2006年9月27－30日

美国华盛顿特区

September 27 - 30, 2006, Washington, DC

Linda Andrist, PhD, RNC, WHNP   

The cesarean section (CS) delivery rate in the United States has increased dramatically since 1999, despite the national goal of Healthy People 2010 to reduce the rate to 15%. The CS rate for 2004 was 29.1%, up from 27.6% in 2003 and a third higher than in 1996. At the same time, vaginal birth after cesarean section (VBAC) has declined by 16%.^[1,2] Similarly, the Canadian CS rate has increased from 18% in 1994-95 to 22.1% in 2001. This increasing trend is recognized around the world, particularly in developed countries.

A total of 2.5% of births in the United States in 2004 were attributed to cesarean delivery at maternal request (CDMR); in other words, a planned CS without medical necessity. There are no systematic data on this trend^[3] and even fewer data on why women "choose" CS, beyond the media's rapture with movie stars who are deemed "too posh to push."^[4] Proponents of CDMR claim benefits to mothers, such as decreased pelvic floor damage as well as avoiding trauma to both mother and baby.^[5,6] Opponents argue that the literature on which these assertions are made is biased.^[7,8]

The US National Institutes of Health (NIH) held a consensus conference in March 2006 to determine the scientific basis for maternal and fetal risks and benefits to CDMR. After 2 days of presentations by experts in the field and input from the audience, the consensus was that "the available information comparing the risks and benefits of Cesarean delivery on maternal request (CDMR) versus planned vaginal birth (VB) do not provide the basis for a recommendation in either direction."^[9] Recommendations from the independent panel of experts included:

1. Individual counseling for each woman regarding risks and benefits;
   
   
2. Women who are considering having more than 2 children should be aware that a CS causes uterine scarring and they should avoid a primary CS; and
   
   
3. Women should not have CS prior to 39 weeks of gestation.^[9]

These recommendations opened the door wide for CDMR without heeding the principle that deviation from accepted practice should not occur unless and until the preponderance of evidence favors the "new" approach.

At least 3 issues are at play here and worthy of critique: (1) safety, (2) ethics ("woman's choice" or subtle coercion by healthcare providers), and (3) the remedicalization of childbirth after several decades of a consumer movement that sought to demedicalize childbirth.

Michael C. Klein, MD, CCFP, FAAP (Neonatal-Perinatal), FCFP, ABFP, Professor Emeritus of Family Practice and Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada, challenged CDMR by commenting on these 3 issues.^[10]

Safety Issues of CS vs Vaginal Birth

Klein pointed out 2 relevant lines of research comparing planned VB and elective CS: (1) pelvic floor dysfunction issues, and (2) classical maternal surgical morbidity and mortality and newborn outcomes.

Pelvic Floor Studies. Many of these studies are bedeviled by conflicting data and uncertain conclusions such as the "potentially large time gap between exposure and outcome, recall bias, and by the subjective nature of the symptoms,"^[11] the significant degree of pelvic floor dysfunction that is inherent as women age, and prepregnancy pelvic floor functioning.^[11] Klein stated that other groups of women who are nulliparous (such as nuns) may have problems with urinary incontinence. Many of the prospective cohort studies have also had small sample sizes and short follow-up, which obviously leads to data of limited clinical relevance.

Although there is evidence that pregnancy affects sexual health, particularly during the first 3 months postpartum, by 6 months postpartum , studies indicate that there is little difference in outcomes between CS and VB. Klein and colleagues^[12] performed a cohort analysis using data from a randomized controlled trial of episiotomy in Montreal from 1990 to 1991. Their sample consisted of 999 women, of whom 135 had CS and 864 had VB. After stratification by parity, they compared incidence of urinary incontinence (UI) and sexual functioning at 3 months postpartum.

They found that while CS offered some early protection against UI, severe UI was similar in both groups; overall sexual functioning was similar, but women who had episiotomies had more sexual dysfunction than did women who had a CS, intact perineum, or second-degree tear. Women with prior history of UI predictably had more symptoms with subsequent pregnancies.

Surgical Mortality/Morbidity and Newborn Outcomes. Research evidence shows that there is increased maternal and newborn mortality and morbidity associated with CS (Table).

