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Chigbu CO, Onyebuchi AK, Odugu BU, Ifebi CO. Pregnancy Outcome Following Treatment of Premalignant Lesion of the Cervix in Southeast Nigeria; A Retrospective Case-Control Study. Niger J Clin Pract 2024; 27:215-220. [PMID: 38409150 DOI: 10.4103/njcp.njcp_624_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/15/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Treatment of cervical pre-cancers involves ablative and excisional therapies, and these have the potential to affect future pregnancy outcomes of women. Understanding the impact of the various treatment modalities on the outcome of pregnancies can motivate the development of interventions to improve pregnancy outcomes in women who had cervical pre-cancer treatment. AIM We aimed to the effect of cervical pre-cancer treatment on second-trimester miscarriages and preterm births. MATERIALS AND METHODS Matched case-control study in which 373 women who had a pregnancy after cervical pre-cancer treatment were matched with 373 controls. McNemar Chi-square was used to compare the prevalence of second-trimester miscarriage and preterm birth between the study group and the matched controls. Conditional logistic regression analysis was done to determine the risk factors for second-trimester miscarriage and preterm birth. RESULTS Second-trimester miscarriages and preterm births were higher in women who had cervical pre-cancer treatment (AOR: 2.05, 95% CI: 1.174 - 3.693, p: 0.01) and (AOR: 2.74, 95% CI: 1.591 - 4.902, p: 0.0001) respectively. In addition, large loop excision of the transformation zone (LLETZ) of the cervix increased the odds of second-trimester miscarriage (AOR: 1.22, 95% CI: 1.034 - 1.441, p: 0.019) and preterm birth (AOR: 2.98, 95% CI: 1.793 - 3.965, p: 0.001). Cryotherapy and thermocoagulation were not associated with increased miscarriage and preterm birth. Treatment to pregnancy interval of ≥ 12 months decreased the odds of second-trimester miscarriage (AOR: 0.605, 95% CI: 0.502 - 0.808, p: 0.031) and preterm birth (AOR: 0.484, 95% CI: 0.317 - 0.738, p: 0.001). CONCLUSION There is an increased odds of second-trimester miscarriage and preterm birth in women treated with LLETZ. A treatment-to-pregnancy interval of ≥ 12 months reduces this odd. Ablative therapies do not increase the odds of miscarriages and preterm births. This information could guide decisions on the choice of method of treatment for cervical pre-cancer in women of childbearing age.
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Affiliation(s)
- C O Chigbu
- Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla Enugu, Nigeria
- Center for Translation and Implementation Research, College of Medicine, University of Nigeria Nsukka, Abakaliki, Nigeria
| | - A K Onyebuchi
- Department of Obstetrics and Gynaecology, Alex Ekwueme University Teaching Hospital, Abakaliki, Nigeria
| | - B U Odugu
- Department of Obstetrics and Gynaecology, Enugu State University Teaching Hospital, Enugu, Nigeria
| | - C O Ifebi
- Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla Enugu, Nigeria
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Risk Factors of Preterm Birth in Women After Local Treatment of Cervical Intraepithelial Neoplasia – a Retrospective Cohort Study. Geburtshilfe Frauenheilkd 2022; 82:1397-1405. [DOI: 10.1055/a-1909-0735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Purpose A previous cervical intraepithelial neoplasia is associated with an increased obstetrical risk. It was the aim of the study to identify risk factors of preterm birth in
patients with cervical intraepithelial neoplasia in dependence of the treatment modality (excisional vs. ablative).
Methods Women with treated cervical intraepithelial neoplasia and subsequent pregnancy (n = 155) were included in this retrospective study. Methods of treatment were either
conization by large loop excision of the transformation zone (LLETZ) or ablative laser vaporization.
Results Of the total population 60.6% (n = 94) had a conization and 39.4% (n = 61) a laser vaporization alone. The frequency of preterm birth < 37 weeks was 9.7% (n = 15) without
differences between conization and laser (11.7 vs. 6.7%, p = 0.407) with an odds ratio (OR) of 1.9 (95% confidence interval [CI] 0.6–6.2). Preterm birth < 34 weeks was found in 2.6%
(n = 4), of which all had a conization (4.3 vs. 0%, p = 0.157). Risk factors for preterm birth were repeated cervical intervention (OR 4.7 [95% CI 1.5–14.3]), especially a combination of
conization and laser ablation (OR 14.9 [95% CI 4.0–55.6]), age at intervention < 30 years (OR 6.0 [95% CI 1.3–27.4]), a history of preterm birth (OR 4.7 [95% CI 1.3–17.6]) and age at
delivery < 28 years (OR 4.7 [95% CI 1.5–14.3]).
Conclusion The large loop excision of the transformation zone as a modern, less invasive ablative treatment did not obviously increase the risk of preterm birth compared to laser
vaporization. The most important risk factor for preterm delivery was the need of a repeated intervention, especially at younger age. We assume that the persistence or recurrence of the
cervical intraepithelial neoplasia following a high-risk human papillomavirus infection is mainly responsible for the observed effect.
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Sun H, Su X, Liu Y, Huang S, Liu X, Li G, Du Q. Association between cervical disorders and adverse obstetric outcomes: A retrospective cohort study. Front Med (Lausanne) 2022; 9:981405. [DOI: 10.3389/fmed.2022.981405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe purpose of this study was to explore the association of cervical disorders on obstetric outcomes of singleton pregnancies in China.MethodsThis hospital-based retrospective cohort study of women with live singleton births included 71,097 Chinese women. We compared the risk of adverse obstetric outcomes in different types of pregnancies with cervical disorders with those with normal cervix. Logistic regression model was used to estimate the association between cervical disorders and adverse obstetric outcomes.ResultsWomen with cervical disorders had a higher risk of premature delivery (10.98 vs. 4.41%), preterm premature rupture of membranes (PPROM) (3.48 vs. 1.62%), low birth weight (LBW) (7.62 vs. 2.92%) and very low birth weight (VLBW) (2.01 vs. 0.28%) than women with normal cervix. After adjusting for confounding factors, compared with women with normal cervix, women with high-grade abnormal cervical cytology are at greater risk of premature birth (adjusted OR 1.971, 95% CI: 1.302–2.983), premature rupture of membranes (PROM) (adjusted OR 1.379, 95% CI: 1.047–1.815), LBW (adjusted OR 1.790, 95% CI: 1.059–3.025), and VLBW (adjusted OR 4.519, 95% CI: 1.662–12.292) than women with low-grade abnormal cervical cytology, and women with abnormal cervical cytology after treatment had a higher risk of premature birth (adjusted OR 2.060, 95% CI: 1.348–3.147), PROM (adjusted OR 1.381, 95% CI: 1.038–1.839), PPROM (adjusted OR 1.995, 95% CI: 1.022–3.892), LBW (adjusted OR 1.801, 95% CI: 1.046–3.102), and VLBW (adjusted OR 4.868, 95% CI: 1.788–13.255) than untreated women.ConclusionsOur research showed that pregnant women with cervical disorders were more likely to have premature delivery, PPROM, LBW, and VLBW. Moreover, pregnant women with high-grade abnormal cervical cytology and abnormal cervical cytology after treatment had a higher risk of premature birth, PROM, LBW, and VLBW.
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Plotti F, Rossini G, Ficarola F, De Cicco Nardone C, Montera R, Guzzo F, Luvero D, Fabris S, Angioli R, Terranova C. Early Mini-Invasive Treatment of Persistent Cervical Dysplasia: Clinical Outcome and Psycho-Relational Impact. Front Surg 2022; 9:888457. [PMID: 35662822 PMCID: PMC9160712 DOI: 10.3389/fsurg.2022.888457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAfter the diagnosis of L-SIL, 77. 3% had a persistent infection and anomalous Pap Test results. Many of these patients had highlighted psychological consequences such as anxiety, hypochondria, fear of cancer, and sexual problems. Several studies suggested that the clearance of HR-HPV infection could be accelerated by cervical excisional procedures, especially in L-SIL. In consideration of the psychological implications for HPV infection and related dysplasia in patients with CIN1 at PAP-smear and HR-HPV positivity at least for 6 months, we decided to plan a prospective study where we tried to anticipate excisional cervical using a minimally invasive treatment: thin loop electrosurgical excision procedure (t-LEEP). This study aims to analyze the clearance of HR-HPV after 6 and 12 months, clinical outcomes related to t-LEEP, and the psycho-relational impact at 12 months after t-LEEP.Materials and MethodsWe enrolled patients with the diagnosis of L-SIL at PAP-smear and HR-HPV positivity with a persistent CIN 1 (at least for 6 months), confirmed by cervical biopsy. All enrolled patients underwent t-LEEP. We followed prospectively and performed for all patients the HPV DNA test at 6 (T1) and 12 months (T2) and STAI-Y and FSFI scores at T0 and T2.ResultsWe prospectively enrolled 158 patients, 22 are excluded for the established criteria. Patients with HR-HPV and CIN 1 lesions treated with t-LEEP had an overall clearance of 83.8% at T2. In subgroups analysis at T2, we had a regression: in smoker 71.8%, in contraceptive users 69.5%, in patients aged <25 years 100%, aged 25–30 years 85%, aged 30–35 years 94.4%, aged 35–40 years 92%, and aged ≥40 years 89.1%, in HPV-16 96.4%, in HPV-53 89.5%, in HPV-18 87.5%, in HPV-31 86.6%, and in coinfected 3.5%. STAI-Y and FSFI after t-LEEP (T2) were statistically significant, reducing anxiety status and improving sexual function.ConclusionBased on these results, the use of t-LEEP in patients with persistent CIN 1 and HPV-HR at least for 6 months could be useful for accelerating HPV-HR clearance, in particular, for a subpopulation patient with an increased risk of progression and/or patients with psychological and sexual consequences of carrying an HR-HPV infection.
