Received: 4 March 2020 | Revised: 17 April 2020 | Accepted: 12 May 2020

DOI: 10.1111/aogs.13917

REVIEW

Management of pregnancy after fertility-sparing surgery for

cervical cancer

Patrik Šimják | David Cibula | Antonín Pařízek | Jiří Sláma

Department of Gynecology and Obstetrics,

First Faculty of Medicine, Charles University
and General University Hospital, Prague,
Czech Republic
Correspondence
Jiří Sláma, Department of Gynecology and
Obstetrics, General University Hospital and
1st Faculty of Medicine, Charles University,
Apolinářská 18, 128 08, Prague 2, Czech
Republic.
Email: jiri.slama@vfn.cz
Funding information
This work was supported within the
framework of the European Social Fund,
Operation Programme Employment
[National Coordination Center for Disease
Early Detection Programmes, grant no. CZ.0
3.2.63/0.0/0.0/15_039/0008166].
Abstract
Cervical cancer is increasingly diagnosed in women who have not yet completed their
reproductive plans. For women with early-stage disease (FIGO stage IA1-IB1), fertil-
ity-sparing procedures, such as conization, trachelectomy or radical trachelectomy,
represent the treatments of choice. However, women who undergo repeated coni-
zation or trachelectomy represent a challenge for obstetricians because they are at
increased risk of infertility, mid-trimester miscarriage, preterm premature rupture of
membranes and preterm delivery. So far, the evidence-based guidance on the man-
agement of these pregnancies is limited. This article reviews the literature discussing
pregnancy management in women after fertility-sparing surgery for early cervical
cancer. Although the evidence is limited, certain measures are desirable, including
screening and treatment of asymptomatic bacteriuria, screening for cervical incom-
petence and progressive cervical shortening by transvaginal ultrasonography, and
fetal fibronectin testing. Vaginal progesterone supplementation should be primary
prevention for all women after trachelectomy. Women with a history of preterm de-
livery or late miscarriage may benefit from cervical cerclage. Elective delivery by ce-
sarean section in the early-term period is desirable.

KEYWORDS

cerclage, fertility-sparing surgery, fetal fibronectin, preterm labor, preterm premature rupture
of membranes, trachelectomy

1 | I NTRO D U C TI O N to spare fertility in case of histologically proven squamous cell carci-

Cervical cancer is one of the most frequent malignant diseases
that has a negative impact on women's fertility. Nearly one-third of
women with cervical cancer are younger than 40 years. Especially
in developed countries, a significant proportion of them are women
who have not yet completed their childbearing potential, as the age
of first pregnancy steadily increases.1
Fertility-sparing surgery (FSS) can be, according to current
guidelines, a reasonable therapeutic option in women with a desire
noma or usual-type (human papillomavirus-related) adenocarcinoma
in tumors ≤2 cm and negative pelvic lymph node status or negative
lymphovascular space invasion in stage IA1. 2,3 The aim of FSS is to
resect the invasive tumor with adequate free margins and preserve
the upper part of the cervix. For this purpose, conization or simple
vaginal trachelectomy for stages IA1-IA2 and radical trachelectomy
for node-negative stage IB1 with tumors <2 cm are usually per-
formed. The oncologic safety of radical vaginal trachelectomy (RVT)
or abdominal radical trachelectomy (ART) seems to be comparable

Abbreviations: ART, abdominal radical trachelectomy; FSS, fertility-sparing surgery; PPROM, preterm premature rupture of membranes; RVT, vaginal radical trachelectomy.

© 2020 Nordic Federation of Societies of Obstetrics and Gynecology (NFOG). Published by John Wiley & Sons Ltd

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wileyonlinelibrary.com/journal/aogs Acta Obstet Gynecol Scand. 2020;99:830–838.