Table. Mortality and Morbidity in CS vs VB^[10]

Maternal consequences

Newborn consequences

• 4330 CS = 1 extra maternal death  • 6102 CS = 1 extra thromboembolic event  • 632 CS to prevent 1 transfusion  • 37 CS = 1 extra operative trauma  • 159 CS = 1 extra infection  • 435 CS = 1 extra case sepsis/DIC  • 156 CS = 1 extra readmission  • 444 CS = 1 extra abruption  • 489 CS = 1 extra ectopic  • 230 CS = 1 extra placenta previa  • 694 CS = 1 extra invasive placenta  • 2667 CS = 1 extra hysterectomy

• 22,641 CS prevent 1 subdural/intracranial bleed  • 19,601 CS prevent 1 IVH  • 7549 CS prevent 1 subarachnoid hemorrhage  • 10,613 CS prevent 1 neonatal convulsion  • 5666 CS prevent 1 newborn CNS depression  • 2164 CS prevent 1 brachial plexus injury  • 338 CS = 1 extra severe feeding difficulty  • 69 CS = 1 extra respiratory problem  • 80 CS = 1 extra TTN  • 129 CS = 1 extra RDS  • 247 CS = 1 extra pneumonia  • 162 CS = 1 extra level III admission  • 153 CS = 1 extra 5 minute Apgar less than 7  • 317 CS = 1 extra newborn on respirator more than 24 hours  • Poorer outcomes in subsequent births for infant -- increased prematurity and low birth weight[13]

CS = cesarean section; VB = vaginal birth; DIC = disseminated intravascular coagulation; IVH = in vitro hemorrhage; CNS = central nervous system; TTN = transient tachypnea of the newborn; RDS = respiratory distress syndrome
See also Bernstein PS. Complications of cesarean deliveries [clinical update]. Medscape Women's Health. 2005. Available at: http://www.medscape.com/viewprogram/4546.

New US data (1998-2001) on neonatal mortality in VB vs planned or elective CS shows 0.62 neonatal deaths per 1000 VB vs 1.77 per 1000 CS, roughly twice the neonatal death rate for CS.^[14] The WHO study^[15] from all of Latin America demonstrated that the hospitals with the highest CS rate also had the highest rates of maternal deaths, illness, neonatal deaths, and ICU admissions. A recent French study by Deneux-Tharaux and colleagues also reported that peripartum maternal death rate was 3.6 times higher in CS vs VB.^[16]

Ethical Issues of CDMR

Klein pointed out that the International Federation of Gynecology and Obstetrics finds CDMR unethical,^[17] while the American College of Obstetricians and Gynecologists' position concurs with CDMR from an informed patient but believes that it is acceptable to decline the request if the obstetrician thinks it is not in the patient's best interest.^[18] On the other hand, the Society of Obstetricians and Gynecologists of Canada stated that VB remains the preferred method of delivery and is "the safest option for women and carries with it less risk of complications in pregnancy and subsequent pregnancies than cesarean births."^[19] The Maternity Center Association of New York did a comprehensive review of the literature and concluded that "in the absence of clear, compelling, and well-supported rationale for cesarean section, vaginal birth is far safer for mothers and babies."^[7]

Informed consent is another ethical issue that must be addressed. Klein stated that a proper informed consent session takes at least an hour. How the material is presented is critical, as is any bias on the part of the provider. Conflict of interest is inherent because a structured, elective CS is easier for the surgeon.

An interesting and controversial issue here is the use of "choice" language. This gives the argument a feminist twist -- seemingly empowering women to choose their method of birth and offering them autonomy and control. Leeman and Plante^[20] argue that women in the United States do not currently have the right to "choose" VBAC or vaginal delivery for a breech presentation. Hence, they caution that CDMR may in fact limit women's options for VB and state that patient choice advocates must see that VB options are preserved as well as CS. Klein adds that although a woman's right to choose needs to be respected, she needs a detailed and accurate account of the pros and cons.