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Affiliation(s)
- Francesco Plotti
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
| | - Gianmarco Rossini
- ASST of the Olona Valley, Department of Obstetrics and Gynecology, Varese, Italy
| | - Fernando Ficarola
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
- *Correspondence: Fernando Ficarola
| | | | - Roberto Montera
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
| | - Federica Guzzo
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
| | - Daniela Luvero
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
| | - Silvia Fabris
- National Center for Control and Emergency Against Animal Diseases and Central Crisis Unit–Office III, Directorate-General for Animal Health and Veterinary Drugs, Italian Ministry of Health, Rome, Italy
- Medical Statistics and Epidemiology Unit, Campus Bio-Medico University, Rome, Italy
| | - Roberto Angioli
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
| | - Corrado Terranova
- Department of Gynecology, Campus Bio-Medico University Hospital Foundation, Rome, Italy
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Known Benefits and Unknown Risks of Active Surveillance of Cervical Intraepithelial Neoplasia Grade 2. Obstet Gynecol 2022; 139:680-686. [PMID: 35271554 DOI: 10.1097/aog.0000000000004705] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/30/2021] [Indexed: 01/18/2023]
Abstract
Cervical intraepithelial neoplasia grade 2 (CIN 2) is an equivocal diagnosis with high interobserver variation. Owing to high regression rates of 50%, many countries recommend active surveillance of CIN 2, especially in women younger than age 25-30 years, where regression rates are even higher (ie, 60%). Additionally, excisional treatment is associated with increased risk of reproductive harm, particularly preterm birth. Active surveillance typically consists of semi-annual follow-up visits for up to 2 years, including colposcopy and either cytology, testing for human papillomavirus, or both. Excisional treatment is recommended for progression or persistent disease after 2 years. Because active surveillance in younger women is relatively new, knowledge on subsequent risk of cervical cancer is limited. Considering human papillomavirus latency, women undergoing active surveillance might be at higher risk of cervical cancer than women undergoing excisional treatment. Furthermore, there are limited data describing preferences of women for the management of CIN 2, and it is also unclear how active surveillance may affect planning for future pregnancy. In this context, biomarkers for risk stratification of CIN 2 into either high or low probability of progression would allow for targeted treatment. Currently, immunohistochemical staining for p16 is used to clarify the histologic diagnosis, but whether it or other biomarkers can be used for risk-stratification in clinical management of women with CIN 2 remains unknown. In conclusion, active surveillance of CIN 2 needs further investigation, including understanding the long-term cervical cancer risk and evaluation of markers that may enable risk stratification of CIN 2.
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Wiik J, Kärrberg C, Nilsson S, Strander B, Jacobsson B, Sengpiel V. Associations between cervical intraepithelial neoplasia during pregnancy, previous excisional treatment, cone-length and preterm delivery: a register-based study from western Sweden. BMC Med 2022; 20:61. [PMID: 35189872 PMCID: PMC8862518 DOI: 10.1186/s12916-022-02276-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Excisional treatment of cervical intraepithelial neoplasia (CIN) has been associated with increased risk of preterm delivery (PTD), although the underlying mechanism is as yet unclear. Studies on formalin-fixed excised tissue indicate that the risk increases with cone-length, but the magnitude of increase is uncertain, especially in case of minor excisions (≤10 mm), as well compared to women with untreated CIN during pregnancy. This study assesses the impact of cone-length at previous treatment for CIN as well as diagnosis of CIN during pregnancy on the risk of PTD. METHODS A register-based cohort study in western Sweden linking cervical cytology, histology, and treatment data from the Swedish National Cervical Screening Registry to data on obstetric outcomes in singleton pregnancies 2008-2016 from the Swedish Medical Birth Registry. These groups were compared for PTD and other obstetric outcomes: (1) women with one excisional treatment (n=3250, including a subgroup (n=2408) with cone-length measured before fixation; (2) women with untreated CIN diagnosed during pregnancy (n=1380); and (3) women with normal cytology (n=42,398). Logistic regression analyses were adjusted for socioeconomic and health-related confounders. RESULTS Treated women had increased risk of PTD (adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.21-2.12), spontaneous PTD (aOR 1.95, 95% CI 1.40-2.72) and preterm prelabor rupture of membranes (pPROM) (aOR 2.74, 95% CI 1.66-4.51) compared to the CIN during pregnancy group. ORs were similar when compared to the normal cytology group. Risks of these outcomes increased with cone-length. Mean cone-length was 9.1 mm. Cone-length ≤10 mm was associated with increased risk of PTD (aOR 1.41, 95% CI 1.02-1.94), spontaneous PTD (aOR 1.73, 95% CI 1.18-2.54), and pPROM (aOR 2.44, 95% CI 1.40-4.28), compared to the CIN during pregnancy group. The PTD risk was similar for cone-lengths 3-10 mm, thereafter increasing by 15% with each additional millimeter. CONCLUSIONS This study suggests that all excisional treatment, including small cones, are associated with increased risk of PTD and pPROM. Risks increase further with cone-length. In women of reproductive age, clinicians should aim to remove all CIN but minimal healthy cervical tissue. Cone-length should be recorded at treatment, for future prenatal risk estimation.
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Affiliation(s)
- Johanna Wiik
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Gynecology and Obstetrics, Østfold Hospital Trust, Kalnes, Norway. .,Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Cecilia Kärrberg
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Regional Cancer Centre West, Region Västra Götaland, Gothenburg, Sweden
| | - Staffan Nilsson
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Björn Strander
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Regional Cancer Centre West, Region Västra Götaland, Gothenburg, Sweden
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Division of Health Data and Digitalisation, Institute of Public Health, Oslo, Norway
| | - Verena Sengpiel
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Collins A, Motiwale T, Barney O, Dudbridge F, McParland PC, Moss EL. Impact of past obstetric history and cervical excision on preterm birth rate. Acta Obstet Gynecol Scand 2021; 100:1995-2002. [PMID: 34698370 DOI: 10.1111/aogs.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To determine the impact on preterm birth (PTB) of a history of large loop excision of the transformation zone (LLETZ)-alone compared with a history of previous preterm birth-alone (PPTB) or a history of both (LLETZ+PPTB). Secondary analyses were performed to evaluate the impact of antenatal interventions, depth of cervical excision, and patient risk factors on PTB rate in each cohort. MATERIAL AND METHODS A retrospective observational cohort study of women referred to a tertiary Antenatal Prematurity Prevention Clinic with a history of LLETZ, PPTB, or LLETZ+PPTB. Information was collated from routinely collected clinical data on patient demographics, previous obstetric history, LLETZ dimensions, antenatal investigations/interventions, and gestation at delivery. RESULTS A total of 1231 women with singleton pregnancies were included, 543 with history of LLETZ-alone, 607 with a history of PPTB-alone and 81 with a history of LLETZ+PPTB. PTB rates were 8.8% in the LLETZ-alone group, which mirrored the PTB rate in the local background obstetric population (8.9%) compared with 28.7% in the PPTB-alone and 37.0% in the LLETZ+PPTB cohorts. PTB rates were higher in LLETZ cohorts treated with antenatal intervention (cervical cerclage or progesterone pessary) and there was no evidence of an effect of intervention on risk of PTB in post-excision patients with identified shortened mid-trimester cervical length. Logistic regression modeling identified PPTB as a strong predictor of recurrent PTB. Excision depth was correlated with gestation at delivery in the LLETZ-alone group (r = -0.183, p < 0.01) although this only reached statistical significance at depths of 20 mm or more (odds ratio [OR] 3.40, 95% CI 1.04-1.11, p = 0.04). Depth of excision was not correlated with delivery gestation in the LLETZ+PPTB group (r = -0.031, p = 0.82). CONCLUSIONS PPTB has a greater impact on subsequent PTB risk compared with depth of cervical excisional treatment. The value and nature of antenatal interventions should be investigated in the post-excision population.
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Affiliation(s)
- Anna Collins
- Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK.,Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Tanushree Motiwale
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Olivia Barney
- Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Frank Dudbridge
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Penelope C McParland
- Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Esther L Moss
- Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK.,Leicester Cancer Research Centre, University of Leicester, Leicester, UK
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Mueller JL, Morhard R, DeSoto M, Chelales E, Yang J, Nief C, Crouch B, Everitt J, Previs R, Katz D, Ramanujam N. Optimizing ethyl cellulose-ethanol delivery towards enabling ablation of cervical dysplasia. Sci Rep 2021; 11:16869. [PMID: 34413378 PMCID: PMC8376953 DOI: 10.1038/s41598-021-96223-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/05/2021] [Indexed: 11/08/2022] Open
Abstract
In low-income countries, up to 80% of women diagnosed with cervical dysplasia do not return for follow-up care, primarily due to treatment being inaccessible. Here, we describe development of a low-cost, portable treatment suitable for such settings. It is based on injection of ethyl cellulose (EC)-ethanol to ablate the transformation zone around the os, the site most impacted by dysplasia. EC is a polymer that sequesters the ethanol within a prescribed volume when injected into tissue, and this is modulated by the injected volume and delivery parameters (needle gauge, bevel orientation, insertion rate, depth, and infusion rate). Salient injection-based delivery parameters were varied in excised swine cervices. The resulting injection distribution volume was imaged with a wide-field fluorescence imaging device or computed tomography. A 27G needle and insertion rate of 10 mm/s achieved the desired insertion depth in tissue. Orienting the needle bevel towards the outer edge of the cervix and keeping infusion volumes ≤ 500 µL minimized leakage into off-target tissue. These results guided development of a custom hand-held injector, which was used to locate and ablate the upper quadrant of a swine cervix in vivo with no adverse events or changes in host temperature or heart rate. After 24 h, a distinct region of necrosis was detected that covered a majority (> 75%) of the upper quadrant of the cervix, indicating four injections could effectively cover the full cervix. The work here informs follow up large animal in vivo studies, e.g. in swine, to further assess safety and efficacy of EC-ethanol ablation in the cervix.
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Affiliation(s)
- Jenna L Mueller
- Department of Bioengineering, University of Maryland, 3102 A. James Clark Hall, 8278 Paint Branch Drive, College Park, MD, 20742, USA.
