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Cervical neoplasia during pregnancy: Diagnosis, management and prognosis

https://doi.org/10.1016/j.bpobgyn.2005.03.002Get rights and content

Pregnancy represents an exceptional opportunity for the early diagnosis of cervical cancer since visual inspection, cytological examination and bimanual palpation are considered to be part of routine antenatal care. An abnormal cervical smear should generally be managed as in the non-pregnant state. However, colposcopy and biopsies are mainly intended to exclude invasive disease because a conservative approach is preferred in cases of pre-invasive disease. The only absolute indication for conization in pregnancy is to rule out (micro-)invasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing or mode of delivery. Overall, earlier stages of cervical cancer are encountered during pregnancy compared with the general population. Although stage of disease and gestational age will largely influence the timing of the interventions, treatment of invasive cervical cancer is similar to the non-pregnant state. In strongly desired pregnancies, the use of neo-adjuvant chemotherapy in order to obtain fetal maturity should be considered and discussed with the patient. Although good evidence supports short-term safety, long-term data regarding the in-utero exposure of cytotoxic drugs need to be consolidated. After stratifying for stage, the outcome is similar to the non-pregnant state.

Section snippets

Diagnosis

Diagnostic evaluation of cervical carcinoma in pregnancy includes clinical and cytological assessment, colposcopy, if necessary with directed biopsy, conization (strict indication) and radiographic imaging.

Signs and symptoms

The presenting signs and symptoms of cervical carcinoma in pregnancy are dependent on the clinical stage at diagnosis and the lesion size. Most patients with FIGO stage I cervical cancer are asymptomatic at the time of diagnosis. Symptomatic patients may present with abnormal vaginal bleeding (mostly postcoital bleeding) or discharge.1, 2 As the symptoms of cervical cancer are not dissimilar to those of an uncomplicated pregnancy, diagnosis is often delayed to some extent. The average duration

The value of cervical cytology in pregnancy

The presence of squamous atypia in a Pap smear taken during pregnancy is significantly associated with cervical intra-epithelial neoplasia (CIN).7 The concordance between cytology and final diagnosis was complete in 55.6% of patients and within one degree of severity in 77.8% of patients, whereas the reliability of cytology did not differ significantly in pregnant and non-pregnant women.14

Although a Pap smear is an effective screening test, it is essential that the cytopathologist is aware of

The value of colposcopy and biopsies in pregnancy

All abnormal smears have to be referred for colposcopic examination. Careful colposcopy excluding micro-invasive or invasive carcinoma allows the gynaecologist to defer definitive therapy to the postpartum period, when the fetal and maternal risks are obviously diminished. On the other hand, delay in diagnosis of an early invasive and potentially curable lesion may result in progression to a point where successful treatment is no longer possible.

Colposcopic arguments for malignancy are based on

Cervical premalignancy during pregnancy

In cases with a well-visualised and identified CIN (on cytology, colposcopy and biopsy), the lesion can be observed every 6–8 weeks using cytology and colposcopy. Additional directed biopsies are rarely required, only if progression to suspected invasive disease is found on colposcopy. Eight weeks post partum, patients are re-evaluated either by cytology, colposcopy and histology for a final diagnosis with immediate treatment (ablation or excision) if the diagnosis is confirmed (two-step

Cervical intra-epithelial neoplasia

Data on the spontaneous evolution of an intra-epithelial neoplasia during pregnancy are relatively diverse. Studies report that 10–70% of dysplasia cases diagnosed during pregnancy regress and sometimes even disappear post partum5, 8, 9, 14, 20, 23, 80, persistence in the severity of cervical neoplasia is reported in 25–47% of cases5, 8, 20 and progression occurs in 3–30% of cases.5, 14, 20, 23 These figures support an adequate follow-up and definitive management in the postpartum period.5

Conclusion

Abnormal cervical smears found in pregnant women should generally be treated as in the non-pregnant state. Colposcopy mainly intends to exclude invasive disease since a conservative approach is preferred in cases of pre-invasive disease. The only absolute indication for conization in pregnancy is to confirm or rule out (micro-)invasive disease when such a diagnosis will alter the timing or mode of delivery. Pregnancy complicated by cervical cancer rarely occurs. A multidisciplinary approach is

References (87)

  • J.A. Nisker et al.

    cervical carcinoma and pregnancy: report of 49 cases

    Am J Obstet Gynecol

    (1983)
  • R.C. Dudan et al.

    Carcinoma of the cervix and pregnancy

    Gynecol Oncol

    (1973)
  • K.A. Prem et al.

