Unique risk factors for unplanned preterm delivery in the uterus transplant recipient

Author:

Johannesson Liza12ORCID,Testa Giuliano1,Petrillo Nicole2,Gregg Anthony R3

Affiliation:

1. Department of Surgery, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center , Dallas, TX, USA

2. Department of Obstetrics and Gynecology, Baylor University Medical Center , Dallas, TX, USA

3. Department of Obstetrics and Gynecology, Prisma Health , Columbia, SC, USA

Abstract

Abstract STUDY QUESTION Do characteristics of the lower uterine segment and cervix modify the risk of preterm delivery in uterus transplant (UTx) recipients? SUMMARY ANSWER The cervical length showed little association with preterm delivery, however, cervical inflammation deserves further exploration as a cause of preterm delivery. WHAT IS KNOWN ALREADY UTx recipients do not have the risk factors normally used to stratify pregnancies that would benefit from cervical length assessment. In addition, unique factors related to absent tissues, a different blood supply, inflammatory processes of rejection, cervical biopsies, and a different microbiome challenge the normal progressive remodeling of the cervix and thus cervical competence. STUDY DESIGN, SIZE, DURATION This is a subanalysis of a clinical trial of 20 women undergoing uterus transplantation at Baylor University Medical Center from 2016 to 2020, in addition to two women who received transplantation outside of a research protocol at our institution through September 2022. In this report, the first 16 UTx recipients that achieved live birth are included. PARTICIPANTS/MATERIALS, SETTING, METHODS The focus of this study was 20 pregnancies that reached the second trimester in 16 women following UTx. We analyzed recipient, transplant, and donor factors to determine if characteristics were associated with delivery outcome. We compared obstetrical outcomes, including planned versus unplanned delivery, by factors such as number of superior venous anastomoses, warm ischemia and cold ischemia times, donor factors including cesarean sections, cervical biopsy results, and cervical ultrasound results. MAIN RESULTS AND THE ROLE OF CHANCE Planned term deliveries occurred in 44% (8/18) of live births. Of the preterm births, 30% (3/10) were planned and 70% (7/10) were unplanned. Unplanned deliveries occurred in women with spontaneous preterm labor, severe rejection, subchorionic hematoma, and placenta previa. Cervical length in UTx recipients averaged 33.5 mm at 24 weeks and 31.5 mm at 28 weeks, comparable to values from the general population. No relationship was seen between delivery outcome and number of veins used, ischemic time, or number of previous cesarean sections. LIMITATIONS, REASONS FOR CAUTION The study’s small size allows limited conclusions. The obstetric history of all donors was limited to mode of delivery. WIDER IMPLICATIONS OF THE FINDINGS Cervical length measurements in the UTx population are not expected to deviate from those with a native uterus. While cervical length surveillance remains important, attention must be paid to the results of cervical biopsies which are obtained to monitor rejection. Inflammatory processes seem most predictive of preterm delivery. STUDY FUNDING/COMPETING INTEREST(S) No funding was provided for this study. The authors report no conflicts of interest. TRIAL REGISTRATION NUMBER NCT02656550

Publisher

Oxford University Press (OUP)

Subject

Obstetrics and Gynecology,Rehabilitation,Reproductive Medicine

Reference18 articles.

1. Human uterus transplantation from living and deceased donors: the interim results of the first 10 cases of the Czech trial;Fronek;J Clin Med,2021

2. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. The length of the cervix and the risk of spontaneous premature delivery;Iams;N Engl J Med,1996

3. Persistence pays off: live birth after uterus transplant, over-coming recurrent pregnancy loss with cerclage placement;Johannesson,2023

4. Uterus transplantation: current progress and future prospects;Johannesson,2016

5. Dallas UtErus Transplant Study: early outcomes and complications of robot-assisted hysterectomy for living uterus donors;Johannesson;Transplantation,2021

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1. Living-Donor Uterus Transplantation: A Clinical Review;Journal of Clinical Medicine;2024-01-29

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