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Robert Morhard
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Michael DeSoto
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Erika Chelales
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Jeffrey Yang
- Department of Bioengineering, University of Maryland, 3102 A. James Clark Hall, 8278 Paint Branch Drive, College Park, MD, 20742, USA
| | - Corrine Nief
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Brian Crouch
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Jeffrey Everitt
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca Previs
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC, USA
| | - David Katz
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC, USA
| | - Nimmi Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
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Cervical intraepithelial neoplasia and the risk of spontaneous preterm birth: A Dutch population-based cohort study with 45,259 pregnancy outcomes. PLoS Med 2021; 18:e1003665. [PMID: 34086680 PMCID: PMC8213165 DOI: 10.1371/journal.pmed.1003665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 06/18/2021] [Accepted: 05/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Excisional procedures of cervical intraepithelial neoplasia (CIN) may increase the risk of preterm birth. It is unknown whether this increased risk is due to the excision procedure itself, to the underlying CIN, or to secondary risk factors that are associated with both preterm birth and CIN. The aim of this study is to assess the risk of spontaneous preterm birth in women with treated and untreated CIN and examine possible associations by making a distinction between the excised volume of cervical tissue and having cervical disease. METHODS AND FINDINGS This Dutch population-based observational cohort study identified women aged 29 to 41 years with CIN between 2005 and 2015 from the Dutch pathology registry (PALGA) and frequency matched them with a control group without any cervical abnormality based on age at and year of pathology outcome (i.e., CIN or normal cytology) and urbanization (<100,000 inhabitants or ≥100,000 inhabitants). All their 45,259 subsequent singleton pregnancies with a gestational age ≥16 weeks between 2010 and 2017 were identified from the Dutch perinatal database (Perined). Nineteen potential confounders for preterm birth were identified. Adjusted odds ratios (ORs) were calculated for preterm birth comparing the 3 different groups of women: (1) women without CIN diagnosis; (2) women with untreated CIN; and (3) women with treated CIN prior to each childbirth. In total, 29,907, 5,940, and 9,412 pregnancies were included in the control, untreated CIN, and treated CIN group, respectively. The control group showed a 4.8% (1,002/20,969) proportion of spontaneous preterm birth, which increased to 6.9% (271/3,940) in the untreated CIN group, 9.5% (600/6,315) in the treated CIN group, and 15.6% (50/321) in the group with multiple treatments. Women with untreated CIN had a 1.38 times greater odds of preterm birth compared to women without CIN (95% confidence interval (CI) 1.19 to 1.60; P < 0.001). For women with treated CIN, these odds 2.07 times increased compared to the control group (95% CI 1.85 to 2.33; P < 0.001). Treated women had a 1.51 times increased odds of preterm birth compared to women with untreated CIN (95% CI 1.29 to 1.76; P < 0.001). Independent from cervical disease, a volume excised from the cervix of 0.5 to 0.9 cc increased the odds of preterm birth 2.20 times (37/379 versus 1,002/20,969; 95% CI 1.52 to 3.20; P < 0.001). These odds further increased 3.13 times and 5.93 times for women with an excised volume of 4 to 8.9 cc (90/724 versus 1,002/20,969; 95% CI 2.44 to 4.01; P < 0.001) and ≥9 cc (30/139 versus 1,002/20,969; 95% CI 3.86 to 9.13; P < 0.001), respectively. Limitations of the study include the retrospective nature, lack of sufficient information to calculate odds of preterm birth <24 weeks, and that the excised volume could only be calculated for a select group of women. CONCLUSIONS In this study, we observed a strong correlation between preterm birth and a volume of ≥0.5 cc excised cervical tissue, regardless of the severity of CIN. Caution should be taken when performing excisional treatment in women of reproductive age as well as prudence in case of multiple biopsies. Fertile women with a history of performing multiple biopsies or excisional treatment for CIN may benefit from close surveillance during pregnancy.
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Associations of treated and untreated human papillomavirus infection with preterm delivery and neonatal mortality: A Swedish population-based study. PLoS Med 2021; 18:e1003641. [PMID: 33970907 PMCID: PMC8143418 DOI: 10.1371/journal.pmed.1003641] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 05/24/2021] [Accepted: 04/29/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Treatment of cervical intraepithelial neoplasia (CIN) is associated with an increased risk of preterm delivery (PTD) although the exact pathomechanism is not yet understood. Women with untreated CIN also seem to have an increased risk of PTD. It is unclear whether this is attributable to human papillomavirus (HPV) infection or other factors. We aimed to investigate whether HPV infection shortly before or during pregnancy, as well as previous treatment for CIN, is associated with an increased risk of PTD and other adverse obstetric and neonatal outcomes. METHODS AND FINDINGS This was a retrospective population-based register study of women with singleton deliveries registered in the Swedish Medical Birth Register 1999-2016 (n = 1,044,023). The study population had a mean age of 30.2 years (SD 5.2) and a mean body mass index of 25.4 kg/m2 (SD 3.0), and 44% of the women were nulliparous before delivery. Study groups were defined based on cervical HPV tests, cytology, and histology, as registered in the Swedish National Cervical Screening Registry. Women with a history of exclusively normal cytology (n = 338,109) were compared to women with positive HPV tests (n = 2,550) or abnormal cytology (n = 11,727) within 6 months prior to conception or during the pregnancy, women treated for CIN3 before delivery (n = 23,185), and women with CIN2+ diagnosed after delivery (n = 33,760). Study groups were compared concerning obstetric and neonatal outcomes by logistic regression, and comparisons were adjusted for socioeconomic and health-related confounders. HPV infection was associated with PTD (adjusted odds ratio [aOR] 1.19, 95% CI 1.01-1.42, p = 0.042), preterm prelabor rupture of membranes (pPROM) (aOR 1.52, 95% CI 1.18-1.96, p < 0.001), prelabor rupture of membranes (PROM) (aOR 1.24, 95% CI 1.08-1.42, p = 0.002), and neonatal mortality (aOR 2.69, 95% CI 1.25-5.78, p = 0.011). Treatment for CIN was associated with PTD (aOR 1.85, 95% CI 1.76-1.95, p < 0.001), spontaneous PTD (aOR 2.06, 95% CI 1.95-2.17, p < 0.001), pPROM (aOR 2.36, 95% CI 2.19-2.54, p < 0.001), PROM (aOR 1.11, 95% CI 1.05-1.17, p < 0.001), intrauterine fetal death (aOR 1.35, 95% CI 1.05-1.72, p = 0.019), chorioamnionitis (aOR 2.75, 95% CI 2.33-3.23, p < 0.001), intrapartum fever (aOR 1.24, 95% CI 1.07-1.44, p = 0.003), neonatal sepsis (aOR 1.55, 95% CI 1.37-1.75, p < 0.001), and neonatal mortality (aOR 1.79, 95% CI 1.30-2.45, p < 0.001). Women with CIN2+ diagnosed within 3 years after delivery had increased PTD risk (aOR 1.18, 95% CI 1.10-1.27, p < 0.001). Limitations of the study include the retrospective design and the fact that because HPV test results only became available in 2007, abnormal cytology was used as a proxy for HPV infection. CONCLUSIONS In this study, we found that HPV infection shortly before or during pregnancy was associated with PTD, pPROM, PROM, and neonatal mortality. Previous treatment for CIN was associated with even greater risks for PTD and pPROM and was also associated with PROM, neonatal mortality, and maternal and neonatal infectious complications.
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11
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Monti M, D'Aniello D, Scopelliti A, Tibaldi V, Santangelo G, Colagiovanni V, Giannini A, DI Donato V, Palaia I, Perniola G, Giancotti A, Muzii L, Benedetti Panici P. Relationship between cervical excisional treatment for cervical intraepithelial neoplasia and obstetrical outcome. Minerva Obstet Gynecol 2021; 73:233-246. [PMID: 33140628 DOI: 10.23736/s2724-606x.20.04678-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
INTRODUCTION The aim of our systematic review was the assessment of effects of excisional treatments for the management of cervical intraepithelial neoplasia (CIN) on preterm delivery (PD), lower birth weight (LBW), preterm premature rupture of membrane (PPROM) and obstetrical outcomes. EVIDENCE ACQUISITION A structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through November 30, 2019. The search included a combination of the following terms: "loop electrosurgical excision procedure (LEEP)," "large loop excision of transformation zone (LLETZ)," "cold-knife conization (CKC)," "laser cervical conization (CLC)," "preterm delivery" and "neonatal outcome." EVIDENCE SYNTHESIS Thirty-two of 561 publications considered were included: 28 retrospective series, 2 prospective studies and 2 multicenter trials. Globally in several studies there was a significant increase in PD, measured by the relative risk, in the women underwent a surgical procedure for the CIN. In their majority, the studies were retrospective and therefore a high risk of bias. CONCLUSIONS This systematic review shows that the surgical treatment of the CIN was associated with an increased risk of PD, LBW and pPROM before 37 pregnancy weeks compared to untreated women, especially in a CKC and LLETZ procedure. Moreover, the increase of the of PD was associated with cone size, cervical length, repeated treatment and a short conization-to-pregnancy interval.
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Affiliation(s)
- Marco Monti
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Debora D'Aniello
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy -
| | - Annalisa Scopelliti
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Valentina Tibaldi
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Giusi Santangelo
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Vanessa Colagiovanni
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Andrea Giannini
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Violante DI Donato
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, Sapienza University, Rome, Italy
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Murakami I, Ohno A, Ikeda M, Yamashita H, Mikami M, Kobayashi Y, Nagase S, Yokoyama M, Enomoto T, Katabuchi H. Analysis of pathological and clinical characteristics of cervical conization according to age group in Japan. Heliyon 2020; 6:e05193. [PMID: 33088958 PMCID: PMC7560578 DOI: 10.1016/j.heliyon.2020.e05193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/29/2020] [Accepted: 10/05/2020] [Indexed: 11/17/2022] Open
Abstract
Objective With increased screening, more patients with precancerous or early cervical cancer are now being identified. Age at pregnancy, and thus number of patients requiring fertility preservation, have also increased, resulting in more diagnostic and therapeutic cervical conization (conization) procedures. We here investigated the pathological and clinical characteristics of patients undergoing conization, with a focus on age. The objectives of our study were to identify the risk factors potentially involved in cervical intraepithelial neoplasia (CIN) recurrence or persistence, additional treatment after conization, the effects of conization on pregnancy, and the actual status of conization in Japan. Study design A "Subcommittee for Investigation of Cervical Conization" within the Gynecologic Oncology Committee in the Japan Society of Obstetrics and Gynecology investigated pathological and clinical characteristics of conization at 205 institutions in Japan. We analyzed pathological and clinical characteristics according to age ≤50 and >50 years. Results Patients aged 20-40 years accounted for 12904 (87%) of the 14,832 study patients (median: 37 years, range: 16-88 years). However, 1838 (12.4%) were aged >50 years. The commonest post-operative diagnosis was CIN grade 3 in all age groups. Rates of invasive cancer, post-operative detection of more advanced lesions, positive surgical margins, additional treatment, and recurrence were significantly higher in patients aged ≥50 years than those aged <50 years (all p < 0.01), whereas rates of post-operative complications did not differ significantly between age groups. The relationship between cerclage and the incidence of amniorrhexis or premature birth did not differ significantly in any age group. Conclusion Post-conization management of patients aged ≥50 years requires considering the high rates of detection of more advanced lesions post-operatively, positive surgical margins, and recurrence. Cerclage should not be performed post-conization without careful consideration.
