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Secondary excision for cervical intraepithelial neoplasia: An evaluation of two treatment methods
Journal of Obstetrics and Gynaecology
Abstract
A small proportion of women require repeat treatments for cervical intraepithelial neoplasia (CIN). This study aimed to compare the effectiveness of two cervical excisional techniques offered within a London teaching hospital (large loop excision of the transformation zone (LLETZ) and laser cone biopsy) when carried out as secondary procedures. A significantly larger volume of tissue was excised following laser cone biopsy, however the depth of the specimen did not differ significantly. A trend for a larger percentage of secondary specimens, resulting in complete endo-cervical margins and a larger proportion of women achieving cytology negative for CIN post-treatment was shown within the laser cone biopsy group.
... Previous studies were mostly small, retrospective studies. [19][20][21] The study was adequately performed and had a long follow-up period. Although the number of women included might appear low, the number chosen was adequate to prove the futility of treatment with imiquimod. ...
... Conversely, the success rate of LLETZ in our study was much higher than the initial estimate of 63%, and other studies have reported success rates of 59%-61%. 20,21 One possible explanation could be that larger re-excisions are performed in a recurrence or in a trial setting. ...
Objective
To investigate the efficacy of imiquimod in women with residual or recurrent cervical intraepithelial neoplasia (rrCIN), compared with large loop excision of the transformation zone (LLETZ).
Design
Randomised controlled non‐inferiority trial.
Setting
One academic and one regional hospital in the Netherlands.
Population
Thirty‐five women with rrCIN were included in the study between May 2016 and May 2021.
Methods
Women were randomised to receive treatment with 5% imiquimod cream (12.5 mg) intravaginally (three times a week for a duration of 16 weeks) or a LLETZ procedure (standard treatment).
Main outcome measures
The primary outcome was reduction to normal cytology at 6 months after starting treatment. Secondary outcomes were clearance of high‐risk human papilloma virus (hr‐HPV) in both groups and reduction to ≤CIN1 in the imiquimod group. Side effects were monitored.
Results
Treatment success was 33% (6/18) in the imiquimod group versus 100% (16/16) in the LLETZ group (P < 0.001), whereas HPV clearance was 22% (4/18) in the imiquimod group versus 88% (14/16) in the LLETZ group (P < 0.001). After the randomisation of 35 women, the futility of treatment with imiquimod was proven and the trial was prematurely finished. In the follow‐up period, three patients remained without additional treatment, whereas all other patients underwent LLETZ, conisation or hysterectomy. In the LLETZ group none of the patients received additional treatment during 2 years of follow‐up.
Conclusions
This is the first randomised controlled trial to show that topical imiquimod has a significantly lower success rate in terms of reduction to normal cytology and hr‐HPV clearance, compared with LLETZ, in women with rrCIN. Additionally, imiquimod has numerous side effects and after using imiquimod most women with rrCIN still required additional surgical treatment.
... In most centers, a second excisional procedure is usually typically performed in case of recurrent high grade CIN. 2,9 Only one study, by Bowring et al, 10 has reported the success rate of a repeated excisional procedure. The authors described findings in 53 women who underwent secondary cervical excisions and compared the efficacy of laser cone biopsy with large loop excision of the transformation zone procedure as second treatment. ...
... Although a second excisional procedure is often advised in case of disease recurrence, guidelines do not provide clear recommendations for the management of residual or recurrent cervical intraepithelial neoplasia, and little is known about the success rate after a second procedure. 2,9 The success rate of 60.7% that we found is comparable with that found by Bowring et al, 10 the only previous study of the efficacy of repeat large loop excision of the transformation zone procedure. In that study, in which only 19 women underwent such a procedure, 10 of 17 women (59%) had negative cytologic results after a secondary large loop excision of the transformation zone procedure. ...
Objective:
To evaluate the efficacy and long-term outcome of repeat large loop excision of the transformation zone in women with residual or recurrent cervical intraepithelial neoplasia.
