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Cervical Procedures and Subsequent Pregnancy Outcomes
Transcript of Cervical Procedures and Subsequent Pregnancy Outcomes
Subsequent Pregnancy Outcomes Andriana Perrachon Treatment and Preterm Birth Cervical Stenosis Definition of Cervical Stensosis LEEP and Cervical Stenosis Scar Tissue CIN and PTD Preterm Birth Depth of Removed Tissue Treatment Options Rates of Cervical Procedures CIN and Cervical Anatomy Research Introduction Incidence and mortality from cervical cancer has decreased by 80% due to regular screening.
250,000 women diagnosed with precancerous lesions every year in the US.
Over-treatment of cervical lesions that will most likely regress without treatment.
50% of women who undergo regular pap screening were submitted to additional diagnostic testing, and 5% were treated for low-grade squamous intraepithelial lesions (LSIL), which often regresses on its own without treatment Research focuses primarily on:
However, research also addresses P-PROM and LBW infants Presentation will focus primarily on loop electrosurgical excision procedure (LEEP) because it is the most popular in the US. Most popular because:
Provides a tissue sample for pathology
Often used as both diagnosis and treatment, which eliminates the loss of 25% of patients who would not come back after a biopsy.
Other treatment options include cold knife conization, cryotherapy, and cone biospy. These other treatments are mentioned less in the research literature. Noehr et al also published a study looking specifically at the depth of tissue removed and the risk of PTD. They found that there was a 6% increase in risk with each millimeter of tissue removed.
Kyrgiou et al's meta-analysis and also evaluated the depth of tissue removed. They found that the risk significantly increased if 10mm or more of tissue was excised. The normal depth of tissue removed is 7 to 8 mm. Bruinsma in 2007 found not only an increased rate of PTD among women treated for CIN, but also among women who had untreated CIN.
Rates of PTD: Control group: 6.2%
Untreated CIN: 9.5%
Treated CIN: 11.5%.
This implies that CIN itself is a factor in the increased risk of PTD, however treated CIN still had a higher rate of PTD.
Another study (Shanbhag) supported the finding that CIN 3 is a risk factor for PTD.
Risk for PTD was 12% compared to the 7% of the general population. However, this study found that treated CIN 3 yielded the same risk as women who never had CIN 3. Cervical stenosis has multiple definitions in the research literature.
Basic definition: Partial or complete obstruction of the cervical canal.
But most of the research has more specific definitions such as "inability to pass a cytobrush through the external cervical os…requirement of dilation with a 2.5mm Hegar dilator, inability to pass a 3-mm endocervical curette, and finally, inability to pass a 4-mm cotton swab” (Martirosian, 2010, p. 2) Some definitions of cervical stenosis can be broad enough to include the formation of scar tissue, however most definitions included in the research literature are specific and cannot be interpreted to include scar tissue.
There is anecdotal evidence of how scar tissue after a LEEP or other cervical procedure can affect labor progession. Midwifery Managment Cervical Length Screening: Included in Management? Recommendations for Midwives Conclusion and Questions Fischer in 2010. Study size: 85 women
Mean cervical length in women with a previous LEEP or cone biopsy was shorter than in women without a history of the procedure.
Everyone delivered at or near term with no complications. Since there were no mid-trimester losses or PTD before 34 weeks the authors do not recommend routine screening of cervical length.
Crane in 2003. Study size: 276 women
Concluded that a cervical length of less than 3cm in the LEEP treatment group is a good predictor of birth before 37 weeks and therefore transvaginal ultrasound (TVUS) to measure cervical length can be a good predictor of PTD in women who have had a previous LEEP. Noehr et al Kyrgiou et al Crane et al Werner et al Theories: Why PTD? Summary of Research A number of studies found a correlation between preterm delivery (PTD) and cervical procedures. Here is the summary of the research. Location and year: Denmark, 2009
Studied 8100 women who had a previous LEEP and compared pregnancy outcomes with 500,000 women who did not have a history of a cervical procedure.
Rate of PTD: 6.5% in study group vs. 3.2% in control group
Rates of PTD among women who had a biopsy: 4.2% in study group vs. 3.2% in control group. Meta-analysis in 2006
Rates of PTD: 11% in LEEP group vs. 7% in control group
Found an increased risk for P-PROM: 5% in the study group vs. 3% in control group.
