The effects of loop excision of the transformation zone on cervical length: implications for pregnancy

Morbidity after local excision of the transformation zone for cervical intra-epithelial neoplasia and early cervical cancer

The awareness that cervical intra-epithelial neoplasia (CIN) treatment increases the risk of preterm birth has led to major changes in clinical practice. Women with CIN have a higher baseline risk of prematurity but local treatment further increases this risk. The risk further increases with increasing cone length and multiplies for repeat excisions; it is unclear whether small cones confer any additional risk to CIN alone. There is no evidence to suggest that fertility is affected by local treatment, although this increases the risk of mid-trimester loss. Caution should prevail when deciding to treat women with CIN of reproductive age. If treatment is offered, this should be conducted effectively to optimise the clearance of disease and minimise the risk of recurrence. Colposcopists should alert women undergoing treatment that this may increase the risk of preterm birth and that they may be offered interventions when pregnant. The cone length should be clearly documented and used as a risk stratifier.

Evaluation of cervical length and optimal timing for pregnancy after cervical conization in patients with cervical intraepithelial neoplasia: A retrospective study

To evaluate the change of cervical length and the best timing for pregnancy after cervical conization in patients with cervical intraepithelial neoplasia (CIN).This was a retrospective study including patients under 40 years with fertility desire treated by cervical conization for CIN. To assess the cervical length, the patients were divided into 2 groups according to different surgery procedure: loop electrosurgical excision procedure (LEEP) and cold knife conisation (CKC). Patients with cervical length < 2.5 cm in CKC group were divided into 2 groups according to whether receiving cervical cerclage. Trans-vaginal ultrasound examination was used to measure cervical length by fixed professional sonographers.In LEEP group, the cervical length preoperative was significantly longer than 3 months postoperatively (3.03 ± 0.45 cm vs 2.84 ± 0.44 cm, P = .000). In CKC group, the cervical length preoperative was significantly longer than 3 and 6 months postoperatively (2.90 ± 0.41 cm vs 2.43 ± 0.43 cm and 2.68 ± 0.41 cm, respectively, P = .000). Cervical length was significantly longer at 12 and 9 months after cerclage compared to that without cerclage. Eighteen patients got pregnant in LEEP group, among which one was pregnant at 5 months postoperatively and had premature delivery. There was 1 inevitable abortion and 1 preterm birth among 39 pregnant patients from CKC group.Patients who have fertility desire with CIN were recommended for pregnancy at 6 and 9 months after LEEP and CKC, respectively. Cerclage effectively prolonged cervical length in patents with that less than 2.5 cm to prevent cervical incompetence.

Pregnancy outcomes following elective abdominal cerclage following cervical excision surgery for neoplastic disease

BACKGROUND

Local excisional treatment of neoplastic disease of the cervix in the form of loop excision (LLETZ) and conisation has been associated with adverse pregnancy outcomes including prelabour premature rupture of membranes (PPROM) and spontaneous preterm birth (SPTB). Insertion of a cervical cerclage is indicated for women with a short cervix <25 mm between 16 and 24 weeks gestation who also have a history of either PPROM or a history of cervical excisional treatment. The optimum timing of the cerclage and surgical technique used are both open to debate. This retrospective review of cases was performed to examine the outcomes of elective pre pregnancy placement of abdominal cervical cerclage in women who have undergone cervical excision surgery for neoplastic disease.

METHODS

This was a retrospective review of case notes. Over a 10 year period 20 women who had previous cervical excision surgery had pre-pregnancy abdominal cerclage placed became pregnant with 26 pregnancies. One woman had a cone biopsy, 9 had a single LLETZ procedure, 8 had 2 LLETZ procedures and 2 women had 3 LLETZ procedures prior to the cerclage.

RESULTS

21 pregnancies were achieved spontaneously, 1 by intrauterine insemination (IUI) and 4 were conceived by in-vitro fertilisation (IVF). Overall, 22 of 26 (84.6 %) pregnancies were delivered at term. There was a single 7 week miscarriage and 3 premature deliveries (12 %) including 1 preterm birth at 29 + 4 weeks gestation after an antepartum haemorrhage (APH) and 2 late preterm births at 36 + 3 (following APH) and 36 + 4 weeks gestation following preterm labour. All 25 women were delivered by Caesarean section and all 25 babies survived.

CONCLUSION

There results of prophylactic minimally invasive insertion of a transabdominal cerclage in women with LLETZ treatments or cone biopsy prior to pregnancy demonstrated 84.6 % of pregnancies resulted in a live birth. The premature delivery rate was 12 %.