Methods:
PALGA (the Dutch Pathology Registry), a database of deidentified cervical cytologic and histologic data, was used to examine women with cervical dysplasia who underwent two or more large loop excision of the transformation zone procedures between January 2005 and June 2015. We obtained cervical cytology and histology results. The main outcome was efficacy of repeated large loop excision of the transformation zone procedure in women with residual or recurrent cervical intraepithelial neoplasia. We also examined subsequent excisional procedures and hysterectomy.
Results:
We identified 499 women who had undergone two or more large loop excision of the transformation zone procedures. After their second procedure, 60.7% of women had a normal first cervical cytologic sample. The mean duration of follow-up was 68 months (0-163 months). Additional cervical excisional procedures were performed in 33.7% of women. Overall, 1.2% of women developed cervical cancer during follow-up. Moreover, 19.0% of women eventually underwent hysterectomy.
Conclusion:
One third of the women who undergo two large loop excision of the transformation zone procedures require an additional excisional procedure or hysterectomy. Almost one fifth of these women eventually undergo hysterectomy.
... One previous study that compared LLETZ versus laser cone biopsy for secondary excision for CIN, showed a high recurrence rate after secondary LLETZ treatment[11]. In the LLETZ group, 59% of the women had normal follow up cytology after 12 months. ...
To assess the relative risk of perinatal mortality, severe preterm delivery, and low birth weight associated with previous treatment for precursors of cervical cancer.
Medline and Embase citation tracking from January 1960 to December 2007. Selection criteria Eligible studies had data on severe pregnancy outcomes for women with and without previous treatment for cervical intraepithelial neoplasia. Considered outcomes were perinatal mortality, severe preterm delivery (<32/34 weeks), extreme preterm delivery (<28/30 weeks), and low birth weight (<2000 g, <1500 g, and <1000 g). Excisional and ablative treatment procedures were distinguished.
One prospective cohort and 19 retrospective studies were retrieved. Cold knife conisation was associated with a significantly increased risk of perinatal mortality (relative risk 2.87, 95% confidence interval 1.42 to 5.81) and a significantly higher risk of severe preterm delivery (2.78, 1.72 to 4.51), extreme preterm delivery (5.33, 1.63 to 17.40), and low birth weight of <2000 g (2.86, 1.37 to 5.97). Laser conisation, described in only one study, was also followed by a significantly increased chance of low birth weight of <2000 g and <1500 g. Large loop excision of the transformation zone and ablative treatment with cryotherapy or laser were not associated with a significantly increased risk of serious adverse pregnancy outcomes. Ablation by radical diathermy was associated with a significantly higher frequency of perinatal mortality, severe and extreme preterm delivery, and low birth weight below 2000 g or 1500 g.
In the treatment of cervical intraepithelial neoplasia, cold knife conisation and probably both laser conisation and radical diathermy are associated with an increased risk of subsequent perinatal mortality and other serious pregnancy outcomes, unlike laser ablation and cryotherapy. Large loop excision of the transformation zone cannot be considered as completely free of adverse outcomes.
It is unclear whether treatments for cervical intraepithelial neoplasia (CIN) increase the subsequent risk of preterm delivery. Most studies have lacked sufficient sample size, mixed heterogeneous subtypes of preterm delivery, and failed to control for confounding factors.
To determine whether cervical laser and loop electrosurgical excision procedure (LEEP) treatments increase risk of preterm delivery and its subtypes.
Retrospective cohort study conducted among women evaluated at a colposcopy clinic serving Auckland, New Zealand (1988-2000), comparing delivery outcomes of untreated women (n = 426) and those treated (n = 652) with laser conization, laser ablation, or LEEP. Record linkage using unique health identifiers identified women who had subsequent deliveries.
Total preterm delivery and its subtypes, spontaneous labor and premature rupture of membranes before 37 weeks' gestation (pPROM).
