Gynecologic Procedures

Similar to the general population, routine gynecologic care is an important part of health care maintenance for stable female transplant recipients. Some problems encountered are similar, but some are distinct from the general population. Mucocutaneous herpes infections from herpes simplex virus type 1 or 2 and condylomata acuminata from human papilloma virus are relatively common. Occasionally, extensive disease may warrant systemic antiviral therapy. Surgical resection is occasionally necessary, and this can be undertaken without jeopardy to patient or graft survival.

The incidence of cervical dysplasia and/or neoplasia is increased among immunosuppressed women, and some authors have suggested an etiologic relationship between the effects of immunosuppression and growth of the human papilloma virus.4 As with other histopathology, an abnormal Papanicolaou smear should be managed aggressively. We recommend a cervical cone biopsy for definitive diagnosis. When indicated hysterectomy can be safely undertaken, but it is necessary to consider the anatomic variations caused by the kidney and/or pancreas transplantation. Often, the intra-operative participation of an experienced transplant surgeon can be helpful in this regard.

Ovarian pathology should also be pursued aggressively. Although laparoscopic management is made more challenging by the presence of adhesions from prior abdominal surgery, and in the case of renal and/or pancreas transplantation by the mass effect of the allograft, this approach to management of pelvic pathology is usually successful.

Pregnancy after organ transplantation is a complex topic, and a detailed discussion is beyond the scope of this essay. However, increasingly transplant recipients have delivered healthy babies. An experienced, high risk obstetrician and an experienced transplant physician should, collaboratively manage pregnancy in the transplant setting. Cyclosporine or tacrolimus dose adjustment is usually required to maintain target levels, and caesarean delivery has commonly been necessary. Importantly, this has been accomplished without jeopardizing the baby, the mother, or the allograft. We have not seen unusual complications of vaginal deliveries.

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