The meta-analysis concluded, “The clinical implications of our findings are that women should be informed of a small risk of pregnancy-related morbidity after excisional treatment for cervical intraepithelial neoplasia” Meta-analysis in 2003
Collective rates of PTD: 12.6% women with previous LEEP vs. 5.4% without.
Found an increased rate of LBW infants, however once the confounding variable of smoking was adjusted for, the increased risk was no longer significant. 2010 study
Did not find any correlation between LEEP and PTD.
Study included 511 women who had a LEEP before the index pregnancy and 842 after the index pregnancy and compared them to 200,000 women without a history of LEEP
The study did not take into account tobacco, alcohol, or drug use, socioeconomic status, or prior history of spontaneous preterm birth.
It seems counterproductive that the researchers would include 842 women who had a LEEP after their current pregnancy. Etiology of increased PTD after cervical procedures is not clear. Proposed theories include:
Decrease in the supportive abilities of the cervix due to removed tissue.
For P-PROM - a shift in natural bacteria flora found in the vagina and cervix.
Change in the function of the naturally occuring immunologic defense mechanism. Research says.... Cervical length screening could provide information on the level of risk a woman with a history of LEEP has for PTD. To screen or not to screen? ACOG does not have a specific practice guideline for women with a previous LEEP and recommendations for cervical length screening.
Medical management of a women with a cervix measured at 2cm or less with no history of spontaneous PTD is vaginal progesterone. Baldauf et al Monteiro et al Cervical intraepithelial neoplasia, or CIN, is precancerous cellular changes and is rated by severity. CIN 2 or 3 are more likely to progress to cervical cancer and usually are treated.
Treatment involves removal or destruction of the affected tissue
CIN occurs in the transformation zone of the cervix and can affect the whole area, therefore the entire transformation zone could potentially be removed with treatment. France, 1996
Defined cervical stenosis as a “cervical narrowing that prevented insertion of a 2.5-mm Hegar dilator”
Found that 1.3 to 5.2% of women develop stenosis after LEEP.
An excision of 20 millimeters or greater was the only significant risk factor for developing cervical stenosis.
Other possible risk factors studied included: age, nulliparity, being postmenopausal, and previous treatment for CIN. Brazil, 2008
Defined cervical stenosis as a “clinically relevant partial or complete obstruction of the cervical canal…that made it impossible to reach the endocervical cells using a cytobrush, guided by colposcopy”
Incidence of cervical stenosis following LEEP was 7.7%, or 3.3 out of 1000 patients a month.
The only risk factor that was statistically significant to predict the risk of developing cervical stenosis was developing a hemorrhagic complication in the immediate pre or postoperative period. The risk became 3.3 times higher Presentation in Labor Strong active labor that seems to be progressing.
Upon vaginal exam there is good effacement but little to no cervical dilation. The cervix feels bumpy and tight.
Protocol is to gently massage the cervix using evening primrose oil to break up the scar tissue. With massage, the cervix immediately dilates to around four centimeters with a lot of bloody show. With more massage, the cervix may even dilate to seven centimeters. Personal Interview with Ellie Daniels There is no research directly discusing cervical scar tissue from a previous cervical procedure Recommendations Prenatal Care Changes Interview with a CPM Once a month screening for asymptomatic bacteriuria
Immediate treatment of any vaginal infections.
Increased nutritional counseling
Routine education about the signs and symptoms of preterm labor and who/when to call.
Counsel about cigarette, drug, and alcohol use during pregnancy.
Check in about personal stress and refer to the appropriate help for stress reduction 1. Request client's medical records if she has a history of a cervical procedure. Note the type of procedure and the depth of the incision site.
2. Perform a vaginal exam early in pregnancy to assess for cervical stenosis. How management changes:
1. Clients begin oral evening primrose oil starting at 37 weeks' to help ripen cervix.
2. Vaginal exams are done more frequently in early labor to assess for cervical scar tissue and the need for massage. Knowledge of the research and possible adverse outcomes after a cervical procedure is essential for midwives to provide best care for women affected by CIN and the treatment for this condition. Questions?