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Affiliation(s)
- Isao Murakami
- Department of Obstetrics and Gynecology, National Hospital Organization Tokyo Medical Center, Japan
- Department of Obstetrics and Gynecology, Toho University Ohashi Medical Center, Japan
| | - Akiko Ohno
- Department of Obstetrics and Gynecology, National Hospital Organization Tokyo Medical Center, Japan
| | - Masae Ikeda
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Japan
| | - Hiroshi Yamashita
- Department of Obstetrics and Gynecology, National Hospital Organization Tokyo Medical Center, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Japan
- Corresponding author.
| | - Yoichi Kobayashi
- Department of Obstetrics and Gynecology, Kyorin University Faculty of Medicine, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Japan
| | - Masatoshi Yokoyama
- Department of Obstetrics and Gynecology, Saga University Faculty of Medicine, Japan
| | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Japan
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13
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2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis 2020; 24:102-131. [PMID: 32243307 PMCID: PMC7147428 DOI: 10.1097/lgt.0000000000000525] [Citation(s) in RCA: 536] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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14
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Aldhous MC, Bhatia R, Pollock R, Vragkos D, Cuschieri K, Cubie HA, Norman JE, Stock SJ. HPV infection and pre-term birth: a data-linkage study using Scottish Health Data. Wellcome Open Res 2019; 4:48. [PMID: 30984880 PMCID: PMC6436145 DOI: 10.12688/wellcomeopenres.15140.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 01/08/2023] Open
Abstract
Background: We aimed to investigate whether infection with high-risk (HR) types of human papilloma virus (HPV) or HPV-associated cervical disease were associated with preterm birth (<37 weeks gestation). In a sub-group of younger women who were eligible for the HPV vaccine, we aimed to determine whether prior vaccination against the specific HPV-types, HPV-16 and -18 modified preterm birth risk. Methods: This was a data-linkage study, which linked HPV-associated viral and pathological information (from the Scottish HPV Archive) from women aged 16-45 years to routinely collected NHS maternity- and hospital-admission records from 1999-2015. Pregnancy outcomes from 5,598 women with term live birth (≥37 weeks gestation, n=4,942), preterm birth (<37 weeks gestation, n=386) or early miscarriage (<13 weeks gestation, n=270). Of these, data from HPV vaccine-eligible women (n=3,611, aged 16-25 years) were available, of whom 588 had been vaccinated. HPV-associated disease status was defined as: HR HPV-positive no disease, low-grade abnormalities or high-grade disease. Results: High-grade HPV-associated cervical disease was associated with preterm birth (odds ratio=1.843 [95% confidence interval 1.101-3.083], p=0.020) in adjusted binary logistic regression analysis, in all women, but there were no associations with HR HPV-infection alone or with low-grade abnormalities. No associations between any HPV parameter and preterm birth were seen in vaccine-eligible women, nor was there any effect of prior vaccination. Conclusions: HPV-associated high-grade cervical disease was associated with preterm birth, but there were no associations with HR HPV-infection or low-grade cervical disease. Thus HPV-infection alone (in the absence of cervical disease) does not appear to be an independent risk factor for preterm birth. For women who have undergone treatment for CIN and become pregnant, these results demonstrate the need to monitor for signs of preterm birth.
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Affiliation(s)
- Marian C. Aldhous
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Ramya Bhatia
- HPV Research Group, Division of Pathology, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Roz Pollock
- Electronic Data Research and Innovation Service (eDRIS), NHS Scotland Information Services Division, Edinburgh, EH16 4UX, UK
| | - Dionysis Vragkos
- Electronic Data Research and Innovation Service (eDRIS), NHS Scotland Information Services Division, Edinburgh, EH16 4UX, UK
| | - Kate Cuschieri
- Scottish HPV Reference Laboratory, Division of Laboratory Medicine, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Heather A. Cubie
- HPV Research Group, Division of Pathology, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jane E. Norman
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Sarah J. Stock
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, EH16 4UX, UK
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Jar-Allah T, Kärrberg C, Wiik J, Sengpiel V, Strander B, Holmberg E, Strandell A. Abnormal cervical cytology is associated with preterm delivery: A population based study. Acta Obstet Gynecol Scand 2019; 98:777-786. [PMID: 30667051 DOI: 10.1111/aogs.13543] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 12/16/2018] [Accepted: 01/11/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Increasing evidence suggests that cervical intraepithelial neoplasia, with or without subsequent treatment, is associated with preterm delivery. We aimed to explore the association between abnormal cervical cytology of different severity and the subsequent obstetric outcomes such as preterm delivery. MATERIAL AND METHODS The historical register-based cohort study comprised 19 822 women in the Western Region of Sweden who had at least one abnormal cervical cytology from 1978 to 2012 before the age of 45 and a subsequent singleton delivery. The reference group comprised 39 644 women with normal cervical cytology and a subsequent singleton delivery, matched by age and parity. Data were retrieved from the Swedish National Cervical Screening Registry, linked to the Swedish Medical Birth Register and Statistic Sweden. The study outcomes were spontaneous preterm delivery before 37 and 34 weeks, low birthweight (≤2500 g), small-for-gestational-age, preterm premature rupture of membranes and neonatal mortality. Multivariable log binominal regression analyses were applied. RESULTS Preterm delivery before 37 weeks was more common among women with abnormal cervical cytology compared with reference group: 6% vs 4.5%; adjusted relative risk 1.30 (95% confidence interval 1.21-1.39). High vs low-grade abnormal cervical cytology implied a higher risk: 7% vs 5.8% (P < 0.001). Early preterm delivery before 34 weeks, preterm premature rupture of membranes and low birthweight, but not small-for-gestational-age and neonatal mortality, were significantly more common in women with abnormal cervical cytology compared with the reference group. CONCLUSIONS Abnormal cervical cytology may imply an increased risk of preterm delivery. Further studies are needed to investigate whether that risk is related to treatment.
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Affiliation(s)
- Tagrid Jar-Allah
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cecilia Kärrberg
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Wiik
- Department of Gynecology and Obstetrics, Østfold Hospital Trust, Kalnes, Norway.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Verena Sengpiel
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn Strander
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Swedish National Cervical Screening Registry, Regional Cancer Center, West Sweden, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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16
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Wiik J, Sengpiel V, Kyrgiou M, Nilsson S, Mitra A, Tanbo T, Monceyron Jonassen C, Møller Tannæs T, Sjøborg K. Cervical microbiota in women with cervical intra-epithelial neoplasia, prior to and after local excisional treatment, a Norwegian cohort study. BMC WOMENS HEALTH 2019; 19:30. [PMID: 30728029 PMCID: PMC6364458 DOI: 10.1186/s12905-019-0727-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/25/2019] [Indexed: 01/27/2023]
Abstract
Background Local treatment for cervical intraepithelial neoplasia (CIN) by Loop Electrosurgical Excision Procedure (LEEP) has been correlated with reproductive morbidity, while the cervicovaginal microbiota is also known to affect the risk of preterm delivery. CIN and treatment by LEEP might change the cervical microbiota. The main aim of this study was to describe the cervical microbiota before and after LEEP and assess its associaton with cone depth and HPV persistence. Further, we aimed to compare the microbiota to references with normal cervical cytology. Methods Between 2005 and 2007, we prospectively identified 89 women planned for LEEP in a Norwegian hospital and recruited 100 references with a normal cervical cytology. Endocervical swabs were collected prior to treatment and at six (n = 77) and 12 months (n = 72) post LEEP for bacterial culture and PCR, and post LEEP for DNA testing for human papillomavirus (HPV). We compared the cervical microbiota composition before and after treatment and between women planned for LEEP vs references. Results There was a reduction in the number of non-Lactobacillus bacterial species six and 12 months after LEEP compared to before treatment and a tendency towards a concomitant increase in Lactobacillus. No association between the detection of cervical bacteria, HPV persistence or cone depth was found. Women planned for LEEP carried significantly more Bacteroides spp., Gardnerella vaginalis, Mycoplasma hominis and Ureaplasma parvum as well as a greater number of bacterial species than the references. Conclusions Local excisional treatment appears to alter the cervical microbiota towards a less diverse microbiota. Women with CIN have a more diverse cervical microbiota compared to women with normal cervical cytology. Electronic supplementary material The online version of this article (10.1186/s12905-019-0727-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johanna Wiik
- Department of Gynecology and Obstetrics, Østfold Hospital Trust, Kalnes, Norway. .,Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Verena Sengpiel
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Kyrgiou
- Department of Surgery & Cancer, IRDB, Faculty of Medicine, Imperial College, London, W12 0NN, UK.,West London Gynaecological Cancer Center, Queen Charlotte's & Chelsea - Hammersmith Hospital, Imperial Healthcare NHS Trust, London, W12 0HS, UK
| | - Staffan Nilsson
- Department of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden.,Department of Pathology and Genetics, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Anita Mitra
- Department of Surgery & Cancer, IRDB, Faculty of Medicine, Imperial College, London, W12 0NN, UK.,West London Gynaecological Cancer Center, Queen Charlotte's & Chelsea - Hammersmith Hospital, Imperial Healthcare NHS Trust, London, W12 0HS, UK
| | - Tom Tanbo
- Department of Reproductive Medicine, Oslo University Hospital, Oslo and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Tone Møller Tannæs
- Department of Clinical Molecular Biology (EpiGen), Division of Medicine, Akershus University Hospital and University of Oslo, Oslo, Norway
| | - Katrine Sjøborg
- Department of Gynecology and Obstetrics, Østfold Hospital Trust, Kalnes, Norway
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Zhuang H, Hong S, Zheng L, Zhang L, Zhuang X, Wei H, Yang Y. Effects of cervical conisation on pregnancy outcome: a meta-analysis. J OBSTET GYNAECOL 2018; 39:74-81. [PMID: 29884103 DOI: 10.1080/01443615.2018.1463206] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Hongmei Zhuang
- Department of Gynaecology and Obstetrics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Shurong Hong
- Department of Gynaecology and Obstetrics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Lin Zheng
- Department of Gynaecology and Obstetrics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Layue Zhang
- Department of Gynaecology and Obstetrics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Xueyi Zhuang
- Department of Gynaecology and Obstetrics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hua Wei
- Prenatal Diagnosis Center, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Yuqing Yang
- Prenatal Diagnosis Center, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
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18
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Baños N, Julià C, Lorente N, Ferrero S, Cobo T, Gratacos E, Palacio M. Mid-Trimester Cervical Consistency Index and Cervical Length to Predict Spontaneous Preterm Birth in a High-Risk Population. AJP Rep 2018; 8:e43-e50. [PMID: 29560285 PMCID: PMC5858952 DOI: 10.1055/s-0038-1636993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 12/09/2017] [Indexed: 12/29/2022] Open
Abstract
Background Short cervical length (CL) has not been shown to be adequate as a single predictor of spontaneous preterm birth (sPTB) in high-risk pregnancies. Objective The objective of this study was to evaluate the performance of the mid-trimester cervical consistency index (CCI) to predict sPTB in a cohort of high-risk pregnancies and to compare the results with those obtained with the CL. Study Design Prospective cohort study including high-risk singleton pregnancies between 19 +0 and 24 +6 weeks. The ratio between the anteroposterior diameter of the uterine cervix at maximum compression and at rest was calculated offline to obtain the CCI. Results Eighty-two high sPTB risk women were included. CCI (%) was significantly reduced in women who delivered <37 +0 weeks compared with those who delivered at term, while CL was not. The area under the curve (AUC) of the CCI to predict sPTB <37 +0 weeks was 0.73 (95% confidence interval [CI], 0.61-0.85), being 0.51 (95% CI, 0.35-0.67), p = 0.03 for CL. The AUC of the CCI to predict sPTB <34 +0 weeks was 0.68 (95% CI, 0.54-0.82), being 0.49 (95% CI, 0.29-0.69), p = 0.06 for CL. Conclusion CCI performed better than sonographic CL to predict sPTB. Due to the limited predictive capacity of these two measurements, other tools are still needed to better identify women at increased risk.
