A Systems-level View of a Pregnancy with Medical Complications 1

Part I—Gynecological Health Issues


Yvonne has been a student of science nearly all her life. She values
her independence and loves her career in the biopharmaceutical industry.
She is extremely focused, as evidenced by her three-, five-, and
10-year plans for her career. Her plans include having a child, once she
has realized her career aspirations.

Yvonne’s recent promotion to senior principal scientist at the young
age of 30 means she now has more responsibilities at work. She feels a
deep sense of security as her dreams are coming to fruition. However,
she is about to learn that the best laid plans have a way of, well, not
working out as planned.

Seldom needing to see a doctor for most of her life, Yvonne has spent
the past several months receiving gynecological treatment for
cervicitis and cervical neoplasia, a disease for which the cause is
unknown. A couple of weeks ago, Dr. James Trent, her
gynecologist/obstetrician, ordered several tests and performed an
in-office diagnostic procedure to try to narrow down the cause of
Yvonne’s condition.

At her next scheduled appointment, Dr. Trent tells Yvonne that the
tests for bacterial or viral causes (which would indicate the presence
of a sexually transmitted disease, or STD) are negative. He explains
that the procedure Yvonne had undergone last month, a colposcopy with
cervical biopsy to evaluate the cervical topography and its epithelial
character, is benign for cervical cancer.

“The results are promising,” Dr. Trent explains, “but I am afraid
that at this point we have more questions then answers. I believe our
best course of action is an outpatient procedure called cervical
cryosurgery.”

“What is the intent of the surgery?” Yvonne asks.

“With cervical cryosurgery, we remove the superficial layers of
tissue lining the cervix in hopes of permanently removing any abnormal
cells, whatever their cause, thereby eliminating the precancerous
condition,” Dr. Trent answers.

The following week, Yvonne has the outpatient cryosurgery procedure.
At her next appointment, Yvonne listens closely as Dr. Trent says, “The
cervical cryosurgery didn’t achieve the result we had hoped for; the
cervical abnormality has in fact recurred.

“Our remaining option is a surgical procedure called cervical
conization (or cone biopsy). We remove a cone-shaped section of tissue
from the endocervix and send it to a pathologist to determine whether
all abnormal tissue containing the precancerous cells is likely to have
been removed.”

Dr. Trent continues, “A cone biopsy will often cure the problem.
However, in a small number of cases, it may interfere with childbearing.
You could choose to have the conization surgery now before a pregnancy,
or after. It’s your decision.

“If you choose to have the procedure now, you will have more time to
prepare for a pregnancy at a later date. However, because cervical
conization involves removing endocervical tissue, the ability of the
uterus to bear weight will be diminished. As the fetus’ weight
increases, added strain will be placed on the muscular wall. About half
way through your pregnancy, you most likely would be placed on bed rest
until the baby comes,” Dr. Trent explains. “If you decide to become
pregnant first, we can perform the surgery at a later date. I would
recommend you start taking daily prenatal vitamins now to prepare for a
pregnancy in case you decide to pursue such an option sooner rather than
later.”

Yvonne’s choices are clear. She must decide between having a child in
the not-too distant future with little to no risk of complications, or
have a high-risk pregnancy at a more fitting time in her life. Yvonne
takes some time to consider her options, turning to the people closest
to her in her private life for support and advice. At age 30, although
still young, Yvonne is cognizant of the medical literature concluding
that a woman’s ability to conceive a child decreases with advancing age.

Questions

1. What is the anatomical relationship between the cervix and the
   uterus?
   
2. What are the current statistics on the frequency of occurrence of
   cervical cancer? Does a women’s race affect her chances of developing
   this cancer? What is the standard test for detecting cervical cancer?
   
3. Most cases of cervical cancer result from human papillomavirus (HPV)
   infection. What information can you find about transmission,
   contraction, and consequences of HPV from valid medical sources?
   
4. The success of the new HPV vaccine (approved in June 2006) will rely
   on parents’ willingness to vaccinate their prepubescent daughters.
   Discuss your own willingness to do so were you a parent of a young girl.
   
5. Yvonne faces a potentially life-changing decision—to have a child
   now or wait until after a surgical procedure. Help her weigh the pros
   and cons as you see them.