The overall rate of preterm delivery was 13.8%. The rate of pPROM was 6.2% and the rate of spontaneous preterm delivery was 3.8%. Analyses showed no significant increase in risk of total preterm delivery (adjusted relative risk [aRR], 1.1; 95% confidence interval [CI], 0.8-1.5) or spontaneous preterm delivery (aRR, 1.3; 95% CI, 0.7-2.6) for any treatment. Risk of pPROM was significantly increased following treatment with laser conization (aRR, 2.7; 95% CI, 1.3-5.6) or LEEP (aRR, 1.9; 95% CI, 1.0-3.8), but not laser ablation (aRR, 1.1; 95% CI, 0.5-2.4). Moreover, risk of pPROM and total preterm delivery increased significantly with increasing height of tissue removed from the cervix in conization. Women in the highest tertile of cone height (> or =1.7 cm) had a greater than 3-fold increase in risk of pPROM compared with untreated women (aRR, 3.6; 95% CI, 1.8-7.5).
LEEP and laser cone treatments were associated with significantly increased risk of pPROM. Careful consideration should be given to treatment of CIN in women of reproductive age, especially when treatment might reasonably be delayed or targeted to high-risk cases.
OBJECTIVE:To investigate whether human papillomavirus (HPV) testing could be used in the follow-up after large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia (CIN).METHODS:We performed a retrospective study of 41 women who developed subsequent CIN after LLETZ (group A) and 82 women without CIN for a minimum of 5 years after LLETZ (group B). The first post-treatment cervical smear was retrieved and examined for high-risk HPV deoxyribonucleic acid. The sensitivity, specificity, positive and negative likelihood ratio of HPV testing, first post-treatment Papanicolaou test, and excision margins for the detection of treatment failure were calculated. Multiple logistic regression analysis was also done.RESULTS:The HPV test was positive in 38 of 41 women in group A and 13 of 82 in group B (P < .001). An abnormal cytologic result in the first post-treatment smear was found in 20 of 41 in group A and 11 of 82 in group B (P < .001). Sixteen women in group A and 18 in group B had involved margins (P = .046). Values for the sensitivity, specificity, and positive and negative likelihood ratios of the HPV test were 93%, 84%, 5.8, 0.08; for the Papanicolaou test they were 49%, 87%, 3.9, 0.586; and for margin status they were 39%, 78%, 1.8, 0.782, respectively. Positive HPV test presents significantly high odds ratio for treatment failure (P < .001), independent of cytology and margin status.CONCLUSION:Women who postoperatively have positive HPV testing are at higher risk of treatment failure. This could be performed at the first post-treatment visit and further follow-up could be adjusted accordingly.
A retrospective study of the complications of cone biopsy showed that among 9 15 women examined between the years 1976 and 1982, 121 (13%) had primary or secondary haemorrhage, 153 (17%) cervical stenosis and 39 (4%) subsequent infertility or an abnormal pregnancy. Cervical stenosis was commonest among women who had had long cones removed. Stenosis occurred more often in the group of women who had been assessed by colposcopy before operation but this was due to the fact that prior colposcopy selected a favourable group of patients with lesions of limited extent that were susceptible to treatment by local destructive therapy, so that prior colposcopic assessment resulted in the removal of longer cones.
OBJECTIVE: To assess the relative risk of perinatal mortality, severe preterm delivery, and low birth weight associated with previous treatment for precursors of cervical cancer. DATA SOURCES: Medline and Embase citation tracking from January 1960 to December 2007. Selection criteria Eligible studies had data on severe pregnancy outcomes for women with and without previous treatment for cervical intraepithelial neoplasia. Considered outcomes were perinatal mortality, severe preterm delivery (<32/34 weeks), extreme preterm delivery (<28/30 weeks), and low birth weight (<2000 g, <1500 g, and <1000 g). Excisional and ablative treatment procedures were distinguished. RESULTS: One prospective cohort and 19 retrospective studies were retrieved. Cold knife conisation was associated with a significantly increased risk of perinatal mortality (relative risk 2.87, 95% confidence interval 1.42 to 5.81) and a significantly higher risk of severe preterm delivery (2.78, 1.72 to 4.51), extreme preterm delivery (5.33,
To compare two excisional treatments, laser cone biopsy and large loop excision of the transformation zone (LLETZ), in terms of the volume of tissue removed, and to determine the relation between the height and the total volume of the cone specimen.
Retrospective cross-sectional study.
Large teaching hospital in London.
A total of 1136 eligible excisional treatments (laser cone or large loop excision of the transformation zone, LLETZ).
