International Journal of Gynecology & Obstetrics 71 Ž2000.

237᎐239

Brief communication

Loop electrosurgical excision procedure žLEEP/ during

first trimester of pregnancy

A. Mitsuhashi U , S. Sekiya
Department of Obstetrics and Gynecology, Chiba Uni¨ ersity School of Medicine, Chiba, Japan

Received 22 March 1999; received in revised form 30 August 1999; accepted 1 September 1999

Abstract

Loop electrosurgical excision procedure ŽLEEP. during pregnancy can be performed safely as in non-pregnant
women and can replace traditional cone biopsy when performed in the first trimester. 䊚 2000 International
Federation of Gynecology and Obstetrics. All rights reserved.

Keywords: LEEP; Pregnancy; First trimester

Management of abnormal Papanicolaou smears no adverse effect on subsequent pregnancy out-

during pregnancy has not been established. The
use of cone biopsy during pregnancy has been
performed to reduce the chance of missing the
diagnosis of invasive carcinoma. However, cold
knife cone biopsy during pregnancy is associated
with high complication rates and with high rates
of residual disease even in the first trimester w1,2x.
Loop electrosurgical excision procedure ŽLEEP.
has become the most popular method of treat-
ment for cervical intraepithelial neoplasia ŽCIN..
The advantages of LEEP include its relative low
cost, the ease of technique, high curative rate and
U
Corresponding author. Fax: q81-43-2262122.
come. Recently, the use of LEEP during preg-
nancy was reported w3x. However, its safety and
efficacy during pregnancy is still unknown. We
performed LEEP limited to the first trimester
and evaluated its safety and efficacy.
Nine patients underwent LEEP of the cervix
within the first 14 weeks of pregnancy. Informed
consent was obtained from all patients. All proce-
dures were performed at Chiba University Hospi-
tal. Indication for LEEP during pregnancy was
cervical punch biopsy proven CIN III Žmainly
CIS.. LEEP was performed using a LEEP SYS-
TEM 6000 ŽATOM, Tokyo, Japan. with wire elec-
trodes ranging in size from 20 = 10 mm to 20 = 8
mm in the outpatient unit using local anesthesia,

0020-7292r00r$20.00 䊚 2000 International Federation of Gynecology and Obstetrics. All rights reserved.
PII: S 0 0 2 0 - 7 2 9 2 Ž 9 9 . 0 0 1 7 3 - 3
238 A. Mitsuhashi, S. Sekiya r International Journal of Gynecology & Obstetrics 71 (2000) 237᎐239

under 1% Lidocaine with 1:10 000 epinephrine.
All resections were cauterized with a ball elec-
trode. The height Ždepth. of specimens measured
was from 8.0 to 15.0 mm. The procedure was
performed in an average of 10 min. A cervical
‘tourniquet’ was not used. Furthermore, a prophy-
lactic cervical cerclage was not performed. These
patients were carefully managed until delivery,
and postpartum follow up was performed every 3
months by cytology and colposcopy.
As shown in Table 1, the age of patients ranged
from 29 to 36 years. The gestational age range at
the time of the procedure was 4᎐14 weeks. One
patient with a gestational age of 4 weeks Žcase 2.
was not known to be pregnant at the time of the
procedure. None of the nine patients had sponta-
neous abortion, premature delivery or excessive
bleeding. However, one patient Žcase 9. exhibited
cervical incompetence at 21 gestational weeks.
The cervix was observed to be shortened to 14
mm without uterine contraction. The McDonald
procedure was performed at 28 weeks, and the
patient had a normal vaginal delivery of a healthy
3100-g infant at 38 weeks. Six patients underwent
normal vaginal delivery without any complications
due to LEEP. Two patients delivered by cesarean
section for previous cesarean section Žcase 3. and
breech presentation Žcase 7., respectively. Histo-
logical evaluation of LEEP specimens demon-
strated CIN I in two, CIN III in five and microin-
vasive carcinoma in two patients. Specimen mar-
gins were interpreted as positive in two out of
nine Ž22.2%. patients. For these patients, resid-
ualrrecurrent CIN II-III was identified by cy-
tology within 6 months and repeat LEEP was
carried out. CIN III Žcase 1. and CIN II Žcase 2.
were found in the second cone. All women includ-
ing repeat cone patients were free of disease for
the following 12᎐36 months.
In some series, 1᎐3% of patients with colpos-
copic diagnosis of CIN III were found to have
microinvasive carcinomas in subsequent coniza-
tion or hysterectomy specimens. Coppola et al. w4x
report a higher rate of underestimation of disease
severity by both cytology and colposcopic impres-
sion during pregnancy. A mid-trimester, colpos-
copically directed biopsy is difficult because of
increased vascularity and softening of the cervix,
therefore, expectant management is not sufficient
for accurate evaluation. Although coloposcopic
finding was not indicated microinvasive carci-
noma, no less than two cases were found microin-
vasive in our cases. We suggest that colposcopic
impression is inadequate to evaluate pregnant
women. If possible, in case of CIN III Žmainly
CIS., we recommend that LEEP should be per-
formed during the first trimester. Nevertheless, in
cases of severe dysplasia, we practice expectant
management.
Cold knife cone biopsy offers the best diagnos-
tic accuracy, but it has significant complications
both for the mother and for fetus when per-
formed during pregnancy. Immediate excessive
blood loss has been reported in an average of

Table 1
Results of LEEP in pregnant patients with CIN III a

Case Age Cytology Gestational age Histology of Complication Gestational age Birth Residualr
no. Žyears. at LEEP LEEP at birth weight recurrent
Žweeks. specimen Žweeks. Žmg. disease

1 30 CIN III 13 MIC 37 3080 CIN III

2 28 CIN II 4 CIN III 37 3213 CIN II
3 30 CIN III 8 CIN III 37 2923
4 24 CIN III 9 CIN I 39 3352
5 36 CIN III 10 MIC 39 2840
6 33 CIN III 12 CIN I 39 2740
7 27 CIN III 11 CIN III 38 2419
8 28 CIN II 11 CIN III 36 2890
9 29 MIC susp 12 CIN III Imcompetent cervix 38 3010
a
CIN, cervical intraepithelial neoplasia; MIC, microinvasive carcinoma.
 A. Mitsuhashi, S. Sekiya r International Journal of Gynecology & Obstetrics 71 (2000) 237᎐239
8.9% Ž5.2᎐13.9%. of cases w1x. Spontaneous abor-
tion even in first-trimester conization has been
reported to occur at a rate of up to 33%. Some
authors have recommended the second trimester
as the optimal time to perform conization. How-
ever, Hannigan et al. w1x report a higher complica-
tion rate for cone biopsy performed during the
second trimester. Although Robinson et al. w3x
reported that LEEP during pregnancy has no
advantage over traditional cone biopsy, our pre-
sent results indicate that LEEP can be performed
safely, as in cases of non-pregnant women, within
the first trimester of pregnancy. However, whether
LEEP during pregnancy can replace traditional
cone biopsy awaits further investigation.
239
References
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