. Placental alpha microglobulin-1 compared with fetal fibronectin to predict preterm delivery in symptomatic women. Obstet Gynecol, 2017, 130, p. 1183–1191.

56. Zemet, R., Schiff, E., Manovitch, Z., et al. Quantitative assessment of physical activity in pregnant women with sonographic short cervix and the risk for preterm delivery: A prospective pilot study. PLoS One, 2018, 13, e0198949.

57. Zhang, Q., Li, W., Kanis, MJ., et al. Oncologic and obstetrical outcomes with fertility-sparing treatment of cervical cancer: a systematic review and meta-analysis. Oncotarget, 2017, 8, p. 46580–46592.

58. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol, 2014, 123, p. 372–379.