A new approach to prevent cervical stenosis in postmenopausal women after loop electrosurgical excision procedure: a randomized controlled trial

To determine whether regular cervical dilatation is effective for preventing cervical stenosis, and to identify the associated risk factors, in postmenopausal women after LEEP. This was a prospective randomized clinical trial in postmenopausal women who underwent LEEP at our hospital between August 2018 and May 2019. Patients who met the study criteria were randomly allocated to three groups: control group (without any intervention), intervention group A (underwent cervical dilatation at the 3^rd, 5^th, and 8^th week after LEEP) and intervention group B (underwent cervical dilatation at the 4^th, 8^th, and 12^th week after LEEP). A colposcopic follow-up examination was conducted at 6 months after LEEP to determine the incidence of cervical stenosis. A total of 404 postmenopausal women were found to be finally eligible for the study. The rate of cervical stenosis in the control group was significantly higher than that in the intervention group, and the rate in group A was significantly lower than that in group B. We found regular dilatation after LEEP in postmenopausal women can prevent cervical stenosis. Further, the 3rd, 5th, and 8th weeks after LEEP are optimal time points. Finally, LEEP frequency and resection depth are significant risk factors and can be used to screen postmenopausal women at risk for cervical stenosis after LEEP.

Evaluation of the Cervix After Cervical Conization by Transvaginal Elastography

OBJECTIVES

The purpose of this study was to investigate the stiffness of the cervix after the loop electrosurgical excision procedure (LEEP) by transvaginal elastography and its potential ability to predict future pregnancy.

METHODS

A retrospective study included patients of reproductive age who underwent LEEP for cervical high-grade squamous intraepithelial lesions on the basis of colposcopic findings and who desired fertility. The characteristics on conventional transvaginal ultrasonography and elastography before and 6 months after LEEP were reviewed and analyzed. Each case had a 12-month follow-up, and the information on pregnancy and a cervical cytologic examination was recorded.

RESULTS

Fifty-three patients who completed the 12-month follow-up were included in the analysis. Thirty-two cases (group 1) were pregnant during the follow-up, and the other 21 (group 2) had pregnancy failure. The cervical lengths of group 1 and 2 as measured by traditional transvaginal ultrasonography were similar before and 6 months after LEEP. The resistive index of group 1 was significantly higher 6 months after LEEP than before LEEP (mean ± SD, 0.88 ± 0.36 versus 0.42 ± 0.22; P = .007). The mean elasticity score for the cervix was statistically significantly lower after LEEP (2.21 ± 0.53) than before (3.46 ± 0.78; P = .001) in group 1. However, in group 2, the mean elasticity scores were similar after LEEP (3.19 ± 0.58) and before (3.25 ± 0.66; P = .75).

CONCLUSIONS

Our results suggest that elastography was a useful technique for evaluating the stiffness of the cervix after LEEP. Elastography could provide a potential means to predict future pregnancy after LEEP.

Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study

PURPOSE

To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia.

METHODS

This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded.

RESULTS

We identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively.

CONCLUSION

We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.

Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease

BACKGROUND

The mean age of women undergoing local treatment for pre-invasive cervical disease (cervical intra-epithelial neoplasia; CIN) or early cervical cancer (stage IA1) is around their 30s and similar to the age of women having their first child. Local cervical treatment has been correlated to adverse reproductive morbidity in a subsequent pregnancy, however, published studies and meta-analyses have reached contradictory conclusions.

OBJECTIVES

To assess the effect of local cervical treatment for CIN and early cervical cancer on obstetric outcomes (after 24 weeks of gestation) and to correlate these to the cone depth and comparison group used.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, 2017, Issue 5), MEDLINE (up to June week 4, 2017) and Embase (up to week 26, 2017). In an attempt to identify articles missed by the search or unpublished data, we contacted experts in the field and we handsearched the references of the retrieved articles and conference proceedings.

SELECTION CRITERIA

We included all studies reporting on obstetric outcomes (more than 24 weeks of gestation) in women with or without a previous local cervical treatment for any grade of CIN or early cervical cancer (stage IA1). Treatment included both excisional and ablative methods. We excluded studies that had no untreated reference population, reported outcomes in women who had undergone treatment during pregnancy or had a high-risk treated or comparison group, or both DATA COLLECTION AND ANALYSIS: We classified studies according to the type of treatment and the obstetric endpoint. Studies were classified according to method and obstetric endpoint. Pooled risk ratios (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model and inverse variance. Inter-study heterogeneity was assessed with I2 statistics. We assessed maternal outcomes that included preterm birth (PTB) (spontaneous and threatened), preterm premature rupture of the membranes (pPROM), chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage and cervical stenosis. The neonatal outcomes included low birth weight (LBW), neonatal intensive care unit (NICU) admission, stillbirth, perinatal mortality and Apgar scores.

