摘要
背景：宫颈锥切(宫颈冷刀锥切术、宫颈环形电切术、激光电切术)是治疗宫颈上皮内瘤变的主要方法,随着宫颈上皮内瘤变(cervical intraepithelial neoplasia, CIN)病例的年轻化和有生育要求的患者的增多,治疗后对生育及妊娠结局的影响受到患者及临床医生的关注。
目的：评价宫颈锥切治疗宫颈上皮内瘤变对妊娠结局的影响。
材料及方法：
1.检索策略：计算机检索PUBMED数据库、MEDLINE数据库、ELSEVIER电子期刊全文数据库、中国科技期刊数据库(CNKI)、中国生物医学文献检索库(CBMdisc)、万方数据资源系统等数据库公开发表的全文文献。
2.纳入及排除标准：
纳入标准：(1)病例-对照研究的全文文献；
(2)文献中提供了相关完整原始数据；
(3)病例组为宫颈上皮内瘤变患者行宫颈环形电切术(loop electrosurgical excisional procedure, LEEP)、宫颈冷刀锥切(cold knife conisation,CKC)、激光电切术(laser conisation, LC)治疗后的妊娠情况；
(4)对照组为至少包括同期两个配对因素(年龄或分娩时期或产次)等的未行锥切治疗的妇女；
排除标准：(1)研究中无未行宫颈锥切治疗的对照组；
(2)研究中包含有2种及以上的宫颈锥切治疗方法,未单独列出妊娠结局的原始数据；
(3)病例组为妊娠期间行宫颈锥切治疗的患者；
(4)宫颈锥切治疗后妊娠期间行宫颈环扎术；
3.妊娠相关指标：包括受孕情况和妊娠结局两方面
受孕情况：受孕率,受孕次数和治疗—受孕时间.
妊娠结局：(1)孕妇方面：早产(孕周<37周),剖宫产率,急产(<2小时)和胎膜早破(pPROM).
(2)胎儿方面：低体重儿(<2500 g),围产期死亡率,新生儿监护室入住情况.
4.数据分析及统计学方法：由作者独立进行资料筛查及质量评估。采用由Cochrane Collaboration提供的RevMan 4.2统计软件进行Meta分析。对原始数据计算加权后合并优势比(RR)以及它们的95%可信区间(95%CI)进行同质性检验,X2检验P>0.05,则具有同质性,选择固定效应模式经行计算分析,若P<0.05,则各研究组为异质性,用随机效应模型进行分析。
结果：
1.本研究共纳入20个病例-对照研究。
2.纳入研究特征：20个研究共计2810例患者,3364例对照者。均报道了至随访终点病例组及对照组妊娠结局的情况。
结论：LEEP术后和LC术后对早产、低体重儿、胎膜早破、围产期新生儿死亡发生相关,增加上述妊娠结局的发生风险,但均无证据证明与剖宫产发生相关,并不增加剖宫产的发生风险,不是剖宫产发生的高危因素；CKC术后对早产、剖宫产发生相关,对剖宫产的发生风险较高,术后妊娠患者应加强随访,可作为剖宫产发生的高危因素；LEEP术后对妊娠结局的影响小于CKC和LC术后,其发生不良影响危险度低于CKC和LC,是相对安全的一种治疗方法。
Background:With the growth numbers of cervical intraepithelial neoplasia(CIN), conisation methods such as cold knife conisation(CKC)、loop electrosurgical excisional procedure(LEEP) and laser conisation(LC) are commonly used especially in young women because of the requirment of pregnancy in the further. The effect of these procedures on subsequent fertility and pregnancy outcomes has been paid high attention to medical practitioners。
Objective:To investigated the effect of these procedures on subsequent fertility and pregnancy outcomes.
Materials and Methods:
1. Search strategy:We searched electronic databases PUBMED、MEDLINE、ELSEVIER、China National Knowledge infrastructure、CBMdise and reference lists of articles and Wan fang data base and targeted reports published between 1979 and 2009.
2. Selection criteria:
Inclusion criteria:
(1) Studies published of case-contorl trials with full text.
(2) The test had been provided the integrated original data.
(3) The case group with obstetric outcomes with a previous conisation intervention(cold knife conisation, LEEP, laser conisation) on the cervix.
(4) The contorl group was match for at least two factors (age, parity) without a conisation methods.
Exclusion criteria:
(1) Studies without an untreated control group.
(2) Studies including different treatment methods were also excluded, if the outcomes for each treatment method were not reported separately.
(3) Studies of treatment undertaken during pregnancy.
(4) Studies undertaken cervical cerclage during pregnancy after conservative methods.
3. Types of outcome measures:The studied were related both to fertility and pregnancy outcome.
Fertility outcomes:included conception rates, number of pregnancies, and time to conception.
The pregnancy outcomes:
(1) Maternal outcomes:preterm delivery (<37 weeks), caesarean section rates, precipitous labour (<2 h), and preterm spontaneous rupture of membranes (pPROM).
(2) Fetal outcomes:low birthweight (<2500 g), perinatal mortality, and neonatal intensive care unit (NICU) admission.
4. Data collection and analysis:
Data extraction and quality assessment was Performed independently by the author. We analysed data by using a random-effects model with Revman 4.2 software. Heterogeneity among studies were calculated after weight Risk ratio(OR) and 95% CIs. If X2 test p value more than 0.05,that is usually taken to indicate asignificant difference for every outcome was assessed by use of a Cochrane Q test.
Main Results:
1. Twenty case-contorl trials were identified and included in this review.
2. The characteristics of inclusive studies:there are 2810 patients and 3346 contorls in all these 20 trials which reported the pregnancy outcome at the end of follow-up.
Conclusion:LEEP and LC was associated with a significant increase in the risk of preterm delivery, low birthweight, premature rupture of the membranes and perinatal mortality, but either of them was not significantly associated with caesarean section; CKC was significantly associated with preterm delivery、caesarean section; caesarean section should be considered as high-risk in subsequent pregnancies and should be given a follow-up; The risk ratio of outcomes of LEEP much lower than CKC and LC, LEEP is much safer than CKC and LC as a method of CIN.
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