Eligible excisional treatments (laser cone or LLETZ) performed between 1 January 2002 and 31 December 2007 in our colposcopy unit were identified using the Infoflex(R) database. The total volume of the cone biopsy was calculated mathematically using the data provided in the histopathology reports.
The volume of the cone biopsy was compared with the technique of excision and the histology grades.
Three hundred and thirty-nine laser cone biopsies were performed, whereas 797 LLETZ biopsies were recorded, during the study period. There was no difference in the mean age in the two groups. However, there is a proportional increase in the volume of the cone as the height of the cone increases, and a significant number of the values are skewed, suggesting that the diameter of the base of the cone contributes significantly to the total volume. Laser cone biopsies (median volume 1.84 cm(3), 95% CI 1.98-2.54 cm(3)) account for a larger volume of tissue excised compared with LLETZ (median volume 0.78 cm(3), 95% CI 0.91-1.02 cm(3)) (P < 0.0001). This relationship is not altered when the two procedures are stratified for grade of lesion, i.e. excision for low-grade cervical intraepithelial neoplasia (CIN) (laser median volume 1.55 cm(3), 95% CI 1.46-2.06; LLETZ median volume 0.62 cm(3), 95% CI 0.73-0.88 cm(3)) (P < 0.0001) or high-grade CIN (laser median volume 1.84 cm(3), 95% CI 2.11-2.53 cm(3); LLETZ median volume 0.82 cm(3), 95% CI 0.94-1.07 cm(3)) (P < 0.0001).
The volume of cervical tissue removed during laser conisation is significantly more than that removed with LLETZ. The indication of the cone biopsy does influence the volume of tissue removed.
To determine the effects of one or two conisations on preterm delivery and perinatal mortality in subsequent pregnancies.
A population-based cohort study.
Aarhus University Hospital.
Preterm delivery and mortality rates were evaluated in 721 deliveries after one conisation, and in 37 deliveries after two conisations, and were compared with 390 deliveries after dysplasia and 74 552 deliveries that were not preceded by conisation or dysplasia.
Cox regression was used to evaluate preterm delivery rates and perinatal mortality.
Birthweight, gestational age (prior to 28, 32, and 37 weeks of gestation, respectively) and perinatal mortality.
The risk of preterm delivery was increased after one conisation [adjusted hazard ratios (95% CI): <37 weeks, 2.8 (2.3-3.5); <28 weeks, 4.9 (2.5-9.7)], and was further increased after two conisations [adjusted hazard ratios (95% CI): <37 weeks, 9.9 (6-17); <28 weeks, 9.8 (1.4-70)], compared with no conisation. One conisation was associated with an increased perinatal mortality [<28 weeks, 9.9 (4.0-25)]. All three methods of conisation [large loop excision of the transformation zone, electroknife and cold knife] increased the risk of preterm delivery.
A single conisation was associated with a 2.8-fold increased risk of perinatal death, most likely because of a 4.9-fold increase in extreme preterm delivery. Only 37 patients had two conisations, and the results showed a ten-fold increase in the risk of preterm delivery.
To determine whether cold knife conization (CKC) or loop electrosurgical excisional procedure (LEEP) is the better option for the treatment of cervical intraepithelial neoplasia (CIN) under specific circumstances.
We retrospectively reviewed the medical records of patients who underwent CKC or LEEP for the treatment of CIN. The proportion of non-negative surgical margins between the two treatment groups was calculated based on their age, parity, previous mode of delivery, and grade of CIN. The Student's t-test and multivariate logistic regression analysis were used to find the better option for the treatment of CIN under the specific circumstances.
A total of 118 patients were enrolled in the study. Between the two treatment groups, there was no significant difference in the overall proportion of non-negative surgical margins (P > 0.05). The grade of CIN, the previous mode of delivery, and parity did not affect the surgical margin status. The CKC treatment group had a significantly lower incidence of non-negative surgical margins than the LEEP treatment group (14.3% vs. 52.6%, respectively; P < 0.05) in the patients >45 years of age. Based on multivariate analyses, LEEP was identified as a significant risk factor for non-negative surgical margins in the patients >45 years of age. Of the 11 patients with non-negative surgical margins who underwent a secondary procedure within 6 months of the initial CKC or LEEP, five patients (45.5%) had residual CIN II and III.