MAIN RESULTS

We included 69 studies (6,357,823 pregnancies: 65,098 pregnancies of treated and 6,292,725 pregnancies of untreated women). Many of the studies included only small numbers of women, were of heterogenous design and in their majority retrospective and therefore at high risk of bias. Many outcomes were assessed to be of low or very low quality (GRADE assessment) and therefore results should be interpreted with caution. Women who had treatment were at increased overall risk of preterm birth (PTB) (less than 37 weeks) (10.7% versus 5.4%, RR 1.75, 95% CI 1.57 to 1.96, 59 studies, 5,242,917 participants, very low quality), severe (less than 32 to 34 weeks) (3.5% versus 1.4%, RR 2.25, 95% CI 1.79 to 2.82), 24 studies, 3,793,874 participants, very low quality), and extreme prematurity (less than 28 to 30 weeks) (1.0% versus 0.3%, (RR 2.23, 95% CI 1.55 to 3.22, 8 studies, 3,910,629 participants, very low quality), as compared to women who had no treatment.The risk of overall prematurity was higher for excisional (excision versus no treatment: 11.2% versus 5.5%, RR 1.87, 95% CI 1.64 to 2.12, 53 studies, 4,599,416 participants) than ablative (ablation versus no treatment: 7.7% versus 4.6%, RR 1.35, 95% CI 1.20 to 1.52, 14 studies, 602,370 participants) treatments and the effect was higher for more radical excisional techniques (less than 37 weeks: cold knife conisation (CKC) (RR 2.70, 95% CI 2.14 to 3.40, 12 studies, 39,102 participants), laser conisation (LC) (RR 2.11, 95% CI 1.26 to 3.54, 9 studies, 1509 participants), large loop excision of the transformation zone (LLETZ) (RR 1.58, 95% CI 1.37 to 1.81, 25 studies, 1,445,104 participants). Repeat treatment multiplied the risk of overall prematurity (repeat versus no treatment: 13.2% versus 4.1%, RR 3.78, 95% CI 2.65 to 5.39, 11 studies, 1,317,284 participants, very low quality). The risk of overall prematurity increased with increasing cone depth (less than 10 mm to 12 mm versus no treatment: 7.1% versus 3.4%, RR 1.54, 95% CI 1.09 to 2.18, 8 studies, 550,929 participants, very low quality; more than 10 mm to 12 mm versus no treatment: 9.8% versus 3.4%, RR 1.93, 95% CI 1.62 to 2.31, 8 studies, 552,711 participants, low quality; more than 15 mm to 17 mm versus no treatment: 10.1 versus 3.4%, RR 2.77, 95% CI 1.95 to 3.93, 4 studies, 544,986 participants, very low quality; 20 mm or more versus no treatment: 10.2% versus 3.4%, RR 4.91, 95% CI 2.06 to 11.68, 3 studies, 543,750 participants, very low quality). The comparison group affected the magnitude of effect that was higher for external, followed by internal comparators and ultimately women with disease, but no treatment. Untreated women with disease and the pre-treatment pregnancies of the women who were treated subsequently had higher risk of overall prematurity than the general population (5.9% versus 5.6%, RR 1.24, 95% CI 1.14 to 1.34, 15 studies, 4,357,998 participants, very low quality).pPROM (6.1% versus 3.4%, RR 2.36, 95% CI 1.76 to 3.17, 21 studies, 477,011 participants, very low quality), low birth weight (7.9% versus 3.7%, RR 1.81, 95% CI 1.58 to 2.07, 30 studies, 1,348,206 participants, very low quality), NICU admission rate (12.6% versus 8.9%, RR 1.45, 95% CI 1.16 to 1.81, 8 studies, 2557 participants, low quality) and perinatal mortality (0.9% versus 0.7%, RR 1.51, 95% CI 1.13 to 2.03, 23 studies, 1,659,433 participants, low quality) were also increased after treatment.

AUTHORS' CONCLUSIONS

Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment appears to further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than it is for ablation. However, the results should be interpreted with caution as they were based on low or very low quality (GRADE assessment) observational studies, most of which were retrospective.

Increase in the cervical length after the loop electrosurgical excision procedure for grade III cervical intraepithelial neoplasia

This study aimed to determine whether the cervical length increases over a period of six months, after the loop electrosurgical excision procedure (LEEP) for grade III cervical intraepithelial neoplasia (CIN), and to identify the factors associated with an increase in the cervical length. We retrospectively reviewed the medical records of 183 patients who underwent the LEEP between April 2011 and March 2014, at the Department of Gynaecology, Kyosai Hospital. Transvaginal ultrasonography was performed at two, three and six months after the LEEP, and the mean increase in the cervical length between two and three months, two and six months, and three and six months were 2.07, 5.23 and 2.92 mm, respectively. The increase in the cervical length was not associated with age, gravidity, parity and the width of CIN. In conclusion, the cervical length may increase gradually over a period of six months after the LEEP.

Four categories of LEEP for CIN of various areas: a retrospective cohort study

PURPOSE

To compare the effectiveness and safety of loop electrosurgical excision procedures (LEEP) with four different excisions in treating cervical intraepithelial neoplasia (CIN) of different areas.

METHODS

Four hundred and sixty-six cases of CIN were treated with different types of LEEP. Following visual inspection with acetic acid and Lugol's iodine, LEEP were performed to excise the transformation zone to a 20-25 mm depth with a 2-3 mm margin. Four categories of procedures are described below: (i) LEEP-A for lesion ≥2/3 of cervical area: conization of ≥2/3 of cervical tissue. (ii) LEEP-B for ≥1/3 but <2/3: conization of 1/3 to <2/3. (iii) LEEP-C for <1/3: conization of <1/3. (iv) LEEP-D: endocervical canal resection.