ŠIMJÁK et al.
to that of radical hysterectomy in tumors ≤2 cm.4 Recently, a pro-
spective trial CONTESSA/NEOCON-F aiming to evaluate the feasi-
bility of preserving fertility in women with stage IB2 (2-4 cm) cervical
tumors has been initiated. The study hypothesis is that downstaging
tumors >2 cm with neoadjuvant chemotherapy comprising three cy-
cles of platinum/paclitaxel will enable FSS without compromising the
oncologic outcome and will result in reduced obstetric morbidity.5
Though the rate of conception after FSS is lower than that of the
general population, with recent advances in artificial reproductive
techniques, clinicians will come across pregnant women after FSS
more often.
Interestingly, the majority of papers dealing with cervical can-
cer patients after FSS do not describe obstetrical care during these
pregnancies. There is a significant lack of scientific data in terms of
specific actions, particularly for preterm labor prophylaxis. Our re-
view aimed to summarize the current level of knowledge in this field,
propose pregnancy management, and indicate directions for further
research.
2 | M E TH O DS
The published literature search was performed using the PubMed
database to look for combinations of the following keywords: “ob-
stetric outcome” or “prenatal care” and “fertility-sparing surgery” or
“trachelectomy” or “conization” or “cervical cancer”. We identified
356 articles and excluded 309 after initial screening. We reviewed
prospective follow-up studies, retrospective reviews, and meta-
analyses reporting obstetric outcomes in women after trachelec-
tomy that contained at least 10 pregnancies. We specifically focused
on the reported prenatal care provided during pregnancy. We also
included expert opinions concerning optimal prenatal care in these
women. Relevant articles were processed and the lists of references
were searched to identify other potentially important publications.
In total, we analyzed 28 articles. The specific prenatal interventions
mentioned were listed and critically reviewed. As strong data sup-
porting these recommendations are mostly lacking, we tried to ex-
trapolate knowledge learned from other specific populations and
provide a rationale for the proposed management.
3 | FE RTI LIT Y A N D PR EG N A N C Y- R E L ATE D
CO M PLI C ATI O N S A S S O C I ATE D W ITH FS S
FO R E A R LY C E RV I C A L C A N C E R
The group of women after FSS is heterogeneous and encompasses
women who underwent conization, repeated conization, or simple or
radical trachelectomy. The radicality of the procedure, the amount
of damage done to paracervical tissue, and uterine artery ligation
affect the risks of different fertility and pregnancy-related complica-
tions; hence, the reported outcomes differ substantially.
Fertility is decreased after any FSS. This can be attributed
to cervical stenosis, impaired cervical function, the formation of
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831
Key message
Screening and treatment of asymptomatic bacteriuria,
screening for cervical incompetence and progressive cervi-
cal shortening by transvaginal ultrasonography, and using
fetal fibronectin are appropriate. Vaginal progesterone
supplementation with cerclage placement in specific con-
ditions may decrease the risk of preterm delivery or late
miscarriage.
adhesions, lack of cervical mucus to facilitate sperm movement,
subclinical endometritis, and vascular compromise. 6 The fertil-
ity rate seems to be inversely associated with the extent of the
parametrium (paracervical tissue) resection.7 The infertility rate
following any radical trachelectomy reaches 30%. 8,9 The overall
pregnancy rate after RVT varies in the literature between 30% and
79%,4,8,10 in contrast to 15%-36% after ART.4,11 At the same time,
assisted reproductive techniques following FSS are associated
with satisfactory pregnancy rates.12 Cervical dilation, intrauterine
insemination, or in vitro fertilization resulted in at least one preg-
nancy in 53% of women.13
The rate of first-trimester miscarriage in women after FSS does
not differ from the rate in the general population.8,14,15 On the
other hand, second-trimester miscarriages are observed in 8%-10%
of women after RVT,8,9,14 which is approximately twice the rate
observed in the general population. The overall preterm delivery
rate after radical trachelectomy is around 26.6%16 but could be as
high as 38%.13 Preterm premature rupture of membranes (PPROM)
resulting from ascending infection is the most common cause of
preterm birth.17-19 Different studies report the incidence of preterm
birth between 15% and 57% with decreasing rates in comparison
with women after ART, RVT, and simple vaginal trachelectomy/
conization.13,14,20-22 Preterm birth before 32 weeks represents the
most feared complication of FSS, with the overall incidence reach-
ing 12%.14 Again, the incidence gradually decreases from 22.1%
(23/104) after ART to 12.6% (36/285) after RVT, and 7.8% (4/51)
after simple trachelectomy.
Data concerning oncologic and obstetric outcomes after con-
ization and radical trachelectomy were published recently in the
comprehensive meta-analysis by Zhang et al.16 The authors con-
cluded that a considerable proportion of women achieve pregnancy.
Conization results in a higher pregnancy rate and better pregnancy
outcomes compared with radical trachelectomy. The principal re-
sults are summarized in Table 1.
4 | R E PRO D U C TI V E CO U N S E LI N G
All women with cervical cancer who are referred for FSS should
be carefully counseled regarding the increased risk of fertility and
pregnancy-related complications. Such consultation before cancer
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832 ŠIMJÁK et al.

