宫颈锥切术对生育能力及妊娠结局影响的研究进展

doi:10.12280/gjfckx.20210280

摘要/Abstract

摘要：

宫颈鳞状上皮内病变（squamous intraepithelial lesion,SIL）与宫颈癌的发生密切相关,近年来发病率逐渐升高且呈年轻化趋势,宫颈锥切术作为宫颈高级别鳞状上皮内病变（HSIL）患者的首选治疗方法被广泛应用。对于锥切术后有生育要求的患者,宫颈锥切术是否对妊娠产生影响目前尚不明确,现有的多数研究认为,宫颈锥切术不会显著影响生育能力,但可能增加早产、流产、胎膜早破和围生期死亡等不良妊娠结局的发生率,不会明显影响产程进展或增加剖宫产率;宫颈环形电刀锥切术（loop electrosurgical excisional procedure,LEEP）术后妊娠结局优于宫颈冷刀锥切术（cold-knife conization,CKC）,锥切术后应至少避孕6个月;锥切的深度和体积增加可增加不良妊娠结局的发生率;锥切术后患者不是必须行预防性宫颈环扎术。对于有生育要求的锥切术患者,应注意术后随诊,根据术中及术后恢复情况,个体化指导受孕,妊娠期严密监测宫颈长度及阴道感染情况,积极鼓励无阴道分娩禁忌患者行阴道试产。

关键词: 宫颈疾病, 锥形切除术, 生育力, 妊娠结局, 治疗

Abstract:

Cervical squamous intraepithelial lesion (SIL) is closely related to the occurrence of cervical cancer. In recent years, the incidence of cervical SIL is gradually increasing and showing a younger trend. Cervical conization is widely used as the first choice for the treatment of cervical high-grade squamous intraepithelial(HSIL) patients. For patients with fertility requirements after conization, most existing studies believe that cervical conization does not affect their fertility, but may increase the incidence of adverse pregnancy outcomes such as preterm delivery, abortion, premature rupture of membranes and perinatal death, and will not significantly affect the progress of labor or increase the rate of cesarean section. The pregnancy outcome after LEEP is better than that of CKC, and contraception should be given at least 6 months after conization. The increase of depth and volume of conization can increase the incidence of adverse pregnancy outcome, and prophylactic cervical ligation is not necessary after conization. For patients with fertility requirements, we should pay attention to postoperative follow-up, individually guide pregnancy according to intraoperative and postoperative recovery, closely monitor cervical length and vaginal infection during pregnancy, and actively encourage patients without vaginal delivery contraindications to carry out vaginal trial delivery.

Key words: Uterine cervical diseases, Conization, Fertility, Pregnancy outcome, Therapy

高悦, 王化丽. 宫颈锥切术对生育能力及妊娠结局影响的研究进展[J]. 国际妇产科学杂志, 2021, 48(6): 660-665.

GAO Yue, WANG Hua-li. Research Progress on the Effect of Cervical Conization on Fertility and Pregnancy Outcomes[J]. Journal of International Obstetrics and Gynecology, 2021, 48(6): 660-665.