RESULTS

The cases included 108 of CIN I, 232 of CIN II, and 106 of CIN III (not including carcinoma in situ) patients. No positive margin was found in any specimens. The cure rates for LEEP-A, B, C, and D were 99.1%, 98.5%, 100.0%, and 93.2%, respectively (p > .05). The pregnancy rate at two years after LEEP was significantly higher in groups C and D compared to group A (p < .05).

CONCLUSIONS

Four categories of LEEP are highly effective in the treatment of CIN when appropriately applied. However, large loop excision may lead to adverse obstetric outcomes in pregnancy.

Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis

OBJECTIVE

 To assess the effect of treatment for cervical intraepithelial neoplasia (CIN) on obstetric outcomes and to correlate this with cone depth and comparison group used.

DESIGN

 Systematic review and meta-analysis.

DATA SOURCES

 CENTRAL, Medline, Embase from 1948 to April 2016 were searched for studies assessing obstetric outcomes in women with or without previous local cervical treatment.

DATA EXTRACTION AND SYNTHESIS

 Independent reviewers extracted the data and performed quality assessment using the Newcastle-Ottawa criteria. Studies were classified according to method and obstetric endpoint. Pooled risk ratios were calculated with a random effect model and inverse variance. Heterogeneity between studies was assessed with I(2) statistics.

MAIN OUTCOME MEASURES

 Obstetric outcomes comprised preterm birth (including spontaneous and threatened), premature rupture of the membranes, chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage, and cervical stenosis. Neonatal outcomes comprised low birth weight, admission to neonatal intensive care, stillbirth, APGAR scores, and perinatal mortality.

RESULTS

 71 studies were included (6 338 982 participants: 65 082 treated/6 292 563 untreated). Treatment significantly increased the risk of overall (<37 weeks; 10.7% v 5.4%; relative risk 1.78, 95% confidence interval 1.60 to 1.98), severe (<32-34 weeks; 3.5% v 1.4%; 2.40, 1.92 to 2.99), and extreme (<28-30 weeks; 1.0% v 0.3%; 2.54, 1.77 to 3.63) preterm birth. Techniques removing or ablating more tissue were associated with worse outcomes. Relative risks for delivery at <37 weeks were 2.70 (2.14 to 3.40) for cold knife conisation, 2.11 (1.26 to 3.54) for laser conisation, 2.02 (1.60 to 2.55) for excision not otherwise specified, 1.56 (1.36 to 1.79) for large loop excision of the transformation zone, and 1.46 (1.27 to 1.66) for ablation not otherwise specified. Compared with no treatment, the risk of preterm birth was higher in women who had undergone more than one treatment (13.2% v 4.1%; 3.78, 2.65 to 5.39) and with increasing cone depth (≤10-12 mm; 7.1% v 3.4%; 1.54, 1.09 to 2.18; ≥10-12 mm: 9.8% v 3.4%, 1.93, 1.62 to 2.31; ≥15-17 mm: 10.1% v 3.4%; 2.77, 1.95 to 3.93; ≥20 mm: 10.2% v 3.4%; 4.91, 2.06 to 11.68). The choice of comparison group affected the magnitude of effect. This was higher for external comparators, followed by internal comparators, and ultimately women with disease who did not undergo treatment. In women with untreated CIN and in pregnancies before treatment, the risk of preterm birth was higher than the risk in the general population (5.9% v 5.6%; 1.24, 1.14 to 1.35). Spontaneous preterm birth, premature rupture of the membranes, chorioamnionitis, low birth weight, admission to neonatal intensive care, and perinatal mortality were also significantly increased after treatment. :

CONCLUSIONS

 Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than for ablation.

[Prevention of obstetrical complications following LEEP, is it possible?]

Recent epidemiological data suggest an increase of the incidence and prevalence of CIN as well as a decrease of the mean age of the patients presenting these lesions. Large loop electrosurgical procedure (LEEP) is the most commonly used treatment method. According to recent studies LEEP provides a 1.4 to 7.0 fold increase of preterm delivery. Cervical cerclage does not show efficiency in reducing this risk, even if cervical shortening is measured by transvaginal ultrasound. Considering histological severity of lesions and the age of patients, number of currently conducted conizations in France could be avoided and so their obstetrical consequences prevented, just because no treatment is necessary or could be done by ablative procedures.

Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis

OBJECTIVE

This study aimed at assessing the association of the relative risk (RR) of adverse pregnancy outcomes with previous treatment of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN).

METHODS

Data sources were from MEDLINE, EMBASE, and SCI citation tracking.

SELECTION CRITERIA

The eligible studies had data on pregnancy outcomes of women with or without previous treatment for CIN. Considered outcomes were severe preterm delivery (<34/32 weeks), extreme preterm delivery (<28 weeks), low birth weight (<2,500 g), stillbirth, preterm spontaneous rupture of membranes, perinatal mortality, and neonatal mortality and induction.