Remedicalization of Childbirth

In the old adage that history repeats itself, Klein pointed out that the language being used in the CDMR debate is very similar to the language used by Dr. DeLee in 1920 as he was musing about the negative effects of VB while encouraging the routine use of episiotomies and forceps. This return to the medicalization of childbirth situated in a seductive package of "choice" may be seen as progress in women's healthcare, yet it is an ironic twist to the natural childbirth movement of the 1970s.

CDMR is controversial, and newer data than those reported at the NIH Consensus conference appear to indicate that CS leads to greater morbidity and mortality than VB. Clinicians need to be ever vigilant in assuring that women who express interest in elective CS understand the associated risks. Detailed informed consent is critical to women's decision-making. Nurses are in a prime position to educate consumers.

References

1. Hamilton BE, Martin JA, Sutton PD. Births: preliminary data for 2003. Natl Vital Stat Rep. 2004;53:1-17.
2. National Institutes of Health. NIH state-of-the-science conference: cesarean delivery on maternal request. 2006. Available at: http://consensus.nih.gov/2006/2006CesareanSOS027html.htm. Accessed November 14, 2006.
3. Declercq G, Norsigian J. Mothers aren't behind a vogue for cesareans. The Boston Globe. April 3, 2006; A15.
4. Brink S. Too posh to push? Cesarean sections have spiked dramatically. US News and World Report. August 5, 2002.
5. Minkoff H, Chervenak FA. Elective primary delivery. N Engl J Med. 2003;348:946-950. Abstract
6. Hannah ME. Planned elective cesarean section: a reasonable choice for some women? CMAJ. 2004;120:813-814.
7. Klein MC. Quick fix culture: the cesarean-section on demand debate. Birth. 2004;31:161-164. Abstract
8. Goer H. The assault on normal birth: the OB disinformation campaign. Midwifery Today. 2002;63:10-14. Abstract
9. NIH News. Panel finds insufficient evidence to recommend for or against maternal-request caesarean delivery. March 29, 2006. Available at: http://www.nih.gov/news/pr/mar2006/od-29.htm. Accessed November 14, 2006.
10. Klein MC. Cesarean on request: ethics and safety issues. Program and abstracts of the National Association of Nurse Practitioners in Women's Health 9th Annual Meeting: Women's Health Care in the New Millennium; September 27-30, 2006; Las Vegas, Nevada.
11. Press J, Klein MC, von Dadelszen P. Mode of delivery and pelvic floor dysfunction: a systematic review of the literature on urinary and fecal incontinence and sexual dysfunction by mode of delivery. Medscape. 2006. Available at: http://www.medscape.com/viewprogram/4989. Accessed November 14, 2006.
12. Klein MC, Kaczorowski J, Firoz T, Hubinette M, Jorgensen S, Gauthier R. A comparison of urinary and sexual outcomes in women experiencing vaginal and cesarean births. J Clin Gynecol. 2005;27:320.
13. Hemminki E, Shelley J, Gissler M. Mode of delivery and problems in subsequent births: a register-based study from Finland. Am J Obstet Gynecol. 2005;193:169-177. Abstract
14. MacDorman MF, Declercq E, Menacker F, Malloy MH. Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts. Birth: Issues in Perinatal Care. 2006; 33:175-182.
15. Villar J, Valladares E, Wojdyla D, et al. Cesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet. 2006;367:1819-1829. Abstract
16. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol. 2006;108:541-548. Abstract
17. FIGO Committee for the ethical aspects of human reproduction and women's health. Gynecol Obstet Invest. 1999;48:73-77. Abstract
18. American College of Obstetrics and Gynecology. Surgery and patient choice: the ethics of decision-making. ACOG Committee Opinion No. 289. Obstet Gynecol. 2003;102:1101-1106. Abstract
19. Society of Obstetricians and Gynecologists of Canada. SOGC's position on elective C-sections. Press release, March 2, 2004.
20. Leeman LM, Plante LA. Patient choice vaginal delivery? Ann Fam Med. 2006;4:265-268.