参考文献 40

[1]	张韶凯, 赵方辉, 乔友林. 中国宫颈癌防治研究20年历程与成就[J]. 中华流行病学杂志, 2020,41(6):809-812. doi: 10.3760/cma.j.cn112338-20191203-00849. doi: 10.3760/cma.j.cn112338-20191203-00849
[2]	Darragh TM. The LAST Project and the diagnostic bottom line[J]. Cytopathology, 2015,26(6):343-345. doi: 10.1111/cyt.12299. doi: 10.1111/cyt.12299 pmid: 26767600
[3]	Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors[J]. J Low Genit Tract Dis, 2020,24(2):102-131. doi: 10.1097/LGT.0000000000000525. doi: 10.1097/LGT.0000000000000525
[4]	Wise LA, Willis SK, Perkins RB, et al. A prospective study of treatments for cervical intraepithelial neoplasia and fecundability[J]. Am J Obstet Gynecol, 2020,223(1):96.e1-96.e15. doi: 10.1016/j.ajog.2019.12.017. doi: 10.1016/j.ajog.2019.12.017
[5]	Jakobsson M, Gissler M, Tiitinen A, et al. Treatment for cervical intraepithelial neoplasia and subsequent IVF deliveries[J]. Hum Reprod, 2008,23(10):2252-2255. doi: 10.1093/humrep/den271. doi: 10.1093/humrep/den271
[6]	Ding L, Li M, Yan L, et al. Effect of cervical conization on pregnancy outcome of in-vitro fertilization/intracytoplasmic sperm injection treatment: a retrospective cohort study[J]. Clin Exp Obstet Gynecol, 2016,43(4):546-549.
[7]	Kalliala I, Anttila A, Nieminen P, et al. Pregnancy incidence and outcome before and after cervical intraepithelial neoplasia: a retrospective cohort study[J]. Cancer Med, 2014,3(6):1512-1516. doi: 10.1002/cam4.300. doi: 10.1002/cam4.300
[8]	Kyrgiou M, Mitra A, Arbyn M, et al. Fertility and early pregnancy outcomes after conservative treatment for cervical intraepithelial neoplasia[J]. Cochrane Database Syst Rev, 2015,2015(9):CD008478. doi: 10.1002/14651858.CD008478.pub2. doi: 10.1002/14651858.CD008478.pub2
[9]	陈兢思, 陈敦金. 宫颈锥切术对生育的影响[J]. 实用妇产科杂志, 2009,25(7):395-396. doi: 10.3969/j.issn.1003-6946.2009.07.007. doi: 10.3969/j.issn.1003-6946.2009.07.007
[10]	Jar-Allah T, Kärrberg C, Wiik J, et al. Abnormal cervical cytology is associated with preterm delivery: A population based study[J]. Acta Obstet Gynecol Scand, 2019,98(6):777-786. doi: 10.1111/aogs.13543. doi: 10.1111/aogs.13543
[11]	Sparić R, Papoutsis D, Kadija S, et al. Psychosexual outcomes in women of reproductive age at more than two-years from excisional cervical treatment-a cross-sectional study[J]. J Psychosom Obstet Gynaecol, 2019,40(2):128-137. doi: 10.1080/0167482X.2018.1445220. doi: 10.1080/0167482X.2018.1445220
[12]	Monti M, D′Aniello D, Scopelliti A, et al. Relationship between cervical excisional treatment for cervical intraepithelial neoplasia and obstetrical outcome[J]. Minerva Obstet Gynecol, 2021,73(2):233-246. doi: 10.23736/S0026-4784.20.04678-X. doi: 10.23736/S0026-4784.20.04678-X
[13]	Maina G, Ribaldone R, Danese S, et al. Obstetric outcomes in patients who have undergone excisional treatment for high-grade cervical squamous intra-epithelial neoplasia[J]. Eur J Obstet Gynecol Reprod Biol, 2019,236:210-213. doi: 10.1016/j.ejogrb.2019.02.025. doi: 10.1016/j.ejogrb.2019.02.025
[14]	Miyakoshi K, Itakura A, Abe T, et al. Risk of preterm birth after the excisional surgery for cervical lesions: a propensity-score matching study in Japan[J]. J Matern Fetal Neonatal Med, 2021,34(6):845-851. doi: 10.1080/14767058.2019.1619687. doi: 10.1080/14767058.2019.1619687