RESULTS

36,954 cases and 1,794,174 controls in 4 prospective cohort and 22 retrospective studies were included in this meta-analysis. LEEP was associated with a higher risk of severe preterm delivery (<32 weeks, relative risk 1.98, 95% CI [1.31, 2.98] 159/11,337 vs. 7,830/860,883), extreme preterm delivery (<28 weeks, RR, 2.33, 95% CI [1.84, 2.94] 97/9,611 vs. 1,559/618,332), preterm premature rupture of the membranes (RR, 1.88, 95% CI [1.54, 2.29] 126/2,837 vs. 7,899/313,094), and low birth weight (<2,500 g, RR, 2.48, 95% CI [1.75, 3.51] 110/1,451 vs. 55/1,742). A cervical length of less than 3 cm was significantly increased in LEEP as compared with that of control group (RR, 4.88, 95% CI [1.56, 15.25]), but increasing LEEP volume or depth was not associated with an increased rate of preterm birth <37 weeks. And LEEP was not associated with a significantly increased risk of perinatal mortality, cesarean section, stillbirth mortality, neonatal mortality, induction, and neonatal intensive care unit admission.

CONCLUSIONS

LEEP is associated with an increased risk of subsequent preterm delivery (<32/34, <28 weeks) and other serious pregnancy outcomes. But increasing LEEP volume or depth is not associated with an increased rate of preterm birth.

[Obstetric outcomes following LOOP-excision]

The obstetrical consequences of conisation for cervical intraepithelial neoplasia (CIN) should be considered since patients affected by these lesions are actually younger and most often desire further pregnancies. The loop electrosurgical excision procedure (LEEP), which is currently mostly used, achieves cure rate varying according to the authors between 80 and 95%. However, the most recent data show an increase of obstetrical morbidity, especially prematurity, after LEEP excision. As the frequency and severity of prematurity is correlated to the size and depth of the LEEP, we should minimize as much as possible the resection for these young patients.

[Ultrasonographic evaluation of the uterine cervix length remaining after LOOP-excision]

OBJECTIVES

To assess whether there is a correlation between the length of a conization specimen and the length of the cervix measured by vaginal ultrasonography after the operation

PATIENTS AND METHODS

Prospective observational study including patients less than 45 years with measurement of cervical length before and the day of the conization, and measuring the histological length of the specimen.

RESULTS

Among the 40 patients enrolled, the average ultrasound measurements before conization was 26.9 mm (± 4.9 mm) against 18.1mm (± 4.4mm) after conization with a mean difference of 8.8mm (± 2.4mm) (difference statistically significant P<.0001). The extent of histological specimen was 9 mm (± 2.2mm) on average. A correlation between ultrasound and histological measurements with a correlation coefficient R=0.85 was found statistically significant (P<0.0001). Moreover, the rate of cervix length remove by loop-excision in our series is 33% (± 8.5%).

DISCUSSION

A good correlation between the measurements of the specimen and the cervical ultrasound length before and after conization was found, as a significant reduction in cervical length after conization. The precise length of the specimen should be known in case of pregnancy and the prevention of prematurity due to conization rests on selected indications and efficient surgical technique.

Regeneration of cervix after excisional treatment for cervical intraepithelial neoplasia: a study of collagen distribution

OBJECTIVE

To study the distribution of collagen in the regenerated cervical tissue after excisional treatment for cervical intraepithelial neoplasia (CIN).

DESIGN

Cohort study.

SETTING

A large tertiary teaching hospital in London.

POPULATION

Women who underwent repeat excisional treatment for treatment failure or persistent CIN.

METHODS

Eligible women who underwent a repeat excisional treatment for treatment failure, including hysterectomy, between January 2002 and December 2007 in our colposcopy unit were identified by the Infoflex(®) database and SNOMED encoded histopathology database. Collagen expression was assessed using picro-Sirius red stain and the intensity of staining was compared in paired specimens from the first and second treatments.

MAIN OUTCOME MEASURE

Differences in collagen expression were examined in the paired excisional treatment specimens.

RESULTS

A total of 17 women were included. Increased collagen expression in the regenerated cervical tissue of the second cone compared with the first cone was noted in six women, decreased expression was noted in five women, and the pattern of collagen distribution was equivocal in six women.

CONCLUSION

There is no overall change in collagen distribution during regeneration following excisional treatment for CIN.

Cervical conization and the risk of preterm delivery

The current body of literature concerning cervical conization and its effect on subsequent pregnancy outcome is conflicting. Depending on the type of conization procedure that is examined and the quality of the control group, the results and conclusions vary widely. Because treatment for cervical intraepithelial neoplasia is commonplace among women of reproductive age, it is imperative that practitioners have an understanding of the issues surrounding the treatment. Therefore, this review will summarize the published literature that addresses excisional procedures of the uterine cervix and the risk of preterm delivery in subsequent pregnancies and provide reasonable treatment recommendations for women with cervical abnormalities and a desire for future fertility.

Pregnancy outcome after cervical conization: risk factors for preterm delivery and the efficacy of prophylactic cerclage

OBJECTIVE

This study examined the risk factors for preterm birth and the efficacy of prophylactic cerclage in patients who had undergone cervical conization due to cervical intraepithelial neoplasia before pregnancy.