Susan M Kendig, RNC, MSN, WHCNP, FAANP   

　

Almost 10 years ago, when I began teaching, my students and I attended a lecture by an oncology clinical nurse specialist. She told the story of a patient she had seen that day who was dying from cervical cancer. "It is so sad," she said. "Her husband told me that his first wife had also died of cervical cancer. There is probably a connection, but we don't know what it is." During the past decade, information about human papillomavirus (HPV) as a causal link to cervical cancer has exploded, culminating in 2006 with FDA approval of a vaccine against HPV types 16 and 18, the most prevalent types associated with cervical cancer.^[1]

HPV: Centers for Disease Control and Prevention (CDC) 2006 Recommendations

J. Thomas Cox, MD, Director of Gynecology and Colposcopy Clinic, Student Health Services, University of California, Santa Barbara, presented an overview of the newly released CDC recommendations related to HPV.^[2] Over 100 types of HPV have been identified and over 30 types can affect the genital area. Of those, types 6 and 11 are most commonly associated with external genital warts (EGW). Persistent infection with types 16, 18, 31, 33, and 35 is strongly associated with cervical neoplasia.^[2] Types 16 and 18 are the most important. Of 3000 cases of cervical cancer reported in a World Health Organization study, 70% were these types, with over 75% of cases due to HPV type 16.^[2]

HPV is one of the most common sexually transmitted diseases (STDs), resulting in approximately 500,000 to 1,000,000 new cases and 264,000 initial office visits for EGWs annually.^[3] Sexual contact with an infected partner is necessary for HPV transmission. Consistent condom use has been shown to reduce the risk of acquiring HPV by 70%.^[2] Because sexual contact includes more than intercourse, areas other than the genitals may be affected by HPV. HPV exposure increases risk of anal cancer, and 20% to 25% of oral cancers are linked to HPV, primarily type 16.^[2]

Approximately 70% to 80% of sexually active persons will contract HPV in their lifetime, with acquisition occurring soon after the first intercourse. Most will clear HPV, including high-risk types. Long-term persistence of HPV is necessary for the accumulation of random mutations that can lead to cancer. The mutations may be promoted by inflammation and repair responses and environmental carcinogens. Environmental carcinogens such as nicotine and cotine, which are present in cigarette smoke, can accumulate in the cervix, where the HPV has hijacked the immune system's ability to respond and repair itself.^[2]

Of women exposed to low-risk HPV types 6 or 11, approximately two thirds will develop EGWs.^[2] Patient-applied and provider-applied therapies are available for EGW treatment. The primary treatment goal is removal of visible warts, and treatment should be guided by patient preference, available resources, and provider experience. No definitive evidence suggests the superiority of one treatment modality over another.^[3] Of the patient-applied therapies, evidence suggests higher initial clearance and less posttreatment recurrence with imiquimod vs podofilox.^[4] Women with cervical warts must be biopsied prior to treatment to exclude high-grade squamous intraepithelial lesion (HSIL), and management of exophytic cervical warts should include evaluation by a specialist.^[2]

Women with a history of STDs, particularly HPV, are at increased risk for cervical cancer. The CDC recognizes the American Cancer Society and American College of Obstetricians and Gynecologists guidelines recommending annual screening for women 21-30 years old, and every 2 to 3 years for women age 30 or older following 3 consecutive negative Pap smears.^[3] HPV testing in conjunction with the Pap test "might be useful" in screening women who are 30 years old or older.^[2,3] Abnormal Pap test results should be managed according to the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines.

Pap Tests: 2006 ASCCP Consensus Conference

In 2001, the ASCCP Consensus Guidelines introduced significant changes in evaluation, reporting, and management of Pap test results. In September 2006, the ASCCP held another consensus conference, with the goal of updating the 2001 guidelines using evidence published since the 2001 Consensus Conference. Thomas C. Wright, Jr., MD, Associate Professor, Division of Gynecologic Pathology, College of Physicians and Surgeons, Columbia University, New York, NY, and a member of the 2006 ACCP Consensus Conference, presented an update.^[5]

The process for developing the Consensus Guidelines included almost 100 participants from women's healthcare, public health, and public policy, representing 28 different federal agencies, professional societies, and professional organizations, including NPWH. This was the culmination of a lengthy process that began with a working group that identified key issues and conducted a literature review, public comment periods, and 2 guideline revisions. The 2006 guidelines are being finalized and have been embargoed until 2007, when the algorithms will be released.^[5]

