Management of Cervical Intraepithelial Neoplasia During Pregnancy with LOOP Excision

ABSTRACT & COMMENTARY

Synopsis: LOOP excision of the cervix during pregnancy has similar morbidity to cold knife conization.

Source: Robinson WR, et al. Gynecol Oncol 1997;64:153-155.

The subjects of a recent study by robinson et al include 20 women who underwent colposcopy and cervical biopsy because of an abnormal Pap smear. In all 20, the colposcopically directed biopsy suggested the possible presence of microinvasion. Eighteen of the procedures were performed in the operating room using general or regional anesthesia. Two procedures were inadvertently performed in the Outpatient Clinic in patients not known to be pregnant. The authors used multiple figure-of-eight sutures prior to performing LOOP excision.

No invasive cancers were identified in any of the LOOP specimens. Nineteen of the 20 women had follow-up examinations and invasive cancer was not identified. Five patients had significant complications, including three cases of premature onset of labor and two cases of hemorrhage. One of the patients who hemorrhaged experienced an intrauterine fetal demise.

The authors conclude that LOOP excision has no advantages over cold knife conization of the cervix in pregnancy and should be used only in the rarest of situations, as should cold knife cone.

COMMENT BY KENNETH L. NOLLER, MD

I have been waiting for a study to be published about the use of LOOP electroexcision during pregnancy. Although the need for any type of conization of the cervix in pregnancy is (and should be) extremely rare, I was certain that someone would attempt a few and report them. Therefore, I read this paper with eager anticipation.

First, the study sample really should only be 18 cases instead of 20. Two of the patients had inadvertent LOOP excisions in the office for diagnosis, and thus did not meet the study criteria since there was no biopsy suggesting the presence of invasive cancer prior to the procedure. These patients had no particular problems and delivered at term. I was somewhat surprised that, apparently, routine screening for pregnancy is not performed on the day a LOOP excision procedure is performed in the authors’ clinic.

The remaining 18 patients were managed in the operating room. While Robinson et al found no reason to recommend LOOP excision over cold knife cone, they also did not document any reason why it could not be performed. The complication rates were virtually identical to those reported in the literature with cold knife conization. It is worrisome that none of these patients had invasive cancer despite colposcopically directed biopsies suggesting cancer.

I have performed LOOP excision on two pregnant patients so far. The first was a patient who was only seven weeks pregnant. Although we routinely perform pregnancy tests a few minutes prior to LOOP excision, I strongly suspected that this patient was pregnant and purposely did not wait for the results of the pregnancy test since we had been trying to get her in for her procedure for more than two years. I know that if I had waited for the test result, the clinic manager would have told me that I couldn’t do the procedure. I crossed by fingers and, luckily, nothing happened.

The second patient was in her early second trimester. A biopsy had suggested the almost certain possibility of invasive cervical cancer in a small area. Therefore, I took her to the operating room, where we placed two large-bore IVs, but gave her no anesthesia except local. I performed LOOP excision as we would in the clinic. However, I only removed one quadrant just as we usually only remove a "wedge" of cervix when a cold knife cone is done in pregnancy. I must have had 10,000 instruments on the back table ready to perform all sorts of emergency hemostatic procedures. Fortunately for the patient, she bled only about six drops. We watched her closely for about two hours in the recovery room before she went home. While it certainly is not a good idea to extrapolate from this small experience, it does appear that it might be possible to perform a wedge resection in pregnant patients without general anesthesia. At the present time, I would not consider doing these procedures anywhere except in the operating room.