METHODS

We reviewed the medical records of all patients who gave live singleton births between May 1996 and April 2009, after having cervical conization. Delivery before 37 gestational weeks was considered as preterm birth. The pregnancy outcomes were analyzed with independent sample t-test, chi-square test, and multiple logistic regression using the SPSS ver. 12.0.

RESULTS

Sixty five cases were found. The mean gestational age at delivery was 37 weeks (SD, 3.5). Eighteen patients (27.7%) had preterm delivery. The type of conization, the volume of the specimen, and second trimester cervical length were related to preterm birth (p≤0.001, p=0.019, p≤0.001, respectively). In multivariate analysis, only mid-trimester cervical length was statistically significant for preterm birth (p=0.012; odds ratio, 0.194; confidence interval, 0.055 to 0.693). Six out of 65 patients had undergone prophylactic cerclage, and three (50%) of them had preterm births, while 15 (25%) patients without cerclage had preterm births.

CONCLUSION

The type of conization, the volume of specimen, and second trimester cervical length may be the risk factors for preterm birth in patients who have a prior history of cervical conization. Prophylactic cerclage may not be helpful in preventing preterm birth, therefore more careful consideration should be paid in deciding cerclage after conization during prenatal counseling.

Cervical sonography in pregnant women with a prior cone biopsy or loop electrosurgical excision procedure

OBJECTIVES

To determine if pregnant women with a prior cone biopsy or loop electrosurgical excision procedure (LEEP) have a shorter midtrimester cervical length than do matched controls without a history of cervical surgery.

METHODS

Eighty-five pregnant women with a singleton gestation and previous cone biopsy or LEEP and 85 controls matched by age (± 5 years), race, gestational age (± 2 weeks), and number of prior vaginal deliveries underwent a single transvaginal cervical sonographic scan at 15-22 weeks' gestation. No patient had a cerclage in either group.

RESULTS

Mean cervical length was significantly shorter in the cone biopsy/LEEP group (3.3 vs. 3.9 cm, P < 0.001), with no significant difference in the proportion of cervical lengths less than 2.5 cm (5.9 vs. 2.4%). Gestational age at delivery was slightly but significantly lower in the cone biopsy/LEEP group (38.1 vs. 39.1 weeks, P = 0.005) than in the control group, with a higher proportion of women delivering late preterm and very preterm in the cone biopsy/LEEP group. However, no woman with a prior cone biopsy/LEEP experienced a midtrimester loss suggestive of cervical insufficiency, and no patient with a cervical length less than 2.5 cm delivered before 34 weeks' gestation.

CONCLUSIONS

Midtrimester cervical length in women with a previous cone biopsy or LEEP is significantly shorter than in those without prior cervical surgery. Based on the low frequency of a short cervix or midtrimester loss in women with prior excisional surgery, the routine use of midtrimester cervical sonography in such women is not supported.

Time From Cervical Conization to Pregnancy and Preterm Birth

OBJECTIVE

To estimate whether the time interval between cervical conization and subsequent pregnancy is associated with risk of preterm birth.

METHODS

Our study is a case control study nested in a retrospective cohort. Women who underwent colposcopic biopsy or conization with loop electrosurgical excision procedure, large loop excision of the transformation zone, or cold knife cone and subsequently delivered at our hospital were identified with electronic databases. Variables considered as possible confounders included maternal race, age, marital status, payor status, years of education, self-reported tobacco use, history of preterm delivery, and dimensions of cone specimen.

RESULTS

Conization was not associated with preterm birth or any subtypes of preterm birth. Among women who underwent conization, those with a subsequent preterm birth had a shorter conization-to-pregnancy interval (337 days) than women with a subsequent term birth (581 days) (P=.004). The association between short conization-to-pregnancy interval and preterm birth remained significant when controlling for confounders including race and cone dimensions. The effect of short conization-to-pregnancy interval on subsequent preterm birth was more persistent among African Americans when compared with white women.

CONCLUSION

Women with a short conization-to-pregnancy interval are at increased risk for preterm birth. Women of reproductive age who must have a conization procedure can be counseled that conceiving within 2 to 3 months of the procedure may be associated with an increased risk of preterm birth.

LEVEL OF EVIDENCE

II.

Transvaginal Ultrasonography in the Prediction of Preterm Birth After Treatment for Cervical Intraepithelial Neoplasia

OBJECTIVE

To estimate whether cervical length measured by transvaginal ultrasonography in women having had loop electrosurgical excision procedure (LEEP), cold knife conization, or cryotherapy predicts spontaneous preterm birth.

METHODS

Women with a history of LEEP, cold knife conization, or cryotherapy and who were subsequently pregnant with singleton gestations were prospectively compared with both a low-risk control group and women with previous spontaneous preterm birth. A transvaginal ultrasonogram measuring cervical length was performed at 24 to 30 weeks of gestation. Primary outcomes included cervical length and spontaneous preterm birth less than 37 weeks. Secondary outcomes were spontaneous preterm birth less than 34 weeks, low birth weight, and maternal and neonatal outcomes.