Despite the embargo, Dr. Wright was able to provide participants with limited information regarding what to expect in 2007. In terms of atypical squamous cells of undetermined significance (ASC-US), studies since 2001 have shown that HPV testing resulted in an equal amount of women being referred for colposcopy, and it is slightly more specific in identifying cervical intraepithelial neoplasia (CIN) 2. Although HPV testing is the preferred follow up to an ASC-US Pap, all 3 follow-up options -- colposcopy, HPV testing, and repeating the Pap smear at 3-month intervals -- are safe and efficient. No substantive changes to ASC-US management are expected.^[5]

Among special populations, almost no data were found to support the common practice of treating postmenopausal women with intravaginal estrogen prior to repeating their Pap test.^[5] Because cancer is rare among adolescent women, the approach to follow-up in this group will be less aggressive than in the previous guideline, with cytologic follow up for 24 months unless an HSIL is present.^[5]

Atypical squamous cells, cannot exclude HSIL (ASC-H) should only account for no more than 5% to 10% of all ASC. No substantive changes to the 2001 guidelines are recommended. Low-grade squamous epithelial lesions (LSIL) will be managed similar to ASC-US in adolescents.^[5] Regarding CIN 1, the 2001 recommendations focused on either follow-up or treatment following a satisfactory colposcopy. The 2006 guidelines focus on follow-up as the primary approach to management for all groups of women.^[5]

Some changes may be expected regarding HSIL. The 2001 guidelines call for colposcopy with endocervical management as the recommended management for nonpregnant women with HSIL. Changes in 2006 suggest that either a diagnostic excisional procedure or colposcopy with endocervical assessment are acceptable for management. If no CIN 2+ is identified, either a diagnostic excisional procedure or planned follow-up would be acceptable.^[5]

Overall, Dr. Wright's presentation indicates that some changes will be recommended in the 2006 guidelines, but the changes will not be as sweeping as those presented in 2001. Stay tuned for release of the finalized embargoed algorithms prior to considering practice changes. Visit the American Society for Colposcopy and Cervical Pathology for updates and watch the NPWH Web site for information on emerging standards for the diagnosis and treatment of cervical disease.

References

1. US Food and Drug Administration. FDA licenses new vaccine for prevention of cervical cancer and other diseases in females caused by human papillomavirus. FDA News. 20006:6-77. Available at: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html. Accessed November 2, 2006.
2. Cox JT. STIs: HPV new recommendations CDC 2006. Program and abstracts of the National Association of Nurse Practitioners in Women's Health 9th Annual Meeting: Women's Health Care in the New Millennium; September 27-30, 2006; Las Vegas, Nevada.
3. Centers for Disease Control and Prevention. STD Treatment Guidelines 2006. MMWR Morb Mortal Wkly Rep. 2006;55:65.
4. American College of Obstetrics and Gynecology. Human papillomavirus. ACOG Practice Bulletin No. 61. Obstet Gynecol. 2005;105:905-918. Abstract
5. Wright TC. 2006 ASCCP Consensus Conference. Program and abstracts of the National Association of Nurse Practitioners in Women's Health 9th Annual Meeting: Women's Health Care in the New Millennium; September 27-30, 2006; Las Vegas, Nevada.

Chris Knutson, ANP, MN   

"Survivorship medicine" is becoming a more frequent challenge for practitioners of all specialties. Women cancer survivors who make their way back into "routine" care following cancer treatment have questions and concerns that could hardly be considered routine. Some will ultimately be cured. Some will deal with cancer's chronicity. All of them find their lives forever changed by cancer.

Michael Krychman, MD, Co-Director of the Sexual Medicine Program at Memorial Sloan-Kettering Cancer Center, New York, recently spoke of the reproductive and sexual concerns of women with cancer. He reminds his patients that "you may survive this illness but your life will never, ever be the same."^[1] Helping patients come to grips with that concept and making accommodations to enhance or preserve sexual functioning and fertility are increasingly frequent and critical components of cancer care.