    Carcinoma of the cervix associated with pregnancy

    Am J Obstet Gynecol

    (1966)
  • B.E. Greer et al.

    Fetal and maternal considerations in the management of stage Ib cervical cancer during pregnancy

    Gynecol Oncol

    (1989)
  • M. Takushi et al.

    Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment

    Gynecol Oncol

    (2002)
  • W. van Vliet et al.

    Cervical carcinoma during pregnancy: outcome of planned delay in treatment

    Eur J Obstet Gynecol Reprod Biol

    (1998)
  • J.A. Hurteau et al.

    Villoglandular adenocarcinoma of the cervix: a case report

    Obstet Gynecol

    (1995)
  • S. Inoue et al.

    A case of clear cell adenocarcinoma of the uterine cervix in pregnancy

    Gynecol Oncol

    (1986)
  • A. Duenas-Gonzalez et al.

    Modern management of locally advanced cervical carcinoma

    Cancer Treat Rev

    (2003)
  • J.A. Green et al.

    Survival and recurrence after concomitant chemotherapy and radiotherapy for cancer of the uterine cervix: a systematic review and meta-analysis

    Lancet

    (2001)
  • E. Cardonick et al.

    Use of chemotherapy during human pregnancy

    Lancet Oncol

    (2004)
  • T.E. Buekers et al.

    Chemotherapy in pregnancy

    Obstet Gynecol Clin N Am

    (1998)
  • P. Kopf-Maier

    Stage of pregnancy-dependent transplacental passage of 195mPt after cisplatinum treatment

    Eur J Cancer Clin Oncol

    (1983)
  • A.J. Jacobs et al.

    Oat cell carcinoma of the uterine cervix in a pregnant woman treated with cis-diamminedichloroplatinum

    Gynecol Oncol

    (1980)
  • C.E. Henderson et al.

    Platinum chemotherapy during pregnancy for serous cystadenocarcinoma of the ovary

    Gynecol Oncol

    (1993)
  • F. Peccatori et al.

    Chemotherapy during pregnancy: what is really safe?

    Lancet Oncol

    (2004)
  • N.R. Van den Broek et al.

    ‘Microinvasive’ adenocarcinoma of the cervix implanting in an episiotomy scar

    Gynecol Oncol

    (1995)
  • R. Stenson et al.

    Incisional recurrence of squamous cell cervical carcinoma following operative staging

    Gynecol Oncol

    (1990)
  • D.N. Sharma et al.

    Cervical carcinoma recurring in an abdominal wall incision

    Clin Oncol (R Coll Radiol)

    (2000)
  • R.A. Potish et al.

    On the lack of demonstrated clinical benefit of neoadjuvant cisplatinum therapy for cervical cancer

    Int J Radiat Oncol Biol Phys

    (1993)
  • L.J. Copeland et al.

    Cervical adenocarcinoma: tumor implantation in the episiotomy sites in two patients

    Gynecol Oncol

    (1987)
  • P.A. Van Dam et al.

    Carcinoma in episiotomy scars

    Gynecol Oncol

    (1992)
  • A.M. Khalil et al.

    Squamous cell carcinoma of the cervix implanting in the episiotomy site

    Gynecol Oncol

    (1993)
  • N.A. Goldman et al.

    Late recurrence of squamous cell cervical cancer in an episiotomy site after vaginal delivery

    Obstet Gynecol

    (2003)
  • C. Nguyen et al.

    Management of stage I cervical cancer in pregnancy

    Obstet Gynecol Surv

    (2000)
  • B. Duggan et al.

    Cervical cancer in pregnancy: reporting on planned delay in therapy

    Obstet Gynecol

    (1993)
  • K. Economos et al.

    Abnormal cervical cytology in pregnancy: a 17-year experience

    Obstet Gynecol

    (1993)
  • C. Palle et al.

    Cervical intraepithelial neoplasia in pregnancy

    Acta Obstet Gynecol Scand

    (2000)
  • N.A. Pavlidis

    Coexistence of pregnancy and malignancy

    Oncologist

    (2002)
  • P.F. Kaminski et al.

    Significance of atypical cervical cytology in pregnancy

    Am J Perinatol

    (1992)
  • G. Vlahos et al.

    Conservative management of cervical intraepithelial neoplasia (CIN (2–3)) in pregnant women

    Gynecol Obstet Invest

    (2002)
  • D. Zemlickis et al.

    Maternal and fetal outcome after invasive cervical cancer in pregnancy

    J Clin Oncol

    (1991)
  • W.B. Jones et al.

    Cervical carcinoma and pregnancy. A national patterns of care study of the American College of Surgeons

    Cancer

    (1996)
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