TA B L E 1 Obstetric outcomes of conization and radical 5.1 | Restriction of physical activity and
trachelectomy16 sexual abstinence
Rates (%)
Activity restriction represents a typical non-specific recommen-
Radical
dation. According to literature data, it does not reduce the rate of
Conization trachelectomy
(N = 347) (N = 2273) preterm birth in low-risk (eg, without a previous history of preterm
labor) women with an asymptomatic short cervix 23-25; neither does
Stage
it prevent miscarriage. 26 Therefore, bed rest in hospitals should be
IA1 46.9 6.0
avoided in asymptomatic women after FSS. On the other hand, it
IA2 8.0 12.1
should be offered to women after FSS who present with symptoms
IB1 44.5 79.9
of immediate preterm delivery, unless the condition is reliably ex-
IB2 0.3 1.5 cluded. This is especially important in cases where severe prema-
IIA 0.3 0.5 turity is at stake. In these cases, hospitalization is justified by the
Fertility and pregnancy outcome improved perinatal outcome of the newborn, which can be achieved
Follow-up period more 82.4 81.4 by the induction of fetal lung maturity, fetal neuroprotection, and
than 2 y managing delivery in a center that is specialized for intensive neo-
Pregnancy (achieved 36.1 20.5 natal care.
pregnancy during follow up)
Bed rest at home should be discussed individually in connec-
Miscarriage (in first or second 14.8 24.0 tion with individual average daily physical activity and occupation.
trimester)
It should be offered as part of the complex management of women
Preterm delivery 6.8 26.6
with ongoing pain, bleeding, or progressive cervical shortening;
however, there is no conclusive evidence of improved outcome. 27
Sexual intercourse is considered a potential source of ascending
treatment is, however, often neglected. Women who underwent infection and preterm labor by some authors. As the avoidance of
radical trachelectomy reported that they did not receive reproduc- intercourse is a simple and harmless intervention, it is usually rec-
tive and pregnancy risks counseling in the preoperative period in 54% ommended, 28 although the evidence of such an approach is lacking
6
and 32%, respectively. Preoperative counseling should also include even in women with cervical incompetence.
the evaluation of the woman's reproductive potential with regard to
ovarian reserve, presence of ovulatory dysfunction, and pertinent gy-
necologic and reproductive history. In many cases, women may bene- 5.2 | Screening and treatment of vaginal and urinary
fit from decreasing time to conception by planning fertility treatment. tract infections
If artificial reproductive techniques are required, care must be taken
to minimize the probability of multiple pregnancy, which significantly Women who underwent trachelectomy are at an increased risk of
increases the risk of prematurity. Preventive measures include trans- intra-amniotic infection, which increases the risk of subsequent
ferring a single embryo and performing intrauterine insemination only PPROM, preterm delivery, or second-trimester miscarriage. A pro-
when monofollicular growth is confirmed by transvaginal ultrasound posed mechanism of increased susceptibility to intra-amniotic
in the follicular phase of the menstrual cycle. infection is the absence of the protective cervical mucus plug. 29
Some authors recommend separating oncologic and reproduc- Ascending microbial infection from the lower genital tract appears
tive counseling to allow women to process all the critical information to be the most common source of intra-amnionic infection, although
from both perspectives.6 other routes have also been described.30 Ureaplasma species,
Gardnerella vaginalis, and Fusobacterium species belong among the
most frequent microorganisms found in the amniotic cavity.31,32 It is
5 | M A N AG E M E NT O F PR EG N A N C Y A F TE R believed that intra-amniotic infection is often inapparent for weeks
FS S before it manifests with symptoms of clinical chorioamnionitis33 or
PPROM.34 At this point, the parturition is virtually irreversible.30
Evidence-based guidance on the management of pregnancy in In order to prevent vaginal infection from ascending into the
women after FSS is limited. Most recommendations originate from uterine cavity in women after FSS, some authors advise giving pro-
underpowered observational studies or are extrapolated from stud- phylactic antibiotics at 16 and 24 weeks of gestation or performing
ies conducted in other specific groups of patients, such as women bimonthly screenings from 16 weeks and treating with antibiotics
with cervical incompetence. We aimed to present both published when necessary.35
experiences and our own with obstetric care for these high-risk pa- Another proposed option is the daily use of vaginal povidone-io-
tients and provide a rationale. Specific recommendations are sum- dine and the insertion of a ulinastatin vaginal pessary to prevent infec-
marized in Table 2. tion.17 On the other hand, other authors do not administer antibiotics
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ŠIMJÁK et al. 833