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Affiliation(s)
- Núria Baños
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Carla Julià
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Núria Lorente
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Silvia Ferrero
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Teresa Cobo
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacos
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Montse Palacio
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Kyrgiou M, Athanasiou A, Kalliala IEJ, Paraskevaidi M, Mitra A, Martin‐Hirsch PPL, Arbyn M, Bennett P, Paraskevaidis E. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. Cochrane Database Syst Rev 2017; 11:CD012847. [PMID: 29095502 PMCID: PMC6486192 DOI: 10.1002/14651858.cd012847] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Maria Kyrgiou
- Imperial College London ‐ Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare TrustSurgery and Cancer ‐ West London Gynaecological Cancer CentreDu Cane RoadLondonUKW12 0NN
| | - Antonios Athanasiou
- Ioannina University HospitalDepartment of Obstetrics and GynaecologyZigomalli 24IoanninaGreece45332
| | - Ilkka E J Kalliala
- Imperial College LondonThe Institute of Reproductive and Developmental Biology (IRDB), Surgery and CancerIRDB Building, 3rd floor, Hammersmith CampusDu cane RoadLondonUKW12 0HS
| | - Maria Paraskevaidi
- University of Central LancashirePharmacy and Biomedical SciencesFylde RoadPrestonLancashireUKPR1 2HE
| | - Anita Mitra
- Imperial College LondonThe Institute of Reproductive and Developmental Biology (IRDB), Surgery and CancerIRDB Building, 3rd floor, Hammersmith CampusDu cane RoadLondonUKW12 0HS
| | - Pierre PL Martin‐Hirsch
- Royal Preston Hospital, Lancashire Teaching Hospital NHS TrustGynaecological Oncology UnitSharoe Green LaneFullwoodPrestonLancashireUKPR2 9HT
| | - Marc Arbyn
- Scientific Institute of Public HealthUnit of Cancer Epidemiology, Belgian Cancer CentreJuliette Wytsmanstreet 14BrusselsBelgiumB‐1050
| | - Phillip Bennett
- Imperial College LondonParturition Research GroupDu Cane RoadLondonUKW12 0NN
| | - Evangelos Paraskevaidis
- Ioannina University HospitalDepartment of Obstetrics and GynaecologyZigomalli 24IoanninaGreece45332
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Bjørge T, Skare GB, Bjørge L, Tropé A, Lönnberg S. Adverse Pregnancy Outcomes After Treatment for Cervical Intraepithelial Neoplasia. Obstet Gynecol 2017; 128:1265-1273. [PMID: 27824756 DOI: 10.1097/aog.0000000000001777] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To explore associations between specific treatments for intraepithelial or early invasive cervical lesions and adverse pregnancy outcomes. METHODS We conducted a population-based cohort study in which treatment data from the Cancer Registry of Norway were linked to the Medical Birth Registry of Norway to identify adverse pregnancy outcomes. All women (n=545,243) with singleton births (N=943,321) in Norway during 1998-2014 were included; 9,554 of births were in women treated before delivery. Hazard ratios (HRs) with 95% confidence intervals (CIs) were derived from Cox regression models. RESULTS There was a significant association between preterm birth and previous treatment of cervical lesions overall (9.7 compared with 5.3%; HR 1.8, 95% CI 1.7-2.0). The strongest associations were seen for cold knife (13 compared with 5.3%; HR 2.6, 95% CI 1.3-5.3) and laser conization (12 compared with 5.3%; HR 2.3, 95% CI 2.0-2.5). The association was stronger for preterm birth at earlier gestational ages and increased with amount of tissue excised. Furthermore, the association weakened with calendar year of treatment. There was also an association with increased risks of spontaneous abortion (0.5 compared with 0.2%; HR 2.5, 95% CI 1.7-3.7), and the strongest associations were seen for laser conization (0.6 compared with 0.2%; HR 3.0, 95% CI 1.8-5.3) and a loop electrosurgical excision procedure (LEEP) (0.4 compared with 0.2%; HR 2.3, 95% CI 1.3-4.0). CONCLUSION Treatment with major excisional procedures, including LEEP, was associated with increased risks of preterm birth and spontaneous abortion. The risk of preterm birth was highest at early gestational ages and for those with the largest amount of tissue excised. Women should be informed about their future risk of adverse pregnancy outcomes, particularly preterm birth, after excisional treatment for cervical lesions.
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Affiliation(s)
- Tone Bjørge
- Departments of Global Public Health and Primary Care and Clinical Medicine and the Centre for Cancer Biomarkers, University of Bergen, and the Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, and the Cancer Registry of Norway and the Department of Gynecologic Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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21
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Triage for management of cervical high-grade squamous intraepithelial lesion patients with positive margin by conization: a retrospective analysis. Front Med 2017; 11:223-228. [DOI: 10.1007/s11684-017-0517-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/23/2017] [Indexed: 12/29/2022]
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Cho SH, Park KH, Jung EY, Joo JK, Jang JA, Yoo HN. Maternal Characteristics, Short Mid-Trimester Cervical Length, and Preterm Delivery. J Korean Med Sci 2017; 32:488-494. [PMID: 28145653 PMCID: PMC5290109 DOI: 10.3346/jkms.2017.32.3.488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/03/2016] [Indexed: 01/30/2023] Open
Abstract
We aimed to determine the maternal characteristics (demographics, an obstetric history, and prior cervical excisional procedure) associated with a short mid-trimester cervical length (CL, defined as a CL of ≤ 25 mm) and whether having a short cervix explains the association between these maternal characteristics and spontaneous preterm delivery (SPTD, defined as a delivery before 34 weeks). This is a single-center retrospective cohort study of 3,296 consecutive women with a singleton pregnancy who underwent routine CL measurement between 20 and 24 weeks. Data were collected on maternal age, weight, height, parity, obstetric history (nulliparity; a history of at least 1 SPTD; and at least 1 term birth and no preterm birth [low-risk history group]), and prior cervical excisional procedure. In the multivariate regression analysis, an obstetric history, prior cervical excisional procedure, and gestational age at measurement were the variables significantly associated with short CL. In contrast, maternal weight, height, age, and parity were not significantly associated with short CL. By using the likelihood of SPTD as an outcome variable, logistic regression indicated that short CL and obstetric history, but not prior cervical excisional procedure, were significantly associated with SPTD after adjustment for potential confounders. A history of SPTD and prior cervical excisional procedure were associated with an increased risk of a short mid-trimester CL. A history of SPTD, but not prior cervical excisional procedure, is associated with an increased risk of SPTD, independent of a short CL.
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Affiliation(s)
- Soo Hyun Cho
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyo Hoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Eun Young Jung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Kyung Joo
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Ae Jang
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ha Na Yoo
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Tracking the Impact of Excisional Cervical Treatment on the Cervix using Biospectroscopy. Sci Rep 2016; 6:38921. [PMID: 27974821 PMCID: PMC5156919 DOI: 10.1038/srep38921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/16/2016] [Indexed: 11/09/2022] Open
Abstract
Local excisional treatment for cervical intra-epithelial neoplasia (CIN) is linked to significant adverse sequelae including preterm birth, with cone depth and radicality of treatment correlating to the frequency and severity of adverse events. Attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy can detect underlying cervical disease more accurately than conventional cytology. The chemical profile of cells pre- and post-treatment may differ as a result of altered biochemical processes due to excision, or treatment of the disease. Since pre-treatment cervical length varies amongst women, the percentage of cervix excised may correlate more accurately to risk than absolute dimensions. We show that treatment for CIN significantly alters the biochemistry of the cervix, compared with women who have not had treatment; this is due to the removal of cervical tissue rather than the removal of the disease. However, the spectra do not seem to correlate to the cone depth or proportion of cervical length excised. Future research should aim to explore the impact of treatment in a larger cohort.