Thanks to earlier diagnosis and more effective treatments, more and more individuals are surviving cancer, and surviving it at earlier ages. As women trend toward later childbearing, the 2 issues will eventually intersect. Frank and open discussions between practitioner and patient can help women overcome fears of infertility, disfigurement, and loss of function or pleasure at a time when intimacy and comfort may be especially necessary as components of recovery.

Evaluation of the cancer patient must include a sensitive inquiry into sexual status and history, with a focus on the disease process, impact of surgical interventions, and sequelae of adjunctive therapies such as radiation or chemotherapy. Special physical concerns of cancer patients are similar to those of anyone with a chronic disease: fatigue, pain, limits in range of motion, or shortness of breath. In addition, the cancer survivor may sometimes need to deal with the issue of an ostomy.

Partners may draw back out of concern or fear of causing pain and wait for the woman to signal her need for physical comfort and intimacy. The woman patient, on the other hand, may be reticent to initiate sexual contact for fear of rejection, loss of a feeling of physical appeal, loss of sensation, and uncertainty of her body's capacity to express and feel pleasure. Structured "safe" intimate tasks and gradually escalating exercises, providing advice for positioning, vaginal stretching, and self-stimulation, can be helpful in moving the woman or couple toward exploring sexual relationships in new dimensions.

Dr. Krychman spoke of some tantalizing new research suggesting that oxytocin and DHEA released during orgasm may have an inhibitory effect on cancer or reduce odds of developing cancer, so the successful return to sexual activity may also have therapeutic advantages beyond physical comfort, intimacy, and pleasure.

Many gynecologic cancer treatments can produce a premature menopausal status, resulting in infertility and reduced sexual desire. Nonhormonal treatment regimens for hot flushes and sleeping or mood problems include administration of selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, sometimes in off-label applications. These include citalopram, fluoxetine, paroxetine, sertraline, and venlafaxine.^[2-4] Off-label use of gabapentin is also showing promise in reduction of hot flushes.^[5]

Use of botanicals and vitamin E have not been shown to be reliably effective, and the plant estrogens (as advertised in soy, red clover, or black cohosh products) may not be safe for breast cancer survivors. The vaginal dryness associated with menopause can be addressed with nonhormonal moisturizers, some of which mimic native vaginal secretions.^[6] Low-dose estrogen-containing products that produce a predominantly local effect such as a vaginal estrogen ring or estrogen pellet may be considered for brief and periodic use.^[7]

When Disease Is Complicated by Pregnancy

Malignancy of any kind is generally treated as if the patient were not pregnant.^[8] Malignancies of the upper abdomen, lung, or extremities should be treated as usual. A pregnancy diagnosis and odds of infant survival must be considered in relation to the stage of cancer and weeks of pregnancy. Therapeutic doses of radiation are lethal to a 1- to 10-day-old embryo and can cause gross malformations up through the eighth week. From 8 weeks to term, intrauterine growth retardation, malformations, and permanent growth retardation can result.

Chemotherapy should be delayed until after the first trimester, if possible. In the second and third trimesters, spontaneous abortion, intrauterine growth retardation, low birth weight, and prematurity may result,^[1] but data are limited and longer-term effects have not been firmly established.^[9]

Breast cancer in particular may be masked during pregnancy due to breast engorgement, delaying the diagnosis. However, any solid mass should be investigated promptly, including the performance of diagnostic mammography as the danger of fetal damage from exposure to a small amount of radiation is less than the imminent danger of undetected disease.^[9]

Reproductive Health Concerns of Young Women With Cancer

Young women diagnosed with cancer may have a desire to preserve fertility, and pregnancy after cancer raises concerns the practitioner can help address. For example, women may worry that they may not survive long enough to raise a child to adulthood or they may have residual physical limitations that will interfere with parenting. Patients may be especially concerned with the possibility of passing on family traits, as with the breast cancer gene.