TA B L E 2 Antenatal care for pregnant women after fertility-sparing surgery (FSS) for early-stage cervical cancer—summary of
recommendations

Preconception care
Women after FSS should be discouraged from delaying the completion of their reproductive plans beyond the reasonable period of
postoperative healing
Artificial reproductive techniques should be offered if the couples are unable to conceive in a reasonable time. If the techniques are used,
singleton pregnancy should be an absolute priority
Screening and treatment of bacterial vaginosis should be done before the pregnancy
Antenatal care
Pregnancies of women who underwent trachelectomy are considered high-risk and require increased antenatal surveillance by a senior
specialist in perinatology centers
Restriction of physical activity and sexual abstinence should be recommended to women with symptoms of preterm delivery or progressive
cervical shortening
Screening for asymptomatic bacteriuria every trimester and treatment of positive urine cultures is recommended
Screening for cervical incompetence by transvaginal ultrasound should be done in the second trimester. Cervical length should be interpreted
with regard to the type of FSS treatment
Biweekly transvaginal ultrasound cervical length measurement starting from mid-trimester should be considered to identify progressive cervical
shortening
Biomarker tests can be used in women with a short cervix or progressive cervical shortening who present with symptoms of preterm labor
- A negative result suggests a low risk of immediate preterm delivery
- A positive result supports the corticosteroid treatment for the induction of lung maturity because the risk of preterm delivery within 2 wk is
increased
Fetal fibronectin can be used in asymptomatic patients with a short cervix or progressive cervical shortening.
- A negative result suggests a low risk of immediate preterm delivery.
- A positive result supports the need for preventive hospitalization and increased surveillance. The administration of corticosteroids should be
considered individually.
Tocolytic treatment is recommended for the time necessary for the induction of lung maturity, once there is an immediate risk of preterm
delivery
Vaginal progesterone (200 mg per dose in the evening) is indicated in:
- women after conization with mid-trimester cervical length <25 mm;
- women after trachelectomy;
- women after FSS with previous history of preterm delivery or late miscarriage
Cervical cerclage should be considered in women with previous history of preterm delivery or late miscarriage if:
- the cervical length is <25 mm after conization;
- the woman underwent trachelectomy
If technically feasible, cervical cerclage should also be considered in women with major cervical dilation
In women after trachelectomy, elective cesarean section should be scheduled after 37 wk of gestation, if possible

