Successful heterotopic pregnancy with prior radical trachele
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Heterotopic pregnancy, defined as the coexistence of an intrauterine pregnancy and an extrauterine pregnancy, is a rare entity, Radical trachelectomy has become an option for patients with early invasive uterine cervical cancer who desire the preservation of fertility. However, pregnancy after radical trachelectomy is still risk-bearing since subsequent shortening of cervical length may bring about preterm delivery or obstetric complications. However, many obstetricians are now suggesting transabdominal cerclage in these, particularly rare situations. According to Sumners et al., indication for transabdominal cerclage includes, in case of failure of a prophylactic vaginal cerclage within prior pregnancy or an exocervix which is significantly attenuated, either globally or focally.3 They also mentioned that other non-classic indications for prophylactic transabdominal cerclage that may be considered include severe cervical hypoplasia without a history of cervical insufficiency, radical trachelectomy, and higher-order multifetal gestations

A 34-year-old gravida 0 para 0 woman at 8 weeks’ gestation who presented heterotopic left interstitial pregnancy with intrauterine pregnancy conceived with IVF. The patient initially came to the out-patient department for a consult on her short cervix due to a previous radical trachelectomy. However, the ultrasonography showed a heterotopic pregnancy presenting both an interstitial and intrauterine gestational sac. The patient had been diagnosed with cervical cancer 1BI and had radical trachelectomy in 2000. She also had laparoscopic left salpingectomy due to an ectopic pregnancy in 2001.

The patient had tried to conceive for 6 years but failed and diagnosed as secondary infertility of cervical factors including cervical stenosis at fertility clinic. she was treated with IVF and conceived. She had no symptoms of vaginal bleeding, acute abdominal pain and showed a hemodynamically stable condition. The patient’s special circumstances were taken into consideration for treatment options. The patient was taken to the operating room initially for interstitial wedge resection with abdominal cerclage under general anesthesia. A midline vertical incision was made along through the patient’s last operation incision. The gestational sac presented on the left interstitial area of the uterus from the preoperative sonographic examination was invisible to the naked eye. Doctors expected the ectopic mass to show a protruding contour at the interstitial area, however, a normal uterus figure without a palpable gestational sac was observed.

Therefore, instead of going through risk-taking of interstitial resection, they injected methotrexate with the help a sterilized plastic-covered transvaginal ultrasound probe. After successfully performing the injection, they continued on to their next purpose, transabdominal cerclage. The suture was done with Mersilene, a 5 mm-wide woven permanent tape. Ascending branches of the uterine arteries were carefully avoided with the palpation of the surgeon’s hand and the tape was fenestrated at the level of the upper cervix with the knot tied anteriorly. A postoperative follow up sonographic scan revealed that the heterotopic interstitial pregnancy had been successfully aborted with the viable intrauterine pregnancy well-maintained. The patient had her antenatal regular check up on an out-patient department basis. The patient eventually had a cesarean section with the cerclage tie removed at 38 weeks of gestation. The patient decided to remove cerclage tie when cesarean section because she did not want the next pregnancy with desire for close to follow up of cervix cancer after delivery, a full-term live female weighing 2.87 kg was delivered.

Source:https://obgyn.onlinelibrary.wiley.com/doi/10.1111/jog.14196
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