Breastfeeding may be perceived as a challenge by women having had mastectomy, lumpectomy, or radiation, but studies show breastfeeding is usually unaffected in the untreated breast. While uncommon, breastfeeding may even be possible in the treated breast, depending on the extent of undamaged glandular tissue remaining after surgery and radiation. Studies show that the milk produced from the treated breast is safe for the infant.^[9,10]

There have been significant advances in fertility-sparing and parenting options for the woman having cervical, uterine, or ovarian cancer. Cervical treatment can sometimes be put off until the pregnancy is advanced to viability. "There is no evidence that pregnancy per se adversely affects the outcome of cervical carcinoma."^[8] Radical trachelectomy, dissection of the cervix while leaving the uterine body intact, is becoming more prevalent, even though it is not yet considered the standard of care. However, this method is the most promising and has high success rates. Trachelectomy may be indicated for women with disease staged at IB1 or earlier who wish to preserve fertility.^[11]

Studies indicate trachelectomy preserves fertility, although assistance may be needed to achieve pregnancy and cerclage required to maintain the pregnancy. Complications requiring hospitalization may include premature rupture of membranes resulting in premature birth; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; and placenta previa.^[12]

Another option for fertility includes embryo cryopreservation, which is now widespread and successful. This method requires delay of treatment in order to stimulate ovulation and undergo in vitro fertilization. The necessity of a male partner or acceptance of donor sperm is another issue when considering this option. Oocyte cryopreservation, while not requiring a male sperm donor or partner, still delays treatment while the woman undergoes ovarian stimulation, and is less successful than other assisted reproductive technologies. Other options include: ovarian tissue cryopreservation of primordial follicles and ovarian tissue transplantation (excision of entire ovary or harvesting ovarian tissue strips for cryopreservation and later reanastomosis), both experimental; shielding from radiation; and assisted conception following treatment. In addition, donor eggs and embryos, surrogacy, adoption, and acceptance of child-free living are all options to be explored.

In summary, clinicians can help women who are pregnant or are still wishing to achieve pregnancy to cope with cancer diagnoses and survivorship issues. Research and resources are growing within an emerging body of research evidence.

References

1. Krychman ML. Sex and pregnancy after cancer. Program and abstracts of the National Association of Nurse Practitioners in Women's Health 9th Annual Meeting; September 27-30, 2006; Las Vegas Nevada.
2. Hoffman RF, Viera AJ, Stone KJ. Off-label uses for selective serotonin inhibitors. Am Fam Physician. 2005;71:43.
3. Longo DL. Venlafaxine, a nonestrogenic antidepressant with efficacy against hot flashes? Update: Harrison's Internal Medicine, 1/24/01. Available at: http://www.accessmedicine.com/updatesContent.aspx?aid=396472 (Fee required.) Accessed October 10, 2006.
4. French L. SSRIs ineffective for the management of hot flashes. Am Fam Physician. 2005;71:2361.
5. Walling AD. Gabapentin reduces hot flashes in breast cancer survivors. Am Fam Physician. 2006;73:1073.
6. The Susan G. Komen Breast Cancer Foundation. After Treatment: Alternatives to Postmenopausal Hormones. Available at: http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?IdcService=SS_GET_PAGE&ssDocName=3-6-6. Accessed November 15, 2006.
7. The Susan G. Komen Breast Cancer Foundation. After Treatment: Sex and Sexuality. Available at: http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?IdcService=SS_GET_PAGE&ssDocName=3-6-4. Accessed November 15, 2006.
8. Cancer in pregnancy. The Merck Manual of Diagnosis and Therapy. Available at: http://www.merck.com/mmpe/sec18/ch261/ch261e.html. Accessed November 15, 2006.
9. Cunningham FG, Leveno KJ, Bloom, SL, et al. Williams Obstetrics. 22nd edition. New York: McGraw-Hill Medical Publishing Division; 2005.
10. The Susan G. Komen Breast Cancer Foundation. After Treatment: Having Children After Breast Cancer. Available at: http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?IdcService=SS_GET_PAGE&ssDocName=3-6-5. Accessed November 15, 2006.
11. Bansal N, Herzog T. Fertility options in women with gynecologic malignancies. Womens Oncol Rev. 2005;5:185-191.
12. Worchester S. Post-radical trachelectomy pregnancy appears safe. Ob Gyn News. 2003;38:10.