23 feb. 2011 ACTIVE ULTRASOUND PREGNANCY MANAGEMENT AFTER CERVICAL SURGERY
M. Munteanu*,**, Monica Cara*,****, D. Iliescu*,**, Stefania Tudorache*,**,
Florentina Tănase*,**, Smărăndiţa Cotarcea***, N. Cernea*,**
* University of Medicine and Pharmacy, Craiova, Romania
** Emergency University Hospital Craiova, Romania
*** “Filantropia” Hospital Craiova
**** University of Medicine and Pharmacy, Craiova, Romania, Public Health Department
Rezumat
Managementul leziunilor intraepiteliale scuamoase de risc înalt (HSIL) la pacientele tinere, în plină perioadă fertilă, reprezintă o mare provocare pentru clinician, deoarece ridică problema prezervării prognosticului obstetrical. Monitorizarea şi managementul sarcinii în cadrul acestui grup de paciente au ca scop principal scăderea incidenţei naşterii premature, şi în consecină îmbunătăţirea prognosticului neonatal.
În cadrul studiului am propus un management activ, prin măsurarea ecografică transvaginală a lungimii canalului cervical (CL) în trimestrul al II-lea şi clasificarea cazurilor după lungimea colului: col scurt (sub 25 mm), col mediu scurtat (25-30 mm), col lung (peste 30 mm). La cazurile cu CL < 25 mm s-a practicat cerclaj şi s-a administrat terapie cu Progesteron, iar la cazurile cu CL >30 mm am optat pentru expectativă şi supraveghere. La o parte din pacientele cu CL între 25-30 mm s-a administrat, la prescrierea medicului curant, terapie cu Progesteron.
Prognosticul acestor paciente a fost comparat cu cel al unui grup de control, studiat retrospectiv, la care managementul sarcinii s-a făcut pe criterii clinice.
Datele obţinute nu au putut demonstra îmbunătăţirea prognosticului obstetrical în cazul pacientelor care prezintă scurtarea moderată a canalului cervical (25-30 mm) dacă este administrat progesteron, dar demonstrează creşterea VG la naştere în grupul pacientelor care dezvoltă col scurt, în cazul în care se practică atât hormonoterapie, cât şi cerclaj.
Abstract – Active ultrasound pregnancy management after cervical surgery
Management of HSIL in young fertile patients has a major importance for clinicians because it is important to preserve their obstetrical outcome. Management of pregnancies in patients who underwent cervical surgery, and especially conization is a challenge, in order to reduce the percentage of premature birth and to improve neonatal outcome.
We proposed an active management of the pregnancy by TVUS-CL in the second trimester. We classified the cervix as long (>30mm), mild short (25- 30mm), and short (< 25 mm). If the cervix was less than 25 mm we decided therapy (progesterone and cerclage) and if was more than 30mm we decided expectative. Progesterone alone was recommended at the physician's convenience if CL was between 25 to 30mm.
The control group was represented by a matched group of patients that were retrospectively assessed from the registries from the two hospitals, and who had a clinic signs based pregnancy management.
Our limited data could not demonstrate that Progesterone alone improves the obstetrical outcome of the patients with prior surgical treatment who developed a moderate shortening of the cervix (25-30 mm) during pregnancy. Cerclage and Progesterone seems a better solution for the patients with a cervical length less than 25 mm. Larger population studies and randomisation are required to confirm our findings.
Keywords: Cervical Intraepithelial Neoplasia (CIN), High Grade Squamos Intraepithelial Lesion (HSIL), Large Loop Excizion of the Transformation Zone (LLETZ), Cold Knife Conization (CKC), premature birth (PB), preterm premature rupture of the membranes (PPROM), transvaginal ultrasound measurement of the cervix (CL).