RESULTS

Women with previous LEEP (N = 75), cold knife conization (N = 21), and cryotherapy (N = 36) had shorter cervical lengths (3.54, 3.69, and 3.75 cm respectively) than the low-risk control group (N = 81, 4.21 cm) (P < .001, P = .03, P = .02 respectively) and similar lengths to women with a previous spontaneous preterm birth (N = 63, 3.78 cm). Loop electrosurgical excision procedure and cold knife conization, but not cryotherapy, were associated with spontaneous preterm birth less than 37 weeks (odds ratio 3.45, 95% confidence interval 1.28-10.00, P = .02; and odds ratio 2.63, 95% confidence interval 1.28-5.56, P = .009, respectively). Using a cutoff of 3.0 cm, transvaginal ultrasonography had a positive predictive value of 53.8% and negative predictive value of 95.2% for spontaneous preterm birth less than 37 weeks in women with LEEP.

CONCLUSION

Women with a history of LEEP, cold knife conization, and cryotherapy all independently have shorter cervical lengths than low-risk controls and similar lengths to women with previous spontaneous preterm birth. Loop electrosurgical excision procedure and cold knife conization are associated with spontaneous preterm birth less than 37 weeks, and transvaginal ultrasonography predicts preterm birth in women who have had LEEP.

LEVEL OF EVIDENCE

II-2.

Transvaginal sonographic evaluation of cervix length after cervical conization

OBJECTIVE

The purpose of this study was to evaluate transvaginal sonographic cervical length before and after cervical conization for squamous intraepithelial lesions.

METHODS

Between November 2002 and October 2004, all women undergoing conization by either cold-knife conization or a loop electrosurgical excision procedure for squamous intraepithelial lesions were prospectively enrolled in this study. Cervical length was measured by transvaginal sonography (TVS) before and after conization.

RESULTS

A total of 48 women were studied before and after a mean of 7 days after conization. Complete excision was achieved in 41 patients, and endocervical margins were involved in 7 patients. Mean TVS cervical length was significantly shorter after than before conization (mean +/- SD, 22.7 +/- 6.9 versus 26.7 +/- 8.1 mm; P < .001). The correlation coefficient between cone specimen length and postoperative length was r = 0.75 (P < .001). Mean TVS cervical lengths were 24.3 +/- 6.7 mm in the group of women who underwent a loop electrosurgical excision procedure and 20.7 +/- 9.4 mm in the group of women who underwent cold-knife conization (P = .13).

CONCLUSIONS

Transvaginal sonographic measurement of cervical length after conization is well correlated with cone specimen length.

Pregnancy outcome after loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia

OBJECTIVE

Previous studies have shown conflicting results on the outcome of pregnancy following loop electrosurgical excision procedure (LEEP). The purpose of this study was to evaluate whether LEEP affects the outcome of pregnancy after 20 weeks' gestation.

METHODS

This is a matched cohort study of all women who had a LEEP for a biopsy-confirmed cervical intraepithelial neoplasia (CIN) in between December 1995 and December 2000 and subsequently delivered (after 20 weeks' gestation) at the University Hospital of Northern Norway. Women who had an ectopic pregnancy or an abortion (spontaneous or induced) following LEEP were excluded from analysis. Two controls matched for the date of delivery, age, parity, previous obstetric history and smoking habit were identified for each case using routinely entered data from the birth register. The main outcome measures were the duration of pregnancy and birth weight. Other variables recorded included the grade of cervical dysplasia, size of the electrosurgical loop, age, parity, pregnancy complications, mode of delivery, and perinatal outcome.

RESULTS

Of a total of 428 women of reproductive age who had LEEP performed during the study period, 89 had a pregnancy after the procedure. Ten women were excluded (three ectopic pregnancies, two induced abortions and five spontaneous abortions) from the study. Data from 79 women whose pregnancies progressed beyond 20 weeks and 158 matched controls were analysed. The mean age at the time of LEEP was 27 (range 19-36) years. The histological diagnosis was normal in 3 (3.8%), CIN1 in 5 (6.3%), CIN2 in 18 (22.8%), and CIN3 in 53 (67.1%) of the cases. Overall, mean gestation at delivery (38.3 vs. 39.1 weeks), mean birth weight (3,412 vs. 3,563 g), prevalence of preterm birth (11.4% vs. 10.8%) and low birth weight (10.1 vs. 5.1%) were not significantly different among the cases and controls. But when a relatively large loop (25 mm) had been used, the risk of preterm delivery (odds ratio 4.0) and low birth weight (odds ratio 14.0) was significantly higher than in controls. Pregnancy complications occurred more frequently (20 vs. 7%; p=0.006) among the cases than the controls.

CONCLUSION

LEEP in women with CIN did not significantly increase the risk of low birth weight or preterm birth in subsequent pregnancy in comparison to their controls, except when the size of electrosurgical loop was relatively large. However, the prevalence of pregnancy complications was significantly higher after LEEP.

