Risks of cervical excisional treatment and PPROM

Risks of cervical excisional treatment and PPROM | Image Credit: © Yuriy - © Yuriy - stock.adobe.com.

According to a recent study published in the American Journal of Obstetrics and Gynecology, cervical excisional treatment leads to greater risks of intraamniotic infection, microbial invasion of the amniotic cavity without inflammation, and early-onset neonatal sepsis development in future pregnancies with preterm prelabor rupture of membranes (PPROM).

PPROM presents as amniotic fluid leakage caused by fetal membrane rupture and occurs before 37 weeks of gestational activity. About 2% to 3% of pregnancies are impacted by PPROM, making prevention, prediction, and management important for maternal and neonatal outcomes.

Many PPROM pregnancies are characterized by microbial invasion of the amniotic cavity (MIAC), with an estimated frequency of 23% to 63%. MIAC presence, increased measures of inflammatory mediators in amniotic fluid, and decreased glucose concentration in amniotic fluid may be used to determine PPROM.

Data has indicated an estimated 250% increased risk of PPROM after cervical excisional treatment of cervical intraepithelial neoplasia. However, the association between cervical excisional treatment and mechanisms underlying PPROM development such as intraamniotic infection are unclear.

To determine the association between cervical excisional treatment and mechanisms underlying PPROM development, investigators conducted a retrospective cohort study. Participants included pregnant women with an admission to the Department of Obstetrics and Gynecology of the University Hospital Hradec Králové, Czech Republic.

Women in the hospital between January 2014 and December 2021 were included in the analysis. Eligibility criteria included being aged 18 years or older, having a singleton pregnancy, having PPROM between 24+0 and 36+6 weeks, and undergoing transabdominal amniocentesis.

A first trimester ultrasound was used to determine gestational age. PPROM was diagnosed based on the presence of amniotic fluid in the vaginal fornix, analyzed through sterile speculum examination.

Intraamniotic environment was evaluated in women with PPROM using transabdominal ultrasound-guided amniocentesis at admission. Antibiotics were used to treat PPROM, while 7 days of intravenous clarithromycin were used to treat intraamniotic inflammation.

Most women with PPROM were managed expectantly, but those at over 28 weeks’ gestation were managed actively. Polymerase chain reaction and amniotic fluid samples were gathered and evaluated.

Five investigators independently examined maternal and perinatal medical records of participants for data on cervical excisional treatment history. When history was found, the patients were contacted by phone and writing to obtain permission to collect further information from hospital records.

Pathological reports were consulted to determine cone length after fixation, and neonatal medical records were reviewed by 2 researchers who recorded short-term neonatal morbidity data. MIAC was determined by microorganism presence in amniotic fluid cell cultures, while intraamniotic inflammation was determined by IL-6 of 745 pg/mL or more in amniotic fluid.

There were 765 women with PPROM complications included in the analysis, 26% of which presented with MIAC and 20% with intraamniotic inflammation. A history of cervical excisional treatment was reported in 10% of women, of which 79% had a loop electrosurgical excision procedure, 12% a needle excision of the transformation zone, and 9% a cold knife conization.

Higher maternal age, administration of corticosteroids, chronic hypertension rates, and acute histologic chorioamnionitis and funisitis were seen in women with a prior cervical excisional treatment. These women also had lower smoking and chronic hypertension rates, gestational ages at admission and delivery, and birthweights.

In women with a history of cervical excisional treatment, MIAC, intraamniotic infection, MIAC without inflammation, and negative amniotic fluid for infection rates were 50%, 25%, 25%, and 42% respectively. For women without a history of cervical excisional treatment, rates were 23%, 12%, 11%, and 71% respectively.

Higher rates of early-onset neonatal sepsis were also seen in women with a history of cervical excisional treatment. Increased intraamniotic infection was also found in women with a cone length from 3 mm to 8 mm, while those with a cone length from 18 mm to 32 mm had an increased risk of early-onset neonatal sepsis.

Overall, pregnancies with PPROM complications had greater risks of intraamniotic infection, MIAC without inflammation, and early-onset neonatal sepsis in women with a history of cervical excisional treatment. Investigators recommended women with PPROM and a history of cervical excisional treatment undergo cervical microbiota composition assessments.

Reference

Kacerovsky M, Musilova I, Baresova S, et al. Cervical excisional treatment increases the risk of intraamniotic infection in subsequent pregnancy complicated by preterm prelabor rupture of membranes. American Journal of Obstetrics & Gynecology. 2023;229(1). doi:10.1016/j.ajog.2022.12.316