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Marcellin L. Prévention de l’accouchement prématuré par cerclage du col de l’utérus. ACTA ACUST UNITED AC 2016; 45:1299-1323. [DOI: 10.1016/j.jgyn.2016.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 12/22/2022]
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Simms KT, Smith MA, Lew JB, Kitchener HC, Castle PE, Canfell K. Will cervical screening remain cost-effective in women offered the next generation nonavalent HPV vaccine? Results for four developed countries. Int J Cancer 2016; 139:2771-2780. [DOI: 10.1002/ijc.30392] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/27/2016] [Accepted: 07/14/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Kate T. Simms
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
| | - Megan A. Smith
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
- School of Public Health; University of Sydney; Australia
| | - Jie-Bin Lew
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
| | | | - Philip E. Castle
- Department of Epidemiology and Population Health; Albert Einstein College of Medicine; Bronx NY
- Global Coalition against Cervical Cancer; Arlington VA
| | - Karen Canfell
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
- School of Public Health; University of Sydney; Australia
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Ryu KJ, Lee S, Min KJ, Hong JH, Song JY, Lee JK, Lee NW. Management of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions of the uterine cervix with human papilloma virus infection among young women aged less than 25 years. Diagn Cytopathol 2016; 44:959-963. [DOI: 10.1002/dc.23533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/17/2016] [Accepted: 06/24/2016] [Indexed: 01/16/2023]
Affiliation(s)
- Ki-Jin Ryu
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
| | - Sanghoon Lee
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
| | - Kyung-Jin Min
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
| | - Jin Hwa Hong
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
| | - Jae Yun Song
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
| | - Jae Kwan Lee
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
| | - Nak Woo Lee
- Department of Obstetrics and Gynecology; Korea University Medical Center, Korea University College of Medicine; Seoul Korea
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Length but not transverse diameter of the excision specimen for high-grade cervical intraepithelial neoplasia (CIN 2–3) is a predictor of pregnancy outcome. Eur J Cancer Prev 2016; 25:416-22. [DOI: 10.1097/cej.0000000000000196] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kyrgiou M, Athanasiou A, Paraskevaidi M, Mitra A, Kalliala I, Martin-Hirsch P, Arbyn M, Bennett P, Paraskevaidis E. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. BMJ 2016; 354:i3633. [PMID: 27469988 PMCID: PMC4964801 DOI: 10.1136/bmj.i3633] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Maria Kyrgiou
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK Queen Charlotte's and Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
| | | | - Maria Paraskevaidi
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Anita Mitra
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK Queen Charlotte's and Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Ilkka Kalliala
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Pierre Martin-Hirsch
- Department of Gynaecological Oncology, Lancashire Teaching Hospitals, Preston, UK Department of Biophotonics, Lancaster University, Lancaster, UK
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
| | - Phillip Bennett
- Institute of Reproductive and Developmental Biology, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK Queen Charlotte's and Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
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Hughes K, Kane SC, Araujo Júnior E, Da Silva Costa F, Sheehan PM. Cervical length as a predictor for spontaneous preterm birth in high-risk singleton pregnancy: current knowledge. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:7-15. [PMID: 26556674 DOI: 10.1002/uog.15781] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/28/2015] [Indexed: 06/05/2023]
Affiliation(s)
- K Hughes
- The University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia
- Pregnancy Research Centre, Department of Maternal-Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - S C Kane
- The University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia
- Pregnancy Research Centre, Department of Maternal-Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
| | - F Da Silva Costa
- The University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia
| | - P M Sheehan
- The University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia
- Pregnancy Research Centre, Department of Maternal-Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
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Jančar N, Mihevc Ponikvar B, Tomšič S. Cold-knife conisation and large loop excision of transformation zone significantly increase the risk for spontaneous preterm birth: a population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2016; 203:245-9. [PMID: 27359080 DOI: 10.1016/j.ejogrb.2016.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/02/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Our aim was to explore the association between cold-knife conisation and large loop excision of transformation zone (LLETZ) with spontaneous preterm birth in a large 10-year national sample. We wanted to explore further the association of these procedures with preterm birth according to gestation. STUDY DESIGN We conducted a population based retrospective cohort study, using data from national Medical Birth Registry. The study population consisted of all women giving birth to singletons in the period 2003-2012 in Slovenia, excluding all induced labors and elective cesarean sections before 37 weeks of gestation (N=192730). We compared the prevalence of spontaneous preterm births (before 28 weeks, before 32 weeks, before 34 weeks and before 37 weeks of gestation) in women with cold-knife conisation or LLETZ compared to women without history of conisation, calculating odds ratios (OR), adjusted for potential confounders. Chi-square test was used for descriptive analysis. Logistic regression analyses were performed to estimate crude odds ratio (OR) and adjusted odds ratio (aOR) and their 95% confidence intervals (95% CI) with two-sided probability (p) values. RESULTS A total of 8420 (4.4%) women had a preterm birth before 37 weeks of gestation, 2250 (1.2%) before 34 weeks of gestation, 1333 (0.7%) before 32 weeks of gestation and 603 (0.3%) before 28 weeks of gestation. A total of 4580 (2.4%) women had some type of conisation in their medical history: 2083 (1.1%) had cold-knife conisation and 2498 (1.3%) had LLETZ. In women with history of cold-knife conisation, the adjusted OR for preterm birth before 37 weeks of gestation was 3.13 (95% CI; 2.74-3.57) and for preterm birth before 28 weeks of gestation 5.96 (95% CI; 4.3-8.3). In women with history of LLETZ, the adjusted OR was 1.95 (95% CI; 1.68-2.25) and 2.88 (95% CI; 1.87-4.43), respectively. CONCLUSIONS Women with cervical excision procedure of any kind have significantly increased odds for preterm birth, especially for preterm birth before 28 weeks and before 32 weeks of gestation.
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Affiliation(s)
- Nina Jančar
- Department of Human Reproduction, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Slovenia.
| | - Barbara Mihevc Ponikvar
- Health Survey and Health Promotion Department, National Institute of Public Health, Ljubljana, Slovenia
| | - Sonja Tomšič
- Health Survey and Health Promotion Department, National Institute of Public Health, Ljubljana, Slovenia
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Munro A, Powell RG, A Cohen P, Bowen S, Spilsbury K, O'Leary P, Semmens JB, Codde J, Williams V, Steel N, Leung Y. Spontaneous regression of CIN2 in women aged 18-24 years: a retrospective study of a state-wide population in Western Australia. Acta Obstet Gynecol Scand 2016; 95:291-8. [PMID: 26660398 DOI: 10.1111/aogs.12835] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/21/2015] [Indexed: 12/01/2022]
Abstract
INTRODUCTION CIN2 has a high rate of spontaneous regression in young women and may be managed conservatively in appropriately selected patients. This study aimed to investigate health outcomes in women aged 18-24 years with biopsy-confirmed CIN2. MATERIAL AND METHODS A retrospective cohort study of Western Australian women aged 18-24 years diagnosed with CIN2 on cervical biopsy from 1 January 2001 to 31 December 2010. Women who had not received treatment at ≥4 months following CIN2 diagnosis were classified as managed 'conservatively'. Subsequent cervical cytology and/or biopsy test results were used to report lesion regression (absence of dysplasia or an epithelial lesion of lower grade than CIN2) and disease persistence (CIN2, CIN3 or ACIS). RESULTS Follow-up data were available for 2417 women of whom 924 (38.2%) were 'conservatively' managed. In all, 152 (16.4%) conservatively managed women had a lesion more severe than CIN2 detected within 24 months of initial diagnosis, of which 144 were CIN3 and eight were ACIS. There was no statistically significant association between rates of regression and patient age, Socio-economic Indexes for Areas or Accessibility/Remoteness Index of Australia indices. The 2-year regression rate for CIN2 was estimated to be 59.5% (95%CI 0.5-0.6) in this cohort of women. CONCLUSION In conservatively managed young women with CIN2 there was a high rate of spontaneous disease regression. Thus, excisional or ablative treatments may be avoided in selected patients who receive appropriate counseling and who are able to comply with more intensive and prolonged follow-up requirements.
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Affiliation(s)
- Aime Munro
- Institute of Health Research, University of Notre Dame Australia, Fremantle, WA, Australia.,St John of God Hospital Bendat Family Comprehensive Cancer Centre, Subiaco, WA, Australia.,Centre for Population Health Research, Curtin University, Bentley, WA, Australia
| | - Rhys G Powell
- Centre for Population Health Research, Curtin University, Bentley, WA, Australia.,School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Paul A Cohen
- Institute of Health Research, University of Notre Dame Australia, Fremantle, WA, Australia.,St John of God Hospital Bendat Family Comprehensive Cancer Centre, Subiaco, WA, Australia.,School of Women's and Infants' Health Research, University of Western Australia, Crawley, WA, Australia
| | - Shirley Bowen
- School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Katrina Spilsbury
- Centre for Population Health Research, Curtin University, Bentley, WA, Australia
| | - Peter O'Leary
- Faculty of Health Science, Curtin University, Bentley, WA, Australia
| | - James B Semmens
- Centre for Population Health Research, Curtin University, Bentley, WA, Australia
| | - Jim Codde
- Institute of Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Vincent Williams
- School of Biomedical Sciences, Curtin University, Bentley, WA, Australia
| | - Nerida Steel
- WA Cervical Cancer Prevention Program, Perth, WA
| | - Yee Leung
- School of Women's and Infants' Health Research, University of Western Australia, Crawley, WA, Australia
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Frey HA, Conner SN. Treatment of cervical dysplasia and the risk of preterm birth: understanding the association. Am J Obstet Gynecol 2015; 213:445-6. [PMID: 26410203 DOI: 10.1016/j.ajog.2015.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/05/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Heather A Frey
- Department of Obstetrics and Gynecology, Ohio State University School of Medicine, Columbus, OH.