[15]	van de Vijver A, Poppe W, Verguts J, et al. Pregnancy outcome after cervical conisation: a retrospective cohort study in the Leuven University Hospital[J]. BJOG, 2010,117(3):268-273. doi: 10.1111/j.1471-0528.2009.02437.x. doi: 10.1111/j.1471-0528.2009.02437.x
[16]	Frega A, Santomauro M, Sesti F, et al. Preterm birth after loop electrosurgical excision procedure (LEEP): how cone features and microbiota could influence the pregnancy outcome[J]. Eur Rev Med Pharmacol Sci, 2018,22(20):7039-7044. doi: 10.26355/eurrev_201810_16176. doi: 10.26355/eurrev_201810_16176
[17]	Zhuang H, Hong S, Zheng L, et al. Effects of cervical conisation on pregnancy outcome: a meta-analysis[J]. J Obstet Gynaecol, 2019,39(1):74-81. doi: 10.1080/01443615.2018.1463206. doi: 10.1080/01443615.2018.1463206
[18]	Guo HJ, Guo RX, Liu YL. Effects of loop electrosurgical excision procedure or cold knife conization on pregnancy outcomes[J]. Eur J Gynaecol Oncol, 2013,34(1):79-82. pmid: 23590007
[19]	Liu Y, Qiu HF, Tang Y, et al. Pregnancy outcome after the treatment of loop electrosurgical excision procedure or cold-knife conization for cervical intraepithelial neoplasia[J]. Gynecol Obstet Invest, 2014,77(4):240-244. doi: 10.1159/000360538. doi: 10.1159/000360538
[20]	Jiang YM, Chen CX, Li L. Meta-analysis of cold-knife conization versus loop electrosurgical excision procedure for cervical intraepithelial neoplasia[J]. Onco Targets Ther, 2016,9:3907-3915. doi: 10.2147/OTT.S108832. doi: 10.2147/OTT.S108832
[21]	El-Nashar SA, Shazly SA, Hopkins MR, et al. Loop Electrosurgical Excision Procedure Instead of Cold-Knife Conization for Cervical Intraepithelial Neoplasia in Women With Unsatisfactory Colposcopic Examinations: A Systematic Review and Meta-Analysis[J]. J Low Genit Tract Dis, 2017,21(2):129-136. doi: 10.1097/LGT.0000000000000287. doi: 10.1097/LGT.0000000000000287
[22]	Kyrgiou M, Athanasiou A, Paraskevaidi M, et al. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis[J]. BMJ, 2016,354:i3633. doi: 10.1136/bmj.i3633. doi: 10.1136/bmj.i3633
[23]	Biliatis I. Pregnancy outcomes after treatment for preinvasive cervical lesions[J]. BMJ, 2016,354:i4027. doi: 10.1136/bmj.i4027. doi: 10.1136/bmj.i4027
[24]	Liverani CA, Di Giuseppe J, Clemente N, et al. Length but not transverse diameter of the excision specimen for high-grade cervical intraepithelial neoplasia (CIN 2-3) is a predictor of pregnancy outcome[J]. Eur J Cancer Prev, 2016,25(5):416-422. doi: 10.1097/CEJ.0000000000000196. doi: 10.1097/CEJ.0000000000000196 pmid: 26317385
[25]	Sozen H, Namazov A, Cakir S, et al. Pregnancy outcomes after cold knife conization related to excised cone dimensions. A retrospective cohort study[J]. J Reprod Med, 2014,59(1/2):81-86.
[26]	Zebitay AG, Güngör ES, Ilhan G, et al. Cervical Conization and the Risk of Preterm Birth: A Population-Based Multicentric Trial of Turkish Cohort[J]. J Clin Diagn Res, 2017,11(3):QC21-QC24. doi: 10.7860/JCDR/2017/22996.9495. doi: 10.7860/JCDR/2017/22996.9495
