Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis

Arbyn, Marc; Kyrgiou, Maria; Simoens, Cindy; Raifu, Amidu O.; Koliopoulos, George; Martin‐Hirsch, Pierre L.; Prendiville, Walter; Paraskevaidis, Evangelos

doi:10.1136/bmj.a1284

Cited by 622 publications

(498 citation statements)

References 38 publications

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“…10,11 The mechanism that explains the effect of conisation on future pregnancies has not been clarified until now. Kristensen raised several hypotheses.…”

Section: Discussionmentioning

confidence: 99%

Pregnancy outcome after cervical conisation: a retrospective cohort study in the Leuven University Hospital

Vijver

Poppe

Verguts

et al. 2010

BJOG

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Objective To assess pregnancy outcome after conisation.Design Retrospective cohort study.Setting Belgium, data from a university hospital.Population Fifty-five pregnancies in 34 women after conisation, and 55 pregnancies in 54 women without a history of conisation or cervical intraepithelial neoplasia (CIN).Methods Hospital data were reviewed and questionnaires were collected from 599 women who had a conisation in a 5-year period, among whom subsequent pregnancies were identified. The control group consisted of matched pregnancies of women without a history of conisation.Main outcome measures Gestational age at delivery, neonatal biometry, neonatal condition at birth.Results Numbers of sexual partners (4.6 ± 3.4 SD versus 2.5 ± 2.5 SD) and ex-smokers were significantly higher in the study group compared with the control group. Gestational age at delivery (266 ± 2 days versus 274 ± 9 days), neonatal head circumference (33.9 ± 2.5 cm, versus 34.6 ± 2.5 cm) and birthweight (3088 ± 754 g versus 3381 ± 430 g) were significantly lower in the study group compared with the control group. Numbers of preterm [<37 weeks; 14/55 (25%) versus 2/55 (4%); P = 0.002] and severe preterm (<34 weeks; 6/ 55 (11%) versus 0/55 (0%); P = 0.031] deliveries in the study group were significantly higher. There were no cases of perinatal mortality.Conclusions Conisation affects obstetrical outcome after conisation for CIN. Babies tend to be born earlier and are smaller. It is not clear whether this is related to the procedure or to factors linked with CIN.

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“…10,11 The mechanism that explains the effect of conisation on future pregnancies has not been clarified until now. Kristensen raised several hypotheses.…”

Section: Discussionmentioning

confidence: 99%

Pregnancy outcome after cervical conisation: a retrospective cohort study in the Leuven University Hospital

Vijver

Poppe

Verguts

et al. 2010

BJOG

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“…Recent evidence supports the conclusion that cervical screening in women aged 20-24 is substantially less effective in preventing cancer than screening in older women (Sasieni et al 2009), not least because changes in the young cervix are normal, and unnecessary treatment in response to putative abnormal features could interfere with fertility (Arbyn et al 2008). Nonetheless, the decision to begin routine screening at 25 rather than 20 has been much debated, and in May 2009 an ‗extraordinary meeting' of the Advisory Committee on Cervical Screening (ACCS) was asked to make recommendations to government ministers about whether the age 25 start date was still the right policy.…”

Section: Introductionmentioning

confidence: 92%

Age Criteria for Cervical Screening in England: Qualitative Study of Women’s Views

Armstrong

Dixon‐Woods

Murphy³

2010

SSRN Journal

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The age criteria applied in the NHS Cervical Screening Programme have been much debated at policy and professional levels, but little is known about women's views on appropriate age criteria. Our objective is to provide insight into women's views on age criteria for the NHS Cervical Screening Programme in England. We present data collected as part of a qualitative interview study conducted in the East Midlands of England. Thirty-five women, representing a range of ages and ethnic groups, were interviewed. Analysis was based on the constant comparative method. Women's views about the age criteria that should appropriately be applied to cervical cancer screening diverged considerably from the technical principles and criteria upon which policy decisions are based. Women called for screening to be extended at both the upper and the lower ends of the age range. However, there was little explicit acknowledgement in women's accounts of the risks posed by screening or of the relative effectiveness and cost-effectiveness of screening in women of different ages. Policy decisions about screening programmes often face problems of legitimacy and acceptability. There is an increasingly pressing need to ensure that the criteria used to make decisions about who will be offered screening are made explicit and communicated effectively, so that people's views can be well-informed.3