| | - Shayna N Conner
- Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO
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Kyrgiou M, Mitra A, Arbyn M, Paraskevaidi M, Athanasiou A, Martin‐Hirsch PPL, Bennett P, Paraskevaidis E. Fertility and early pregnancy outcomes after conservative treatment for cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2015; 2015:CD008478. [PMID: 26417855 PMCID: PMC6457639 DOI: 10.1002/14651858.cd008478.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cervical intra-epithelial neoplasia (CIN) typically occurs in young women of reproductive age. Although several studies have reported the impact that cervical conservative treatment may have on obstetric outcomes, there is much less evidence for fertility and early pregnancy outcomes. OBJECTIVES To assess the effect of cervical treatment for CIN (excisional or ablative) on fertility and early pregnancy outcomes. SEARCH METHODS We searched in January 2015 the following databases: the Cochrane Gynaecological Cancer Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 12, 2014), MEDLINE (up to November week 3, 2014) and EMBASE (up to week 52, 2014). SELECTION CRITERIA We included all studies reporting on fertility and early pregnancy outcomes (less than 24 weeks of gestation) in women with a history of CIN treatment (excisional or ablative) as compared to women that had not received treatment. DATA COLLECTION AND ANALYSIS Studies were classified according to the treatment method used and the fertility or early pregnancy endpoint. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effects model and inter-study heterogeneity was assessed with I(2). Two review authors (MK, AM) independently assessed the eligibility of retrieved papers and risk of bias. The two review authors then compared their results and any disagreements were resolved by discussion. If still unresolved, a third review author (MA) was involved until consensus was reached. MAIN RESULTS Fifteen studies (2,223,592 participants - 25,008 treated and 2,198,584 untreated) that fulfilled the inclusion criteria for this review were identified from the literature search. The meta-analysis demonstrated that treatment for CIN did not adversely affect the chances of conception. The overall pregnancy rate was higher for treated (43%) versus untreated women (38%; RR 1.29, 95% CI 1.02 to 1.64; 4 studies, 38,050 participants, very low quality), although the inter-study heterogeneity was considerable (P < 0.01). The pregnancy rates in treated and untreated women with an intention to conceive (88% versus 95%, RR 0.93, 95% CI 0.80 to 1.08; 2 studies, 70 participants, very low quality) and the number of women requiring more than 12 months to conceive (14% versus 9%, RR 1.45, 95% CI 0.89 to 2.37; 3 studies, 1348 participants, very low quality) were no different. Although the total miscarriage rate (4.6% versus 2.8%, RR 1.04, 95% CI 0.90 to 1.21; 10 studies, 39,504 participants, low quality) and first trimester miscarriage rate (9.8% versus 8.4%, RR 1.16, 95% CI 0.80 to 1.69, 4 studies, 1103 participants, low quality) was similar for treated and untreated women, CIN treatment was associated with an increased risk of second trimester miscarriage, (1.6% versus 0.4%, RR 2.60, 95% CI 1.45 to 4.67; 8 studies, 2,182,268 participants, low quality). The number of ectopic pregnancies (1.6% versus 0.8%, RR 1.89, 95% CI 1.50 to 2.39; 6 studies, 38,193 participants, low quality) and terminations (12.2% versus 7.4%, RR 1.71, 95% CI 1.31 to 2.22; 7 studies, 38,208 participants, low quality) were also higher in treated women.The results should be interpreted with caution. The included studies were often small with heterogenous design. Most of these studies were retrospective and of low or very low quality (GRADE assessment) and were therefore prone to bias. Subgroup analyses for the individual treatment methods and comparison groups and analysis to stratify for the cone length was not possible. AUTHORS' CONCLUSIONS This meta-analysis suggests that treatment for CIN does not adversely affect fertility, although treatment was associated with an increased risk of miscarriage in the second trimester. These results should be interpreted with caution as the included studies were non-randomised and many were of low or very low quality and therefore at high risk of bias. Research should explore mechanisms that may explain the increase in mid-trimester miscarriage risk and stratify this impact of treatment by the length of the cone and the treatment method used.
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Affiliation(s)
- Maria Kyrgiou
- Imperial College ‐ Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare TrustSurgery and Cancer ‐ West London Gynaecological Cancer CenterDu Cane RoadLondonUKW12 0NN
| | - Anita Mitra
- Imperial College LondonInstitute of Reproductive and Developmental BiologyLondonUK
| | - Marc Arbyn
- Scientific Institute of Public HealthUnit of Cancer Epidemiology, Belgian Cancer CentreJuliette Wytsmanstreet 14BrusselsBelgiumB‐1050
| | - Maria Paraskevaidi
- University of IoanninaDepartment of ChemistryAdamadiou Kasioumi 27IoanninaStavrakiGreece45500
| | - Antonios Athanasiou
- Ioannina University HospitalDepartment of Obstetrics and GynaecologyZigomalli 24IoanninaGreece45001
| | - Pierre PL Martin‐Hirsch
- Royal Preston Hospital, Lancashire Teaching Hospital NHS TrustGynaecological Oncology UnitSharoe Green LaneFullwoodPrestonLancashireUKPR2 9HT
| | - Phillip Bennett
- Imperial College LondonParturition Research GroupDu Cane RoadLondonUKW12 0NN
| | - Evangelos Paraskevaidis
- Ioannina University HospitalDepartment of Obstetrics and GynaecologyZigomalli 24IoanninaGreece45001
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The risk of preterm birth of treated versus untreated cervical intraepithelial neoplasia (CIN): a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2015; 188:24-33. [PMID: 25770844 DOI: 10.1016/j.ejogrb.2015.02.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/28/2015] [Accepted: 02/19/2015] [Indexed: 11/22/2022]
Abstract
Cervical surgery is associated with preterm birth (PTB) and neonatal morbidity. However, it is unknown whether this increased risk is due to the surgery itself or to the cervical intraepithelial neoplasia (CIN) underlying the surgery. Our objective was to assess the risk for PTB in women with treated and untreated CIN. We performed an electronic literature search in MEDLINE, Embase and CENTRAL for studies that reported on pregnancy outcome after treated and untreated CIN. The methodological quality was scored using the STROBE combined checklist for observational studies. We extracted data on PTB<37 weeks, very PTB<32 weeks, spontaneous PTB<37 weeks, (preterm) premature rupture of membranes ((P)PROM), perinatal mortality and section caesarean each before and after treatment for CIN. We used the Mantel-Haenszel method to estimate summarizing odds ratios. Our search identified 620 studies, of which 20 were reporting on pregnancy outcome for a total of 12,159,293 women. There were 20,832 women who gave birth after treatment for CIN before pregnancy, 52 women who gave birth after treatment for CIN during pregnancy, 64,237 women with CIN who gave birth before treatment, and 8,902,865 women who gave birth without CIN. Compared to women with untreated CIN, women treated for CIN before or during pregnancy, had a significantly higher risk of PTB<37 weeks (OR 1.7, 95% CI 1.0-2.7). When comparing women treated for CIN before pregnancy (n=20,832) to women with untreated CIN (n=64,162), we found an OR of 1.4 with a 95% confidence interval of 0.85-2.3. Women treated during pregnancy had a clearly increased risk for PTB (OR 6.5, 95% CI 1.1-37), and (P)PROM (OR 1.8, 95% CI 1.4-2.2). In women with cervical surgery, the risks for spontaneous PTB<37 weeks (OR 0.87, 95% CI 0.54-1.4), caesarean section (OR 1.0, 95% CI 0.71-1.5) and perinatal mortality (OR 1.0, 95% CI 0.38-2.8) were not increased. The increased risk of PTB in women who underwent cervical surgery for CIN is especially increased when performed during pregnancy. When performed before pregnancy the risk of PTB is increased, although insignificant.
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Kyrgiou M, Mitra A, Arbyn M, Stasinou SM, Martin-Hirsch P, Bennett P, Paraskevaidis E. Fertility and early pregnancy outcomes after treatment for cervical intraepithelial neoplasia: systematic review and meta-analysis. BMJ 2014; 349:g6192. [PMID: 25352501 PMCID: PMC4212006 DOI: 10.1136/bmj.g6192] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine the impact of cervical excision for cervical intraepithelial neoplasia on fertility and early pregnancy outcomes. DESIGN Systematic review and meta-analysis of cohort studies. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA Studies assessing fertility and early pregnancy outcomes in women with a history of treatment for cervical intraepithelial neoplasia versus untreated women. We classified the included studies according to treatment type and fertility or early pregnancy endpoint. ANALYSIS Pooled relative risks and 95% confidence intervals using a random effect model, and interstudy heterogeneity with I(2) statistics. RESULTS 15 studies fulfilled the inclusion criteria and were included. The meta-analysis did not provide any evidence that treatment for cervical intraepithelial neoplasia adversely affected the chances of conception. The overall pregnancy rate was higher for treated women than for untreated women (four studies; 43% v 38%, pooled relative risk 1.29, 95% confidence interval 1.02 to 1.64), although the heterogeneity between studies was high (P<0.0001). Pregnancy rates did not differ between women with an intention to conceive (two studies; 88% v 95%, 0.93, 0.80 to 1.08) and the number requiring more than 12 months to conceive (three studies, 15% v 9%, 1.45, 0.89 to 2.37). Although the rates for total miscarriages (10 studies; 4.6% v 2.8%, 1.04, 0.90 to 1.21) and miscarriage in the first trimester (four studies; 9.8% v 8.4%, 1.16, 0.80 to 1.69) was similar for treated and untreated women, cervical treatment was associated with a significantly increased risk of miscarriage in the second trimester. The rate was higher for treated women than for untreated women (eight studies; 1.6% v 0.4%, 16,558 women; 2.60, 1.45 to 4.67). The number of ectopic pregnancies (1.6% v 0.8%; 1.89, 1.50 to 2.39) and terminations (12.2% v 7.4%; 1.71, 1.31 to 2.22) was also higher for treated women. CONCLUSION There is no evidence suggesting that treatment for cervical intraepithelial neoplasia adversely affects fertility, although treatment was associated with a significantly increased risk of miscarriages in the second trimester. Research should explore mechanisms that may explain this increase in risk and stratify the impact that treatment may have on fertility and early pregnancy outcomes by the size of excision and treatment method used.
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Affiliation(s)
- Maria Kyrgiou
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London W12 0NN, UK
| | - Anita Mitra
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London W12 0NN, UK
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Brussels
| | - Sofia Melina Stasinou
- Create Infertility Clinic, London, UK Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Greece
| | - Pierre Martin-Hirsch
- Department of Gynaecologic Oncology, Lancashire Teaching Hospitals, Preston, UK Department of Biophotonics, Lancaster University, Lancaster, UK
| | - Phillip Bennett
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London W12 0NN, UK
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Abstract
OBJECTIVE This study aimed to determine if there are differences in the histological findings of excisional biopsies between younger women (aged ≤25 years) and older women who undergo large loop excision of the transformation zone or cone biopsy for a biopsy-proven high-grade squamous intraepithelial lesion (HSIL). MATERIALS AND METHODS A retrospective cohort analysis of women referred to a tertiary hospital colposcopy clinic with a colposcopically directed biopsy of HSIL (cervical intraepithelial neoplasia 2 [CIN 2] or CIN 3) during the period of 2008 to 2011 was performed.The histological excisional biopsy specimens for younger women (aged ≤25 years) were compared with those of older women (aged >25 years.) Bivariate analysis comparing demographic characteristics and outcomes across the 2 study groups was initially undertaken to identify potential confounders for inclusion in the multivariate analysis. RESULTS Of 348 women who had a satisfactory colposcopic assessment and reported no previous treatment for cervical intraepithelial neoplasia, 87 were 25 years or younger, and 261 women were older than 25 years. After excisional biopsy of the cervix, the histological specimen for younger women was more likely to be reported as CIN 1 or no dysplasia (16.3% vs 8.2%). When adjusted for confounders (parity, smoking, previous sexual infection, and referring Pap smear), age less than 25 years remained an independent predictor of having a histological excisional biopsy specimen reported as CIN 1 or no dysplasia (adjusted odds ratio = 2.35; 95% confidence interval = 1.0-5.49). CONCLUSIONS Younger women with biopsy-proven HSIL (CIN 2/3), have a higher likelihood that the histological specimen after an excisional biopsy of the cervix will be reported as CIN 1 or no dysplasia.