[27]	Castanon A, Landy R, Brocklehurst P, et al. Risk of preterm delivery with increasing depth of excision for cervical intraepithelial neoplasia in England: nested case-control study[J]. BMJ, 2014,349:g6223. doi: 10.1136/bmj.g6223. doi: 10.1136/bmj.g6223
[28]	van Velthoven K, Poppe W, Verschuere H, et al. Pregnancy outcome after cervical conisation: A 2nd retrospective cohort study in the Leuven University Hospital[J]. Eur J Obstet Gynecol Reprod Biol, 2017,216:224-231. doi: 10.1016/j.ejogrb.2017.06.043. doi: S0301-2115(17)30320-2 pmid: 28822944
[29]	Conner SN, Cahill AG, Tuuli MG, et al. Interval from loop electrosurgical excision procedure to pregnancy and pregnancy outcomes[J]. Obstet Gynecol, 2013,122(6):1154-1159. doi: 10.1097/01.AOG.0000435454.31850.79. doi: 10.1097/01.AOG.0000435454.31850.79
[30]	Zhang X, Tong J, Ma X, et al. Evaluation of cervical length and optimal timing for pregnancy after cervical conization in patients with cervical intraepithelial neoplasia: A retrospective study[J]. Medicine (Baltimore), 2020,99(49):e23411. doi: 10.1097/MD.0000000000023411. doi: 10.1097/MD.0000000000023411
[31]	Brie C, Turck M, Cheret A, et al. Case-control study of obstetrical outcomes of conisation. J Gynecol Obstet Biol Reprod (Paris), 2016,45(2):192-197. doi: 10.1016/j.jgyn.2015.07.005. doi: 10.1016/j.jgyn.2015.07.005
[32]	Champer M, Wong AM, Champer J, et al. The role of the vaginal microbiome in gynaecological cancer[J]. BJOG, 2018,125(3):309-315. doi: 10.1111/1471-0528.14631 doi: 10.1111/1471-0528.14631
[33]	Ortoft G, Henriksen T, Hansen E, et al. After conisation of the cervix, the perinatal mortality as a result of preterm delivery increases in subsequent pregnancy[J]. BJOG, 2010,117(3):258-267. doi: 10.1111/j.1471-0528.2009.02438.x. doi: 10.1111/j.1471-0528.2009.02438.x
[34]	孟然, 戚红. 宫颈锥切术后妊娠结局临床分析[J]. 中国实用妇科与产科杂志, 2012,28(7):524-526.
[35]	Jin G, LanLan Z, Li C, et al. Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis[J]. Arch Gynecol Obstet, 2014,289(1):85-99. doi: 10.1007/s00404-013-2955-0. doi: 10.1007/s00404-013-2955-0
[36]	Kyrgiou M, Athanasiou A, Kalliala I, et al. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease[J]. Cochrane Database Syst Rev, 2017,11(11):CD012847. doi: 10.1002/14651858.CD012847. doi: 10.1002/14651858.CD012847
[37]	Lee SM, Jun JK. Prediction and prevention of preterm birth after cervical conization[J]. J Gynecol Oncol, 2010,21(4):207-208. doi: 10.3802/jgo.2010.21.4.207. doi: 10.3802/jgo.2010.21.4.207
[38]	Kliemann LM, Silva M, Reinheimer M, et al. Minimal cold knife conization height for high-grade cervical squamous intraepithelial lesion treatment[J]. Eur J Obstet Gynecol Reprod Biol, 2012,165(2):342-346. doi: 10.1016/j.ejogrb.2012.08.016. doi: 10.1016/j.ejogrb.2012.08.016 pmid: 22948133
[39]	Wang T, Jiang R, Yao Y, et al. Can prophylactic transvaginal cervical cerclage improve pregnancy outcome in patients receiving cervical conization? A meta-analysis[J]. Ginekol Pol, 2021,92(10):704-713. doi: 10.5603/GP.a2021.0020. doi: 10.5603/GP.a2021.0020
[40]	Cho GJ, Ouh YT, Kim LY, et al. Cerclage is associated with the increased risk of preterm birth in women who had cervical conization[J]. BMC Pregnancy Childbirth, 2018,18(1):277. doi: 10.1186/s12884-018-1765-6. doi: 10.1186/s12884-018-1765-6