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

Vijver, Arne van de; Poppe, Willy; Verguts, Jasper; Arbyn, Marc

doi:10.1111/j.1471-0528.2009.02437.x

Cited by 38 publications

(40 citation statements)

References 24 publications

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“…[8][9][10] However, recent studies have reported that conization can lead to impaired outcomes of pregnancy. [11][12][13] The incidence of preterm deliveries following conization varies in recent publications between 14 and 25%. 11,12 These conflicting findings might be explained by differences in the study period population, and operative techniques such as instruments used for conization, depth, width and volume of the removed cones.…”

Section: Discussionmentioning

confidence: 99%

“…[11][12][13] The incidence of preterm deliveries following conization varies in recent publications between 14 and 25%. 11,12 These conflicting findings might be explained by differences in the study period population, and operative techniques such as instruments used for conization, depth, width and volume of the removed cones. Leiman et al 14 found that the risk of premature delivery and late spontaneous abortion increased in direct proportion to the cone size.…”

Section: Discussionmentioning

confidence: 99%

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The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

et al. 2010

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Objective: To evaluate pregnancy outcomes after electrosurgical conization. Methods: We retrospectively analyzed the outcomes of 56 singleton pregnancies after electrosurgical conization of the uterine cervix. Of the 56 cases, 25 women underwent prophylactic cerclage with McDonald procedure (cerclage group), and 31 were managed expectantly (expectant group). Pregnancy outcomes including rate of preterm delivery were compared, and the effect of potential risk factors such as depth of cone, interval between conization and pregnancy, and cervical length on the risk of preterm delivery was assessed. Results: The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization than those without (32.1% vs. 15.2%, p＜0.001). However, preterm delivery rate was not different between the two groups (expectant group vs. cerclage group; ＜28 week, 6.5% vs. 8.0%, p=1.000; ＜34 week, 19.4% vs. 20.0%, p=1.000; ＜37 week, 29.0% vs. 36.0%, p=0.579). All obstetric and neonatal outcomes were similar in the two groups. Even when we confined the study subjects to 19 women (19/56, 33.9%) with cervical length less than 25 mm, the preterm delivery rate also was not significantly different between the expectant (n=7) and cerclage group (n=12). Finally, the potential risk factors for preterm delivery were not associated with risk of preterm delivery in patients with a history of electrosurgical conization. Conclusion:The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization before pregnancy. However, prophylactic cervical cerclage did not prevent preterm delivery in these patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

et al. 2010

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“…Treatment of CIN is associated with a small but real increase in risk of pregnancyrelated morbidity, such as premature delivery (<37 weeks), low birthweight (<2,500 g) and preterm prelabour rupture of membranes. [25][26][27] These disadvantages must be weighed against the advantages of the extra cervical cancer cases that are potentially preventable using a more sensitive screen test.…”

Section: Discussionmentioning

confidence: 99%

How many cervical cancer cases can potentially be prevented using a more sensitive screening test at young age?