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Kirn V, Geiger P, Riedel C, Bergauer F, Friese K, Kainer F, Knabl J. Cervical conisation and the risk of preterm delivery: a retrospective matched pair analysis of a German cohort. Arch Gynecol Obstet 2014; 291:599-603. [PMID: 25234516 DOI: 10.1007/s00404-014-3463-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 09/09/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Since the routine screening program for cervical dysplasia by Pap smear was established in the early 1970s, the rate of cervical cancer has continually dropped. Even if a high percentage of cervical dysplasia shows spontaneous restitution, the only effective therapy for persisting cervical dysplasia is local ablation or excision which might be associated with an increased risk of preterm delivery in subsequent pregnancies. However, data from German patients are missing, so the aim of this study was to evaluate the risk of preterm delivery and associated risks in a cohort of patients who had undergone cervical conisation previous to their pregnancies. METHODS A total of 144 patients with conisation and subsequent pregnancy were identified. They were compared regarding week of delivery and preterm birth, fetal birth weight, fetal outcome and birth procedure (spontaneous delivery, vacuum extraction, primary and secondary cesarean section) with their matched partners. RESULTS 135 patients with singleton pregnancies and their matched partners were evaluated in the final analysis. The mean age was 33.5 years. Comparing the case and control group we reached significant different results for week of delivery, but not preterm birth defined as birth prior to 37 weeks of gestation. CONCLUSIONS Within this German cohort cervical conisation did not increase the risk for preterm birth, cesarean section or poor fetal outcome. We therefore conclude that cervical conisation is an appropriate method to treat women with cervical dysplasia also at childbearing age when prevention of cervical cancer is needed.
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Affiliation(s)
- Verena Kirn
- Department of Obstetrics and Gynecology, University of Cologne, Kerpener Str. 34, 50931, Cologne, Germany,
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Conner SN, Frey HA, Tuuli MG. In reply. Obstet Gynecol 2014; 124:163. [PMID: 24945448 PMCID: PMC4162514 DOI: 10.1097/aog.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Shayna N Conner
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri
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Liu Y, Qiu HF, Tang Y, Chen J, Lv J. Pregnancy Outcome after the Treatment of Loop Electrosurgical Excision Procedure or Cold-Knife Conization for Cervical Intraepithelial Neoplasia. Gynecol Obstet Invest 2014; 77:240-4. [DOI: 10.1159/000360538] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 02/10/2014] [Indexed: 11/19/2022]
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Practice Bulletin No. 140: management of abnormal cervical cancer screening test results and cervical cancer precursors. Obstet Gynecol 2014; 122:1338-67. [PMID: 24264713 DOI: 10.1097/01.aog.0000438960.31355.9e] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Long S, Leeman L. Treatment options for high-grade squamous intraepithelial lesions. Obstet Gynecol Clin North Am 2014; 40:291-316. [PMID: 23732033 DOI: 10.1016/j.ogc.2013.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The introduction of testing for high-risk HPV types and P16 immunostaining of CIN2 histologic specimens allows for determination of the risk of progression versus regression for a woman with a particular cytologic or histologic specimen. Observation with serial cytological or colposcopic examinations is now appropriate for women with low-grade histologic lesions as well as pregnant and young women with certain high-grade histologic lesions. Current recommendations for management of high-grade lesions, the efficacy of treatment options (cryotherapy and LEEP), and the immediate (bleeding, infection) and longer term complications (cervical incompetence, preterm delivery) of cervical dysplasia treatment are presented.
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Affiliation(s)
- Stephanie Long
- Department of Family & Community Medicine, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131, USA
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Lie AK, Kristensen G. Human papillomavirus E6/E7 mRNA testing as a predictive marker for cervical carcinoma. Expert Rev Mol Diagn 2014; 8:405-15. [PMID: 18598223 DOI: 10.1586/14737159.8.4.405] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
MESH Headings
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- DNA, Neoplasm/genetics
- DNA, Neoplasm/metabolism
- DNA, Viral/genetics
- DNA, Viral/metabolism
- Female
- Humans
- Papillomaviridae/genetics
- Papillomaviridae/metabolism
- Papillomavirus E7 Proteins/genetics
- Papillomavirus E7 Proteins/metabolism
- Papillomavirus Infections/diagnosis
- Papillomavirus Infections/metabolism
- Papillomavirus Infections/virology
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- RNA, Neoplasm/genetics
- RNA, Neoplasm/metabolism
- RNA, Viral/genetics
- RNA, Viral/metabolism
- Uterine Cervical Neoplasms/diagnosis
- Uterine Cervical Neoplasms/genetics
- Uterine Cervical Neoplasms/metabolism
- Uterine Cervical Neoplasms/virology
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Affiliation(s)
- A Kathrine Lie
- Department of Pathology, The Norwegian Radium Hospital, Rikshospitalet, N-0310 Oslo, Norway.
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Ehsanipoor RM, Jolley JA, Goldshore MA, Szymanski LM, Haydon ML, Gaffaney CL, Lagrew DC. The relationship between previous treatment for cervical dysplasia and preterm delivery in twin gestations. J Matern Fetal Neonatal Med 2013; 27:821-4. [PMID: 23962130 DOI: 10.3109/14767058.2013.836178] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe the impact of previous cervical surgery on preterm birth prior to 34 weeks in twins. METHODS A retrospective review of twin pregnancies delivered between January 1998 and December 2005 at two institutions was performed. Women with a prior cold knife cone (CKC), loop electrosurgical excision procedure (LEEP), or ablative procedure were compared to a control group of women who had not undergone a previous treatment for cervical dysplasia. The primary outcome was delivery before 34 weeks of gestation. RESULTS A total of 876 women met inclusion criteria. Of these, 110 (12.6%) had previous surgical procedures for cervical dysplasia, including CKC (n = 10), LEEP (n = 36), cryotherapy (n = 59) and CO2 laser treatment (n = 5). Delivery prior to 34 weeks was more common in women with a previous CKC compared to women with no prior treatment (40% versus 11.3%; odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-8.0). Delivery prior to 34 weeks was not more common in women with a previous LEEP (8.3%; OR, 0.8; 95% CI, 0.3-2.3) or ablative procedure (9.4%; OR, 0.9; 95% CI, 0.4-1.9) in comparison to the untreated group. Adjusting for the potential confounders of age, tobacco use, infertility treatments and previous preterm birth did not change the results. CONCLUSIONS Previous CKC is associated with delivery prior to 34 weeks while LEEP and ablative procedures are not. CKC should be carefully considered and avoided when possible in reproductive age women.
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Affiliation(s)
- Robert M Ehsanipoor
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Jin G, LanLan Z, Li C, Dan Z. Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis. Arch Gynecol Obstet 2013; 289:85-99. [PMID: 23843155 DOI: 10.1007/s00404-013-2955-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 07/01/2013] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Gong Jin
- West China Second Hospital, Sichuan University, No.20, the Third Part of Renmin Road, Wuhou District, Chengdu, 610041, Sichuan Province, People's Republic of China
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[Obstetric outcomes following LOOP-excision]. ACTA ACUST UNITED AC 2013; 42:534-40. [PMID: 23809573 DOI: 10.1016/j.jgyn.2013.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 05/13/2013] [Accepted: 05/23/2013] [Indexed: 11/20/2022]
Abstract
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.
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Thorp JM. Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later. SCIENTIFICA 2012; 2012:980812. [PMID: 24278765 PMCID: PMC3820464 DOI: 10.6064/2012/980812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 10/15/2012] [Indexed: 06/02/2023]
Abstract
During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.
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Affiliation(s)
- John M. Thorp
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
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Stern PL, van der Burg SH, Hampson IN, Broker TR, Fiander A, Lacey CJ, Kitchener HC, Einstein MH. Therapy of human papillomavirus-related disease. Vaccine 2012; 30 Suppl 5:F71-82. [PMID: 23199967 PMCID: PMC4155500 DOI: 10.1016/j.vaccine.2012.05.091] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 04/10/2012] [Accepted: 05/03/2012] [Indexed: 12/18/2022]
Abstract
This chapter reviews the current treatment of chronic and neoplastic human papillomavirus (HPV)-associated conditions and the development of novel therapeutic approaches. Surgical excision of HPV-associated lower genital tract neoplasia is very successful but largely depends on secondary prevention programmes for identification of disease. Only high-risk HPV-driven chronic, pre-neoplastic lesions and some very early cancers cannot be successfully treated by surgical procedures alone. Chemoradiation therapy of cervical cancer contributes to the 66-79% cervical cancer survival at 5 years. Outlook for those patients with persistent or recurrent cervical cancer following treatment is very poor. Topical agents such as imiquimod (immune response modifier), cidofovir (inhibition of viral replication; induction apoptosis) or photodynamic therapy (direct damage of tumour and augmentation of anti-tumour immunity) have all shown some useful efficacy (~50-60%) in treatment of high grade vulvar intraepithelial neoplasia (VIN). Provider administered treatments of genital warts include cryotherapy, trichloracetic acid, or surgical removal which has the highest primary clearance rate. Patient applied therapies include podophyllotoxin and imiquimod. Recurrence after "successful" treatment is 30-40%. Further improvements could derive from a rational combination of current therapy with new drugs targeting molecular pathways mediated by HPV in cancer. Small molecule inhibitors targeting the DNA binding activities of HPV E1/E2 or the anti-apoptotic consequences of E6/E7 oncogenes are in preclinical development. Proteasome and histone deacetylase inhibitors, which can enhance apoptosis in HPV positive tumour cells, are being tested in early clinical trials. Chronic high-risk HPV infection/neoplasia is characterised by systemic and/or local immune suppressive regulatory or escape factors. Recently two E6/E7 vaccines have shown some clinical efficacy in high grade VIN patients and this correlated with strong and broad systemic HPV-specific T cell response and modulation of key local immune factors. Treatments that can shift the balance of immune effectors locally in combination with vaccination are now being tested. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
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Affiliation(s)
- Peter L Stern
- Paterson Institute for Cancer Research, University of Manchester, Manchester M20 4BX, UK.
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