Management of cervical premalignant lesions

Management of cervical preneoplasia starts with an abnormal smear result. The use of the Bethesda system is recommended. The management of patients with low-grade abnormal smear results varies around the world. Patients with atypical squamous cells on cytology are recommended to be subclassified into atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells where high-grade squamous intra-epithelial lesions (HSIL) cannot be excluded (ASCH) groups. While patients with ASCUS can be followed with cytology or colposcopy, the risk of having cervical intra-epithelial neoplasia (CIN) is higher in patients with ASCH. Such patients, as well as those with low-grade squamous intra-epithelial lesions on cytology, should be referred for colposcopy to ensure that diagnosis and treatment in CIN is detected. Patients with HSIL should be referred promptly for colposcopic assessment. This should, usually at the same clinic visit, be followed by large loop excision of the transformation zone (LLETZ). Although this is effective treatment, around 15% of patients will have persistent/recurrent disease on cytological follow-up. Patients with positive human papillomavirus DNA tests at follow-up seem to have a considerably higher risk of recurrent preneoplasia than those who have negative tests. Patients over 50 years of age have much higher recurrence risks than younger patients. These factors impact on second-line treatment and follow-up schedules. An important benefit of conservative treatment for CIN with LLETZ is retention of fertility. LLETZ is associated with an increased risk of preterm prelabour rupture of membranes and preterm birth, but not with other adverse pregnancy outcome measures. Conservative excisional management of adenocarcinoma in situ by LLETZ or cold knife cone biopsy is not reported to be as effective as that of CIN, with high risk of residual and recurrent disease at follow-up. Conversely, LLETZ may be acceptable treatment for micro-invasive squamous carcinoma if the excision margins are free of disease and there is no evidence of lymphovascular involvement. The ability to detect and treat premalignant lesions on the cervix reversed the natural history of cervical cancer. Methods of conservative treatment that evolved over decades have been proven safe and effective, allowing retention of fertility. Good clinical guidelines have been developed for most clinical scenarios while some uncertainties persist for other scenarios.

The Effect of Loop Electrosurgical Excision Procedure on Future Pregnancy Outcome

OBJECTIVE

To estimate whether the loop electrosurgical excision procedure (LEEP) is associated with an adverse effect on the outcome of subsequent pregnancies.

METHODS

A retrospective cohort study was performed. The study group comprised women who had a LEEP in Halifax County between 1992 and 1999 and then had a subsequent singleton pregnancy of greater than 20 weeks of gestation with delivery at the IWK Health Centre in Halifax, Nova Scotia. The comparison group comprised women with no history of cervical surgery who were matched for age, parity, smoking status, and year of delivery. There were 571 women in each group. The primary outcome was rate of preterm delivery at less than 37 weeks of gestation. Secondary outcomes included delivery at less than 34 weeks and various neonatal and maternal outcomes. The effect of specific LEEP characteristics was analyzed separately.

RESULTS

Women who had a LEEP were more likely to deliver preterm overall (7.9% versus 2.5%; odds ratio [OR] 3.50, 95% confidence interval [CI] 1.90-6.95; P < .001) and to deliver preterm after premature rupture of membranes (PROM) (3.5% versus 0.9%; OR 4.10, 95% CI 1.48-14.09). The increase in delivery at less than 34 weeks was not statistically significant (1.25% versus 0.36%; OR 3.50, 95% CI 0.85-23.49; P = .12). Women with LEEP also delivered more low birth weight (LBW) infants (5.4% versus 1.9%; OR 3.00, 95% CI 1.52-6.46; P = .003). There were no differences in other neonatal or maternal outcomes. No association was found between the characteristics of the LEEP, including depth, and the rate of preterm delivery.

CONCLUSION

Loop electrosurgical excision procedure is associated with an increased risk of overall preterm delivery, preterm delivery after PROM, and LBW infants in subsequent pregnancies at greater than 20 weeks of gestation. Women who are considering future pregnancies should be counseled about these risks during informed consent for LEEP.

LEVEL OF EVIDENCE

II-2.

Cervical regeneration after diathermy excision of cervical intraepithelial neoplasia as assessed by transvaginal sonography

OBJECTIVE

To evaluate regeneration in cervical craters following large loop excision of the transformation zone (LLETZ) and to investigate possible differential healing patterns depending on the cone's size.

STUDY DESIGN

A prospective study of 100 nulliparous women who underwent LLETZ. They underwent transvaginal scanning estimation of the cervical craters (diameter, depth) immediately post-operatively and at 3, 6 and 12 months. The crater dimensions of the women with the 25 largest cones were compared to those of the women with the 25 smallest cones in each of the above points of time.

RESULTS

The mean crater size of all women at 12 months was significantly smaller from the crater size immediately post-operatively. Although, there was a statistically significant difference in mean crater dimensions between the two quartile groups immediately post-operatively, no difference was found at 6 and 12 months.

CONCLUSION

There is a healing process of the cervical crater, which is almost completed by the sixth post-treatment month. The defect remaining in the cervix is similar whether a large or small excision was performed.