Kok

Rosmalen

Rozemeijer

et al. 2013

Intl Journal of Cancer

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The human papilloma virus (HPV) DNA test has higher sensitivity than cytology for cervical cancer screening. Therefore, cervical cancer cases that are missed by cytology could potentially be identified if we use primary HPV testing. Studies showed that HPV screening is the preferred primary test at age 35 and over. Given the high prevalence of harmless HPV infections, the use of HPV testing at younger age is less obvious. The number of cancers in young age is often mentioned to indicate the possible benefits of a more sensitive test. We actually estimated the proportion of those cases that is potentially preventable in The Netherlands by the use of a more sensitive screen-test at the first screening age 30, given that the more sensitive test is used at age 35 and over. We analysed the screening history of women diagnosed with cervical cancer in the period 2004 to March 2009, using data from the Dutch National Pathology Registry. Only 15-30% (two to four cases per 100,000 women) of the cases was preceded by negative cytology under age 35 and therefore could have been prevented by a more sensitive test at age 30. The lower the screening coverage and the shorter the screening interval in those screened at young age, the smaller the gain of a more sensitive test. So, as long as the current screening pattern is not changed, the majority of the cervical cancer cases at young age would still occur even when applying a more sensitive test at the younger ages.Mass screening for cervical cancer has been operational for women from age 30 years onwards in The Netherlands since 1996.1 Nevertheless, still approximately 700 women are diagnosed with cervical cancer annually in The Netherlands, of which 160 cases in the age group 30-39.2 Some of these cases were diagnosed based on symptoms while unscreened or were detected by their first screening moment.3 In these women, lack of screening test sensitivity did not play a role. However, some cases had screening but tested negative, 3 which might well be due to lack of sensitivity of, in the current situation, cytological screening. Meta-analyses and pooled analyses have established that human papilloma virus (HPV) DNA tests have higher sensitivity than cytology for detecting high grade, clinically relevant, cervical intraepithelial neoplasia (high grade CIN).4,5 Therefore, cervical cancer cases that are missed by cytology could have been identified if we had used primary HPV DNA testing as the primary screening test. Several studies showed that HPV screening is the preferred primary test at age 35 and over.6-12 HPV testing is less specific than cytology because it can detect harmless HPV infections. As these are considerably more prevalent in young women, the net benefits of using HPV testing under age 35 is less obvious. 13,14 Frequent screening at a young age detects many transient infections, cytological and histological abnormalities and every screening round adds to unnecessary triage, overdiagnosis and overtreatment as a consequence. Conversely, the number of life years gai...

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“…In the same issue, Van de Vijver et al 2 further recommend that expectant management of all lesions should be considered in young women.…”

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Preterm birth and previous conisation of the cervix

Ørtoft

Henriksen

et al. 2010

BJOG

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Preterm birth and previous conisation of the cervix Sir, The paper from Ørtoft et al.1 demonstrates a hazard to future pregnancy proportional to the length of cervical canal excised at conisation. In the same issue, Van de Vijver et al. 2 further recommend that expectant management of all lesions should be considered in young women.We question, however, whether these findings are relevant to current UK practice.Measuring histological specimen size is difficult, and the technique of transport in saline, opening and stretching before fixation may result in different dimensions from those that we typically see in our practice.The dimensions of the large loop excision of the transformation zone (LLETZ) specimens described by Ørtoft et al. were mean height of 15.8 ± 4.2 mm and mean ectocervical diameter (D = C/p) of 13.2 ± 2 mm. This suggests a long thin cone with a focus on excising the endocervical canal.The vast majority of our patients undergoing the standard outpatient LLETZ procedure have a visible squamocolumnar junction (SCJ), and therefore excision of the transformation zone is effected by a much shallower excision of the order of 8-12 mm in depth. This would have less effect on future pregnancy, and our advice to patients should take account of this.Finally, if one manages all lesions expectantly in young women, why screen them at all? j Preterm birth and previous conisation of the cervix References Authors' ReplySir, We wish to thank Drs Bamford and Hall for some interesting and very relevant comments. 1 We agree with their statement that a small and shallow LLETZ (large loop excision of the transformation zone) cone biopsy may do little or no harm in relation to preterm delivery. The size of a cone can be difficult to measure, which may account for why different studies show different results. However, our study 2 agrees with many others that there is a positive correlation between the depth of the cone and the risk of subsequent preterm delivery, and we think this agreement is unlikely to have occurred by chance. It therefore seems logical that the clinician should try to avoid a deep cone when this can be done without putting women at risk for cervical cancer. Bamford and Hall also speculate that the depth of the cone biopsies in our study was greater than is usual in UK practice. The decision to make a deep or shallow biopsy is related to the colposcopic findings-particularly the location of the transformation zone, the severity of the dysplasia and the histology-as for example with adenocarcinoma in situ. In our study the indications for cone biopsy were cervical intraepithelial neoplasia, stage 3 (CIN3) for 89% of cases and, CIN1 or 2 in only 11% of the women. Only lesions located in a visible transformation zone were treated conservatively. The severity of the lesions seen in our practice may have caused us to make wider and deeper cones, and thereby created a higher risk of preterm delivery. However, this risk is likely to represent a continuum rather than be 'all or nothing'. The fact that we r...

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

Cited by 38 publications

References 24 publications

The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

How many cervical cancer cases can potentially be prevented using a more sensitive screening test at young age?

Preterm birth and previous conisation of the cervix

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