Design: Case Report with multi year follow up

Setting: Academic, tertiary-care medical center

Patients or Participants: 30 year old female who underwent fertility sparing laparoscopic excision of endometriosis. Physical exam was significant for fibrotic nodule involving the rectovaginal septum. Uterine manipulator was not used out of concern for loss of pneumoperitoneum during anticipated colpotomy. Surgery complicated by complete cervical amputation, identified by entry into anterior cul-de-sac from posterior dissection.

Interventions: Primary cervico-uterine anastomosis was performed. A metal uterine sound was passed through the cervix into the fundus to ensure alignment. Unidirectional barbed suture was used in a running fashion to repair the anterior laceration, and then the posterior laceration with two separate sutures. Pediatric foley catheter was placed intrauterine in an attempt to maintain postoperative cervical patency.

Measurements and Main Results: Patient resumed spontaneous menses 2 months post-operatively, demonstrating patent cervical canal. Patient did not come to clinic for desired hysteroscopic evaluation of repair. Patient spontaneously conceived 22 months after surgery. Early ultrasound confirmed location and placentation in relation to the surgical site out of concern for ectopic and risk for incisional pregnancy. We could not find any cases or data regarding management of pregnancies following cervical re-anastomosis so a multidisciplinary team came together to recommend the following guidelines: cervical lengths up to 24 weeks to monitor for cervical insufficiency and 37 0/7 week primary cesarean delivery for concern of uterine dehiscence or rupture. Patient had a term pregnancy complicated by severe fetal growth restriction. At the time of delivery lower uterine segment was extremely thin and transparent.

Conclusion: We demonstrated a successful surgical management of an inadvertent complete cervical amputation followed by viable, term pregnancy. This case demonstrates pregnancy can be safe and successful following iatrogenic intraoperative complete cervical amputation.