in asymptomatic women after trachelectomy.27 Moreover, recently
published papers do not recommend treating bacterial vaginosis, as it is
not associated with a reduced rate of late miscarriage or spontaneous
preterm birth.36,37 Once the bacteria gain access to the amniotic cav-
ity, they form biofilms that increase antibiotic resistance.38 Although
the intra-amniotic infection can possibly be eradicated by intravenous
antibiotics,39 currently there is no evidence that prophylactic antibi-
otic administration reduces the risk of miscarriage, PPROM, or preterm
labor. At the same time, invasive diagnostic approaches to detect in-
tra-amniotic infection with subsequent treatment with broad-spec-
trum intravenous antibiotics are considered an experimental approach.
Asymptomatic bacteriuria commonly occurs during pregnancy
and is associated with a significant risk of acute pyelonephritis, which
is a recognized risk factor of preterm birth.33 The reference standard
for detecting asymptomatic bacteriuria is quantitative midstream
urine culture. Screening and treatment of asymptomatic bacteriuria
decrease the risk of acute pyelonephritis and most probably even
preterm birth.40 We, therefore, encourage screening of asymptom-
atic bacteriuria once per trimester in pregnant women after FSS.
5.3 | Transvaginal ultrasound cervical length
measurement
In the general population, mid-trimester cervical length meas-
ured by transvaginal sonography correlates with the risk of pre-
term delivery.41 Surgical procedures on the cervix contribute to a
short cervical length, which in turn increases the risk of premature
delivery.
Women with a history of excisional treatment for precancerous
cervical lesions have slightly but significantly shorter transvaginal ul-
trasound cervical length.42 In this group, cervical length of <25 mm
 |
834
between 16 and 24 weeks of gestation is predictive of preterm de-
livery at <35 weeks with positive and negative predictive values of
30% and 94%, respectively.43 Furthermore, the increasing depth
and volume of the specimen removed also correlated with the risk
of preterm birth.44 Removal of >1 cm3 of tissue was associated with
a significant risk of PPROM, prematurity, and lower birthweight.
Repeated treatment multiplied the risk of overall prematurity.45
Sequential cervical length screening did not provide additional in-
formation to single mid-trimester cervical length measurement in
women after large loop excision of the transformation zone.46
Trachelectomy, on the other hand, dramatically reduces the
cervical length and this needs to be reflected in the transvaginal ul-
trasound evaluation of the cervix. A recent publication by Alvarez
et al showed a significant increase in the incidence of PPROM
(36.8% vs 0%) and premature delivery (66.7% vs 22.2%) when the
residual cervix after RVT was shortened to <10 mm.47 In the light of
these facts, the effort to preserve at least 1 cm of the cervix at the
time of trachelectomy is required. Oncologic safety represented by
adequate free margins must be carefully balanced with the length
of preserved cervical tissue. Ultrasound or MRI preoperative mea-
surement of the distance between internal cervical os and proximal
margin of the tumor is, therefore, essential.48 In a retrospective co-
hort study of 33 deliveries after 22 weeks of gestation in 30 women
who underwent radical trachelectomy, mid-trimester cervical length
showed a significant correlation with gestational age at delivery.
Mid-trimester cervical length <13 mm was a good predictor of
preterm birth before 34 weeks, with a sensitivity of 67%, specific-
ity of 75%, positive predictive value of 55%, and negative predictive
value of 86% (area under the curve 0.75).49 Mid-trimester cervical
length measurement can be used to estimate the risk of preterm
birth before 34 weeks of gestation.
In cases when the cervix is short from the beginning of the
pregnancy, progressive cervical shortening may be an important
sign of threatened preterm delivery in otherwise asymptomatic
women. Therefore, some authors encourage serial cervical length