In patients >45 years of age, CKC is the preferred treatment for CIN.
In a randomized study, 62 women were submitted to cold knife conization with application of Sturmdorf sutures, 60 to cold knife conization without sutures, and 61 to laser conization. Early hemorrhage occurred in 1.6, 13.3, and 6.6% of women, respectively (P less than .05), and late hemorrhage in 15.3, 3.6, and 11.7%, respectively. Considering early and late hemorrhage together, there was no significant difference among the three treatment groups. Dysmenorrhea tended to be more common after application of Sturmdorf sutures, as it was reported by 27.8, 13.2, and 14.3% of patients, respectively, but the difference was not statistically significant. Dysmenorrhea occurred in 13% of the cases with a cone height of 20 mm or less and in 26% of the cases with a cone height greater than 20 mm (P less than .05). Endocervical cells were present significantly more often after sampling with a cytobrush than with a cotton swab (P less than .0001), whereas the method of conization had no influence. In smears obtained with a cytobrush, endocervical cells were present in 88.0, 84.9, and 82.5% of the cases; in smears obtained with a cotton swab, endocervical cells were present in 46.6, 57.7, and 54.5%, respectively. We conclude that cold knife conization without Sturmdorf sutures is about equal to laser conization in overall complications, but the laser is preferable for outpatient treatment because of a lower frequency of early hemorrhage. Sturmdorf sutures should be avoided. Smears at follow-up should be taken with a cytobrush and a wooden spatula.
The literature dealing with the natural history of cervical intraepithelial neoplasia (CIN) since 1950 is reviewed, in particular from the viewpoint of regression, persistence, and progression. When stratified into the various grades of severity, the composite data indicate the approximate likelihood of regression of CIN 1 is 60%, persistence 30%, progression to CIN 3 10%, and progression to invasion 1%. The corresponding approximations for CIN 2 are 40%, 40%, 20%, and 5%, respectively. The likelihood of CIN 3 regressing is 33% and progressing to invasion greater than 12%. It is obvious from the above figures that the probability of an atypical epithelium becoming invasive increases with the severity of the atypia, but does not occur in every case. Even the higher degrees of atypia may regress in a significant proportion of cases. As morphology by itself does not predict which lesion will progress or regress, future efforts should seek factors other than morphological to determine the prognosis in individual patients.
Cervical intra-epithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the severity of the disease. The objective of this review was to assess the effects of alternative surgical treatments for cervical intra-epithelial neoplasia.
We searched the Cochrane Gynaecological Cancer Group trials register and MEDLINE up to July 1997.
Randomised and quasi-randomised trials of alternative surgical treatments in women with cervical intra-epithelial neoplasia.
Trial quality was assessed and two reviewers abstracted data independently.
Twenty-three trials were included. Seven surgical techniques were tested in various comparisons. No significant difference in eradication of disease was shown, other than between laser ablation and loop excision. This was based on one trial where the quality of randomisation was doubtful. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology. Morbidity was lower than with laser conisation, although all five trials did not provide data for every outcome. There were not enough data to assess the effect on morbidity compared with laser ablation.
The evidence suggests that there is no obviously superior surgical technique for treating cervical intra-epithelial neoplasia.
To document the pattern of recurrence of disease following large loop excision of the transformation zone (LLETZ) to identify a low risk group of women who might benefit from less intensive cytological surveillance.
Analysis of prospectively collected information with retrospective review of follow up smears.
Three thousand, five hundred and sixty women who underwent LLETZ (median age 31 years; IQR 12 years).
Colposcopy clinic at Northern Gynaecological Oncology Centre, Gateshead.
Women treated with LLETZ from 1988 to 1995 were reviewed. Information on the pathology from LLETZ was collected prospectively and information on the subsequent smears was obtained from the family health authorities.