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“…2,3 A clinically useful way to express this association is that a single treatment with cold-knife conisation or laser conisation resulted in about one perinatal death in every 70 pregnancies, 3 and large loop excision of the transformation zone (LLETZ) was associated with a lesser risk, of two perinatal deaths in 1000 pregnancies. 3 The more cervical tissue excised the greater the risk of preterm birth; cold-knife cone biopsy was associated with a higher risk than LLETZ, 2,3 and two treatments were associated with a higher risk than one. 1 The association between excisional cervical surgery and preterm delivery has been consistently reported in over 30 cohort studies.…”

Section: Author's Replymentioning

confidence: 99%

“…1 The association between excisional cervical surgery and preterm delivery has been consistently reported in over 30 cohort studies. [2][3][4] It is biologically plausible that excising some of the cervix would weaken the physical and immunological barrier to infection ascending from the vagina into the fetal-placental unit, which is commonly seen and in preterm labour.…”

Section: Author's Replymentioning

confidence: 99%

Obstetric outcomes and management after cervical conisation for cervical intraepithelial neoplasia

Ørtoft

Henriksen

et al. 2010

BJOG

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Sir,We are grateful for the reaction to our paper Pregnancy outcome after cervical conisation, a retrospective cohort study in the Leuven University Hospital. 1,2 The limitations of our retrospective study and other published data are clearly discussed in the paper. As women with cervical intraepithelial neoplasia, stage 3 (CIN3) must be treated, the adverse effects on obstetrical outcome in future pregnancies will remain, whether the surgical intervention or factors related to the pathology, or both, are causal. I doubt if a proper randomised trial will ever be possible unless future therapeutical human papillomavirus (HPV) vaccines offer the opportunitiy to compare CIN3 treated medically with CIN3 treated with conisation or ablative therapy. Meanwhile, clinicians better adhere to approved management principles in cases with CIN3, and tailor the size of cones and the area of ablation to the lesion size and geography of the transformation zone in order to minimise the structural damage to the cervix. Obstetricians and their patients have to be aware of the possible adverse effects of a history of CIN3 and/or conisation on pregnancy outcome, especially preterm delivery. It remains unclear how to manage these women in subsequent pregnancies. Future studies should focus on the predictive value of cervical length measurements and the preventive effect of cerclage in cases with short or distended cervical canals. j Obstetric outcomes and management after cervical conisation for cervical intraepithelial neoplasia References Authors' ReplySir, Thank you for your interesting and relevant comments on the association between cervical conisations and obstetric outcomes. 1,2 We agree that a randomised study would be needed to fully establish a cause and effect relationship between previous conisation and obstetrics outcome. However, we only had the option to do a population-based cohort study, as a randomised study in patients with severe cervical dysplasia is not feasible in Danish patients, as neither the patients nor the Danish Ethical Committee would accept any randomisation that included a 'no-treatment' option. Our data were analysed using a wide variety of statistical methods such as adjusted or unadjusted odds ratios, adjusted or unadjusted relative risks, and adjusted or unadjusted hazard ratios. After statistical counselling we ended up using unadjusted and adjusted hazards ratios from Cox analysis. This choice enabled us to include women who were delivered electively preterm because of maternal or fetal pathology, allowing their time to delivery to be included in the analysis. These patients were censored at the time of delivery. However, independent of which statistical method we used, we found the same strong relationship between one or two conisations and preterm birth. We included adjustment for possible confounding factors such as maternal age, smoking status, parity, marital status, and educational level, as stated in the methods section. In the final analysis, only confounding factors that affected the haz...

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Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis

Abstract: Objective To assess the relative risk of perinatal mortality, severe preterm delivery, and low birth weight associated with previous treatment for precursors of cervical cancer. Data sources Medline and Embase citation tracking from

Cited by 622 publications

References 38 publications

Pregnancy outcome after cervical conisation: a retrospective cohort study in the Leuven University Hospital

Pregnancy outcome after cervical conisation: a retrospective cohort study in the Leuven University Hospital

Age Criteria for Cervical Screening in England: Qualitative Study of Women’s Views

Obstetric outcomes and management after cervical conisation for cervical intraepithelial neoplasia

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