measurements every 2 weeks, starting from the second trimester
of pregnancy. 27
For women with threatened preterm labor, it has been suggested
that clinical management that is based on measuring the cervical
length results in later gestational age at delivery, although the im-
pact on neonatal outcome was inconclusive.50
5.4 | Biomarker tests for the prediction of
preterm labor
The prediction of preterm labor has been one of the big challenges in
perinatology. Inaccurate identification of women at risk of preterm
delivery can lead to unnecessary hospitalization and treatment and
inappropriate timing of corticosteroid administration. Many biomark-
ers associated with the increased risk of preterm delivery have been
identified, but only a few of them have utility in routine clinical prac-
tice. Nowadays, several bedside tests for the prediction of preterm
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ŠIMJÁK et al.
labor from the cervicovaginal secretion are available. The cervicov-
aginal fluid proteome reflects changes of the vagina, cervix, and fetal
membranes. Although many triggers of preterm labor were identified,
they all share similar pathways of cervical ripening, myometrial activa-
tion, or membrane rupture.51 The increase of concentration of the bi-
omarker in the cervicovaginal fluid above the detection limit denotes
the activation of fetal membranes, which precedes preterm delivery.
Currently, the most widely used bedside test identifies the
presence of fetal fibronectin, placental α-microglobulin-1, and in-
sulin-like growth factor-binding protein 1. However, in the gen-
eral population, none of the above-mentioned tests can reliably
predict preterm delivery in either asymptomatic or symptom-
atic women. In fact, the American College of Obstetricians and
Gynecologists discourages from directing clinical management
solely by the positive predictive value of a fetal fibronectin test
or short cervix alone in women with acute symptoms. 52 It is im-
portant to interpret the results of the test together with cervical
length, and then, eventually, its development over time and the
presence of symptoms of preterm delivery.
On the other hand, high negative predictive value allows us to
exclude women who are unlikely to deliver within 14 days after the
test, thus reducing unnecessary intervention.53,54 In symptomatic
women, placental α-microglobulin-1 seems to perform better at
predicting spontaneous preterm birth compared with fetal fibronec-
tin,55 but quantitative fetal fibronectin further improves diagnostic
accuracy.56 So far, no studies evaluated the use of bedside tests in
symptomatic women after cervical surgery. In asymptomatic women
after previous cervical surgery, quantitative fetal fibronectin is
a valid predictive option and has comparable accuracy to that for
women with a history of preterm labor.57
Bedside tests, especially when the result is negative, can facili-
tate clinical management in women after trachelectomy who present
with progressive cervical shortening or stable, but non-reassuring,
cervical length.
5.5 | Progesterone supplementation
Progesterone promotes uterine quiescence and prevents cervical
ripening, probably through its anti-inflammatory effect on the feto-
placental unit.58 Studies have shown that exposure to progesterone
in experimental inflammatory models was associated with reduced
expression of interleukin-6 in placental chorionic plate arteries and
the reduced fetal and maternal mononuclear cell expression of
interleukin-6.59,60
Romero et al 61 conducted a meta-analysis of five high-quality
randomized controlled trials comparing vaginal progesterone sup-
plementation with placebo or no treatment on perinatal outcome
in women with pre-randomization cervical length ≤25 mm. The
authors conclude that vaginal progesterone decreases the risk of
preterm birth and improves perinatal outcomes in singleton ges-
tations with a mid-trimester sonographic short cervix. Previous
cervical surgery as a primary reason for sonographic short cervix