Invasive cancer was detected on the original LLETZ in 134 women who were excluded from the study. Of the remaining 3,426 women, histology of LLETZ showed high grade CIN (II and III) in 2,371 (69%). At least one follow up smear was undertaken in 3,385 women (99%). This constituted 9,765 women years of follow up with a mean duration of 35 months. Four hundred and seventeen women (12.2%) had a dyskaryotic follow up smear. Incomplete excision of the lesion and an age of > or = 50 years at the time of the LLETZ were associated with an increased risk of recurrent CIN. Based on these risk factors the study group was divided into three risk groups: 1. women aged < 50 with no disease at the margins (n = 1680); 2. women aged > or = 50 with disease at the margins (n = 93); and 3. women aged < 50 with positive margins, or aged > or = 50 with negative margins (n = 1653). The cumulative survival without recurrent CIN at five years for these groups were 92%, 57% and 86%, respectively.
Women aged > or = 50 with CIN at the margins of excision constituted a small minority high risk group (3%). Consideration should be given to repeat treatment of these women rather than surveillance. Women aged < 50 with complete excision of low grade CIN comprised 51% of the study group. These women were at low risk of recurrent CIN and might benefit from less intensive cytological surveillance following LLETZ.
To investigate whether human papillomavirus (HPV) testing could be used in the follow-up after large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia (CIN).
We performed a retrospective study of 41 women who developed subsequent CIN after LLETZ (group A) and 82 women without CIN for a minimum of 5 years after LLETZ (group B). The first post-treatment cervical smear was retrieved and examined for high-risk HPV deoxyribonucleic acid. The sensitivity, specificity, positive and negative likelihood ratio of HPV testing, first post-treatment Papanicolaou test, and excision margins for the detection of treatment failure were calculated. Multiple logistic regression analysis was also done.
The HPV test was positive in 38 of 41 women in group A and 13 of 82 in group B (P <.001). An abnormal cytologic result in the first post-treatment smear was found in 20 of 41 in group A and 11 of 82 in group B (P <.001). Sixteen women in group A and 18 in group B had involved margins (P =.046). Values for the sensitivity, specificity, and positive and negative likelihood ratios of the HPV test were 93%, 84%, 5.8, 0.08; for the Papanicolaou test they were 49%, 87%, 3.9, 0.586; and for margin status they were 39%, 78%, 1.8, 0.782, respectively. Positive HPV test presents significantly high odds ratio for treatment failure (P <.001), independent of cytology and margin status.
Women who postoperatively have positive HPV testing are at higher risk of treatment failure. This could be performed at the first post-treatment visit and further follow-up could be adjusted accordingly.
Invasive cancer of the cervix after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the incidence of invasive disease. The rate of invasive cervical or vaginal cancer following treatment for CIN in UK remains elevated for at least 8 years. The aim of our study was to determine from international data how long this rate remains elevated and whether the rate of invasive disease reflects the rate of posttreatment CIN. The aim was to determine why the rate of invasive disease does not fall. A search of Medline and a secondary search of cited references identified 1,848 articles referring to the success rate of the treatment of CIN. Only 26 cohorts from 25 articles met all the inclusion criteria. The policy in these was to perform at least annual smears. After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 woman years until at least 20 years after treatment. This rate is approximately 2.8 times greater than expected. In contrast, the risk of posttreatment CIN declined steadily with time to about 190 per 100,000 women in the 10th year. Although the posttreatment rate of CIN falls with time, the rate of invasive disease remains static. It seems likely that this is due to diminishing compliance with follow-up. Women should be encouraged to persevere with annual smears for at least 10 years after their treatment as this may offer them the best chance of detecting recurrence at a treatable stage.
The aims of this study were (i) to examine whether women referred for assessment of precancerous changes in the cervix had higher rates of preterm birth compared with those in the general population and (ii) to compare preterm birth rates for treated and untreated women adjusting for possible confounding factors.
Retrospective cohort design.
Teaching hospital.
All women referred to the Royal Women's Hospital, Melbourne (1982-2000), who subsequently had a birth recorded on the Victorian Perinatal Data Collection system (n = 5548).
Record linkage of hospital dysplasia clinic records and population-based birth records.
