Loop electrosurgical excision of the cervix and the subsequent risk of preterm delivery
ABSTRACT To investigate the association between loop electrosurgical excision procedure (LEEP) and other potential risk factors, and subsequent preterm delivery (<37 weeks), using data from a large cohort study of Danish women.
The Danish prospective cohort study was initiated in 1991, with the original aim of investigating the role of human papillomavirus in the natural history of cervical neoplasia. The study included 11,088 women aged 20-29. The cohort was invited for 2 follow-up examinations in 1993-1995 and 1999-2000, respectively. At all 3 examinations, the women answered questions about a number of different lifestyle variables. We assessed the relationship between preterm delivery and potential risk factors, such as previous LEEP treatments, smoking during pregnancy, age, parity and previous preterm delivery. The cohort was followed until 2004, through linkages with the nationwide Pathology Data Bank and the Medical Birth Registry.
Of the 14,982 deliveries in the cohort during follow up, 542 were preterm (21-37 weeks). Among deliveries with no previous LEEP, 3.5% ended as a preterm delivery, whereas this applied to 6.6% among deliveries following a LEEP, yielding a significantly increased risk of preterm birth after LEEP (OR=1.8; 95% CI: 1.1-2.9). The strongest risk factor for preterm delivery was a previous preterm delivery (OR=2.3; 95% CI: 1.4-3.7). Other significant risk factors were smoking during pregnancy and low educational status.
Our study showed an almost 2-fold increase in the risk of preterm delivery after LEEP treatment. Thus, women in their reproductive age should be informed about the increased risk of preterm delivery, if treated with LEEP.
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ABSTRACT: Las neoplasias intraepiteliales (neoplasia intraepitelial cervical [CIN]) preceden a los carcinomas epidermoides, que constituyen alrededor del 80-90% de las lesiones invasivas del cuello uterino. La infección persistente de la mucosa cervical por el virus del papiloma humano (VPH) constituye una condición necesaria para el desarrollo del cáncer del cuello uterino y de las CIN. Los mecanismos de la carcinogénesis relacionada con la infección por VPH se conocen cada vez mejor en la actualidad. La integración del genoma viral en el genoma celular interviene en las primeras fases de la evolución hacia un cáncer. Los datos epidemiológicos recientes sugieren un aumento de la incidencia y de la prevalencia de las CIN y una disminución del promedio de edad de las pacientes portadoras de estas lesiones. La existencia de lesiones precancerosas (CIN) durante un período prolongado explica la pertinencia y la eficacia de la detección sistemática del cáncer del cuello uterino. La colposcopia desempeña un papel fundamental en el diagnóstico de las CIN. Es indispensable para dirigir las biopsias. Permite precisar la topografía de las lesiones y, asociada a la citología y al estudio histológico de la biopsia dirigida, contribuye a las indicaciones terapéuticas. Una vacunación profiláctica permite prevenir la infección por el virus del papiloma humano y sus consecuencias, como las CIN, con una eficacia cercana al 100% si se realiza en condiciones óptimas. Las CIN son lesiones asintomáticas. Su tratamiento sólo está justificado para evitar su evolución a un cáncer. Se puede proponer la abstinencia terapéutica, en determinadas circunstancias, para las lesiones susceptibles de experimentar una regresión espontánea. La elección del método y de la extensión del tratamiento debe buscar a la vez su eficacia y la menor iatrogenia posible.09/2013; 49(3):1–23. DOI:10.1016/S1283-081X(13)65435-1
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ABSTRACT: To assess whether loop electrosurgical excision procedure (LEEP) increases the risk for preterm birth before 37 weeks of gestation and clarify whether the increased risk for preterm birth is attributable to the procedure itself or to risk factors associated with cervical dysplasia. Two authors performed a search of the relevant data through February 2013 using PubMed, Embase, Scopus, CENTRAL, and ClinicalTrials.gov. We included observational studies that compared rates of preterm birth in women with prior LEEP with women with no history of cervical excision. Nineteen of 559 identified studies met selection criteria. We compared women with a history of LEEP with two unexposed groups without a history of cervical excision: 1) women with an unknown or no history of cervical dysplasia; and 2) women with a history of cervical dysplasia but no cervical excision. The primary outcome was preterm birth before 37 weeks of gestation. Secondary outcomes were preterm birth before 34 weeks of gestation, spontaneous preterm birth, preterm premature rupture of membranes, and perinatal mortality. DerSimonian-Laird random effects models were used. We assessed heterogeneity between studies using the Q and I tests. Stratified analyses and metaregression were performed to assess confounding. Nineteen studies were included with a total of 6,589 patients with a history of LEEP and 1,415,015 without. Overall, LEEP was associated with an increased risk of preterm birth before 37 weeks of gestation (pooled relative risk 1.61, 95% confidence interval [CI] 1.35-1.92). However, no increased risk was found when women with a history of LEEP were compared with women with a history cervical dysplasia but no cervical excision (pooled relative risk 1.08, 95% CI 0.88-1.33). Women with a history of LEEP have similar risk of preterm birth when compared with women with prior dysplasia but no cervical excision. Common risk factors for both preterm birth and dysplasia likely explain findings of association between LEEP and preterm birth, but LEEP itself may not be an independent risk factor for preterm birth.Obstetrics and Gynecology 04/2014; 123(4):752-761. DOI:10.1097/AOG.0000000000000174 · 4.37 Impact Factor
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ABSTRACT: Infection with high-risk human papillomavirus (HPV) is causally related to cervical, vulvar and vaginal pre-invasive neoplasias and cancers. Highly effective vaccines against HPV types 16/18 have been available since 2006, and are currently used in many countries in combination with cervical cancer screening to control the burden of cervical cancer. We estimated the overall and age-specific incidence rate (IR) of cervical, vulvar and vaginal cancer and pre-invasive neoplasia in Denmark, Iceland, Norway and Sweden in 2004-2006, prior to the availability of HPV vaccines, in order to establish a baseline for surveillance. We also estimated the population attributable fraction to determine roughly the expected effect of HPV16/18 vaccination on the incidence of these diseases. Information on incident cervical, vulvar and vaginal cancers and high-grade pre-invasive neoplasias was obtained from high-quality national population-based registries. A literature review was conducted to define the fraction of these lesions attributable to HPV16/18, i.e., those that could be prevented by HPV vaccination. Among the four countries, the age-standardised IR/10(5) of cervical, vaginal and vulvar cancer ranged from 8.4-13.8, 1.3-3.1 and 0.2-0.6, respectively. The risk for cervical cancer was highest in women aged 30-39, while vulvar and vaginal cancers were most common in women aged 70+. Age-standardised IR/10(5) of cervical, vulvar and vaginal pre-invasive neoplasia ranged between 138.8-183.2, 2.5-8.8 and 0.5-1.3, respectively. Women aged 20-29 had the highest risk for cervical pre-invasive neoplasia, while vulvar and vaginal pre-invasive neoplasia peaked in women aged 40-49 and 60-69, respectively. Over 50% of the observed 47,820 incident invasive and pre-invasive cancer cases in 2004-2006 can be attributed to HPV16/18. In the four countries, vaccination against HPV 16/18 could prevent approximately 8500 cases of gynecological cancer and pre-cancer annually. Population-based cancer and vaccination registries are essential to assess the predicted public health effects of HPV vaccination.PLoS ONE 02/2014; 9(2):e88323. DOI:10.1371/journal.pone.0088323 · 3.53 Impact Factor