ŠIMJÁK et al.
was not an exclusion criterion, which offers the possibility of
extrapolating these results to this specific population. A recent,
multicenter, randomized controlled trial evaluating the efficacy
of 17α-hydroxyprogesterone caproate in prolonging gestation in
women with a short cervix and other risk factors for preterm de-
livery, such as previous preterm birth, cervical surgery, or uterine
anomalies, was discontinued after failing to demonstrate efficacy
in prolonging pregnancy. 62
In women with a history of preterm birth, vaginal progesterone
was more effective at preventing preterm birth before 28, 32, and
34 weeks of gestation and had fewer adverse effects compared to
the 17α-hydroxyprogesterone caproate.63 In this trial, administra-
tion of progesterone started between 14 and 18 weeks and contin-
ued until 36 weeks of gestation.
Vaginal progesterone could be considered as a treatment of choice
in women after FSS and early administration seems to be of great im-
portance. After FSS, women with a sonographically shortened cervix
detected before 24 weeks of gestation might benefit from daily vagi-
nal progesterone at 200 mg per dose. In women after FSS, who have
already experienced preterm labor or who present with a short cervix
from the beginning of the pregnancy, vaginal progesterone supple-
mentation should commence after the first trimester at the latest.
5.6 | Cerclage placement
Another proposed prevention of preterm delivery is cervical cer-
clage. It should provide additional mechanical support and avert
cervical dilation. Cerclage has been in use for decades, but the
effectiveness and safety of the procedure remain controversial.
If indicated, another issue is timing its placement. The decision
between permanent cerclage placement during FSS or temporary
cerclage placement as late as during pregnancy remains unclear.
Although it is widely used in women after previous cervical sur-
gery, studies performed in this specific population are lacking and
data are inconsistent. It is, therefore, necessary to extrapolate the
results obtained from other populations to suggest the possible
use of cervical cerclage in women who underwent FSS. Cervical
cerclage can be indicated based on history or ultrasonographic or
physical examination. 64
History-indicated cerclage is performed early after the first tri-
mester of pregnancy. Originally, it was reserved for women after
three or more mid-trimester pregnancy losses or preterm deliveries.
However, the American College of Obstetricians and Gynecologists
encourages history-indicated cerclage in women with a history of
64
single mid-trimester pregnancy loss. Lee et al support this rec-
ommendation by demonstrating that cerclage is equally effective
in preventing preterm birth, PPROM, and neonatal intensive care
unit admission in women with single and two or more spontaneous
65
preterm births. In contrast, Harpham et al found that history-indi-
cated cerclage before 14 weeks of gestation resulted in worse out-
comes in women with a single previous mid-trimester delivery.66
Nevertheless, it can be presumed that cervical cerclage after the
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835
first trimester of pregnancy could benefit a post-FSS women with a
history of mid-trimester pregnancy loss or preterm delivery.
Ultrasound-indicated cerclage is reserved for women with a
history of spontaneous preterm birth and simultaneously ultraso-
nographically detected short cervix. In women with a history of spon-
taneous preterm birth, singleton gestation, and mid-trimester cervical
length <25 mm, cerclage placement reduced recurrent preterm birth
by 30% and composite perinatal mortality and morbidity by 36%.67
The improvement of outcome in cerclage was not, however, demon-
strated in the low-risk group without previous preterm delivery.68 The
addition of 17α-hydroxyprogesterone caproate to cervical cerclage
does not seem to further decrease the rate of recurrent spontaneous
preterm birth and PPROM.69 On the other hand, a combination of cer-
vical cerclage with vaginal progesterone in women with an extremely
shortened cervix (<10 mm) was associated with a significant decrease
in spontaneous preterm birth, neonatal respiratory distress syndrome,
necrotizing enterocolitis, and neonatal death when compared with
vaginal progesterone alone.70 Given the proven solitary effects and
different mechanisms of action of cerclage and vaginal progesterone,
concomitant use of both in specific indications may lead to further im-
provement in the prevention of recurrent spontaneous preterm birth
in women after FSS, although currently there is no evidence.
The approach to cerclage placement traditionally can be vaginal
or transabdominal, often minimally invasive. When compared with a
vaginal approach, transabdominal cerclage is not associated with sig-
nificant improvement in the rates of preterm delivery and PPROM.71
Shirodkar cerclage is considered to be more effective at preventing
preterm birth and neonatal morbidity compared with the MacDonald
technique, so is the treatment of choice.72,73 However, transvaginal
cervical cerclage placement in women after FSS, especially after rad-
ical trachelectomy, may be challenging. Transabdominal cerclage may
be considered if the short residual cervical length or scarring after tra-