Total preterm delivery (<37 weeks of gestation) and subtypes.
Both treated and untreated women were at a significantly increased risk for preterm birth compared with those in the general population: treated--standardised prevalence ratio (SPR) 2.0, 95% CI 1.8-2.3 and untreated--SPR 1.5, 95% CI 1.4-1.7. Within the cohort, the treated women were significantly more likely to give birth preterm (adjusted OR 1.23, 95% CI 1.01-1.51). An increased risk of preterm birth was also associated with a history of induced or spontaneous abortions, illicit drug use during pregnancy or a major maternal medical condition. Cone biopsy, loop electrosurgical excision procedure and diathermy were associated with preterm birth. After adjusting for possible confounding factors, only diathermy remained significant (adjusted OR 1.72, 95% CI 1.36-2.17). Women treated using laser ablation were not at an increased risk for preterm birth (adjusted OR 1.1, 95% CI 0.8-1.4).
Diagnosis of precancerous changes in the cervix (regardless of the treatment) was associated with an increased risk of preterm birth. Consideration should be given to the preferential use of ablative treatments.
To study whether a treatment of cervical intraepithelial neoplasia (CIN) is associated with an adverse outcome in the subsequent pregnancies.
This study is a register-based retrospective cohort study from Finland. National data of 25,827 women having a surgical treatment of the cervix for CIN in 1986-2003 and their 8,210 subsequent singleton births in 1987-2004 were studied. Main outcome measures were preterm birth rate, low birth weight rate, and perinatal mortality rate.
The risk of any preterm delivery (less than 37 weeks of gestation), especially the risk of very preterm delivery (28-31 weeks of gestation), and extremely preterm delivery (less than 28 weeks of gestation) was increased after cervical conization (relative risk [RR] 1.99, 95% confidence interval [CI] 1.81-2.20; RR 2.86, 95% CI 2.22-3.70; and RR 2.10, 95% CI 1.47-2.99, respectively). After cervical ablation, the risk of preterm delivery was also increased. The risk of low birth weight and perinatal death was increased after conization (RR 2.06, 95% CI 1.83-2.31 and RR 1.74, 95% CI 1.30-2.32, respectively). Adjusting for maternal age, parity, and maternal smoking did not affect our results.
Any treatment for CIN, including loop electrosurgical excision procedure, increases the risk of preterm delivery. It is important to emphasize this when treating young women with CIN.
II.
To investigate the effect of cervical laser conisation (CLC) or loop electrosurgical excision procedure (LEEP) on the outcome of subsequent pregnancies. Methods. Multi-centre, retrospective, case-control study, which included a cohort of 742 women, who, after treatment with LEEP or CLC, gave birth or suffered second trimester miscarriage. Control women (n=742) were extracted from the respective hospital birth registries and matched by age and parity. Outcome measures were perinatal mortality, length of gestation, birth weight and preterm premature rupture of membranes (pPROM).
There was no significant difference in perinatal mortality among women treated with LCL or LEEP compared to controls, 6/742 versus 2/742: odds ratio (OR)=3.1 (95% CI: 0.6-15.2). Excluding second trimester miscarriages, ORs for giving birth before week 37, 32 and 28 after conisation compared to the controls were 3.4 (95% CI: 2.3-5.1), 4.6 (95% CI: 1.7-12.5), and 12.4 (95% CI: 1.6-96.1), respectively, after adjusting for smoking habits during pregnancy, marital status and educational level. Adjusted ORs of birth weight <2,500, <1,500 and <1,000 g after conisation compared to controls were 3.9 (95% CI: 2.4-6.3), 4.4 (95% CI: 1.5-13.6), and 10.4 (95% CI: 1.3-82.2), respectively. The adjusted OR for pPROM was 10.5 (95% CI: 3.7-29.5).
Treatment by CLC and LEEP increases the risk of preterm delivery, low birth weight and pPROM in subsequent pregnancies.
Colposcopy and programme management
- Nhs
Natural history of cervical intraepithelial neoplasia: a critical review
- Ag Ostor
Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia
- W P Soutter
- P Sasieni
- T Pamoskaltsis
- Martin-Hirsch P