chelectomy limits a vaginal approach or in women who experienced
previous complications with vaginal cerclage.74 It can be performed
at the time of FSS, before intended pregnancy, early after the first tri-
mester of pregnancy, or even later. There are concerns that cerclage
placed at the time of vaginal radical trachelectomy may cause cervical
canal stenosis, which could hamper conception.10 On the other hand,
Kim et al reported that 66% of women after radical trachelectomy,
pelvic lymphadenectomy, and cervical cerclage were able to conceive
and only one of six cases with cerclage was complicated with thread
erosion through the vaginal wall and had to be removed.75
Placing transabdominal cervical cerclage before pregnancy can
be considered in women who have a history of preterm birth.76
There are doubts that cerclage itself may increase the risk of ascend-
ing intrauterine infection, so increasing the risk of PPROM. 20 It is
believed that transabdominal cerclage can be safely left in place for
2 years.77 Moreover, there are not enough data to recommend an-
tibiotic prophylaxis during the procedure or prior treatment of bac-
terial vaginosis.
Transabdominal cerclage demands delivery by cesarean section.
In cases of vaginal cerclage, the stitch can be removed, and vaginal
delivery should be possible, though it is not advised in women after
 |
836
trachelectomy. The stitch is removed once the uterine contractions
develop. In cases of PPROM and the absence of indication for imme-
diate delivery, cerclage can be left in place if expectant management
is intended in favor of the fetus.
Cerclage can also be indicated based upon physical examination
in cases of major dilation of the cervix, with or without protrusion of
the fetal membranes. This so-called “emergency cerclage”, regularly
performed vaginally using the MacDonald technique, can also be
considered in women after FSS if technically feasible.
Based on a survey, 66% of Society of Gynecologic Oncology mem-
bers perform cerclage at the time of trachelectomy.78 Intraoperative
placement of cervical cerclage is also endorsed by the European
Society of Gynaecological Oncology.3 In case the woman did not
receive cerclage before pregnancy, cerclage placement should be
considered in women after trachelectomy with a history of preterm
delivery or late miscarriage. In women after cervical conization, the
cerclage should be reserved for women with a short cervix and pre-
vious unfavorable obstetric history.
5.7 | Timing and mode of delivery
Vaginal delivery is a reasonable option for women after conization, but,
in agreement with other authors,10,27,79 we believe it should be avoided
in women after trachelectomy because of the potential risk of tearing in
the terrain of a scarred cervix. If the tear extends laterally to the nearby
uterine vessels, severe hemorrhage occurs. Severe scarring can also
impact cervical ripening and can result in prolonged, traumatic delivery
especially when accompanied by uterine hyperactivity. Uterine hyper-
activity results in shorter resting phase between uterine contractions,
which may lead to fetal metabolic acidosis. This aspect is especially
important in very-low-birthweight infants.80 Therefore, performing ce-
sarean section before uterine contractions develop is desirable.
Knight et al suggest performing cesarean section at 34 weeks of
pregnancy. 27 In our opinion, the prevention of hemorrhage does not
balance the potential risk of neonatal morbidity and we believe that
cesarean section can be postponed to the early-term period in the
same way it is done in cases of placenta previa.79 If the concerns
about the onset of labor are serious but the woman is asymptom-
atic, preventive hospitalization can be offered. Similar to our prac-
tice, other authors do not recommend performing a cesarean section
before 37 weeks.10 Some authors speculate that transverse uterine
incision in the lower uterine segment can predispose for injury of
uterine arteries.19 They advocate performing a classical uterine inci-
sion encompassing the corporal myometrium, which is however as-
sociated with greater risk for the following pregnancy.10,17 Given the
lack of data, the type of hysterotomy should be chosen individually.
6 | CO N C LU S I O N
The management of pregnancy in women after FSS is not uniform,
which is not surprising given the lack of evidence-based data. Most
16000412, 2020, 7, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.13917 by Cochrane Portugal, Wiley Online Library on [20/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ŠIMJÁK et al.
recommendations so far are derived from personal experience or
underpowered observational studies, or are extrapolated from stud-
ies conducted in other specific groups of patients, such as women
with cervical incompetence.
One can expect that the increasing number of pregnancies fol-
lowing FSS and the high number of pregnancy-associated complica-
tions would prompt clinical research in this field.
C O N FL I C T O F I N T E R E S T
None.
ORCID
Patrik Šimják https://orcid.org/0000-0003-0811-2085
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How to cite this article: Šimják P, Cibula D, Pařízek A, Sláma
J. Management of pregnancy after fertility-sparing surgery
for cervical cancer. Acta Obstet Gynecol Scand. 2020;99:830–
838. https://doi.org/10.1111/aogs.13917