Best Practice & Research Clinical Obstetrics & Gynaecology
10Cervical neoplasia during pregnancy: Diagnosis, management and prognosis
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)
- et al.
Colposcopy in pregnancy
Obstet Gynecol Clin North Am
(1993) - et al.
The clinical course of cervical carcinoma in situ diagnosed during pregnancy
Gynecol Oncol
(1997) Cancer in pregnancy
Ann Oncol
(2003)- et al.
Colposcopy and directed biopsy reliability during pregnancy: a cohort study
Eur J Obstet Gynecol Reprod Biol
(1995) - et al.
Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions
Obstet Gynecol
(1999) - et al.
Management of cervical intraepithelial neoplasia during pregnancy with loop excision
Gynecol Oncol
(1997) - et al.
Management of cervical intra-epithelial neoplasm during pregnancy
Gynecol Obstet Fertil
(2003) - et al.
Chemotherapy in the treatment of locally advanced cervical cancer and pregnancy
Gynecol Oncol
(2001) - et al.
Surgical management of early invasive cancer of the cervix associated with pregnancy
Gynecol Oncol
(1993) - et al.
Stage I squamous cell cervical carcinoma in pregnancy: planned delay in therapy awaiting fetal maturity
Gynecol Oncol
(1995)
cervical carcinoma and pregnancy: report of 49 cases
Am J Obstet Gynecol
Carcinoma of the cervix and pregnancy
Gynecol Oncol
Carcinoma of the cervix associated with pregnancy
Am J Obstet Gynecol
Fetal and maternal considerations in the management of stage Ib cervical cancer during pregnancy
Gynecol Oncol
Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment
Gynecol Oncol
Cervical carcinoma during pregnancy: outcome of planned delay in treatment
Eur J Obstet Gynecol Reprod Biol
Villoglandular adenocarcinoma of the cervix: a case report
Obstet Gynecol
A case of clear cell adenocarcinoma of the uterine cervix in pregnancy
Gynecol Oncol
Modern management of locally advanced cervical carcinoma
Cancer Treat Rev
Survival and recurrence after concomitant chemotherapy and radiotherapy for cancer of the uterine cervix: a systematic review and meta-analysis
Lancet
Use of chemotherapy during human pregnancy
Lancet Oncol
Chemotherapy in pregnancy
Obstet Gynecol Clin N Am
Stage of pregnancy-dependent transplacental passage of 195mPt after cisplatinum treatment
Eur J Cancer Clin Oncol
Oat cell carcinoma of the uterine cervix in a pregnant woman treated with cis-diamminedichloroplatinum
Gynecol Oncol
Platinum chemotherapy during pregnancy for serous cystadenocarcinoma of the ovary
Gynecol Oncol
Chemotherapy during pregnancy: what is really safe?
Lancet Oncol
‘Microinvasive’ adenocarcinoma of the cervix implanting in an episiotomy scar
Gynecol Oncol
Incisional recurrence of squamous cell cervical carcinoma following operative staging
Gynecol Oncol
Cervical carcinoma recurring in an abdominal wall incision
Clin Oncol (R Coll Radiol)
On the lack of demonstrated clinical benefit of neoadjuvant cisplatinum therapy for cervical cancer
Int J Radiat Oncol Biol Phys
Cervical adenocarcinoma: tumor implantation in the episiotomy sites in two patients
Gynecol Oncol
Carcinoma in episiotomy scars
Gynecol Oncol
Squamous cell carcinoma of the cervix implanting in the episiotomy site
Gynecol Oncol
Late recurrence of squamous cell cervical cancer in an episiotomy site after vaginal delivery
Obstet Gynecol
Management of stage I cervical cancer in pregnancy
Obstet Gynecol Surv
Cervical cancer in pregnancy: reporting on planned delay in therapy
Obstet Gynecol
Abnormal cervical cytology in pregnancy: a 17-year experience
Obstet Gynecol
Cervical intraepithelial neoplasia in pregnancy
Acta Obstet Gynecol Scand
Coexistence of pregnancy and malignancy
Oncologist
Significance of atypical cervical cytology in pregnancy
Am J Perinatol
Conservative management of cervical intraepithelial neoplasia (CIN (2–3)) in pregnant women
Gynecol Obstet Invest
Maternal and fetal outcome after invasive cervical cancer in pregnancy
J Clin Oncol
Cervical carcinoma and pregnancy. A national patterns of care study of the American College of Surgeons
Cancer
Cited by (94)
Serum CYFRA21–1 and SCC-Ag levels in women during pregnancy and their diagnostic value for cervical cancer
2024, Cancer Treatment and Research CommunicationsBritish Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice
2021, European Journal of Obstetrics and Gynecology and Reproductive BiologyPremalignant disease in the genital tract in pregnancy
2016, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :Colposcopy is a safe and effective method for the further evaluation of cytological abnormalities; however, procedural difficulties can arise when performing colposcopy in pregnancy. Firstly, vaginal wall laxity is common, and secondly, the cervix is more vascular during pregnancy leading to increased friability and the possibility of traumatic bleeding [10,11]. The colposcopic appearances of CIN in pregnancy are generally similar to that of the non-gravid cervix.
Endocervical adenocarcinoma implantation in episiotomy scar: a case report and review of the literature
2023, Journal of Medical Case ReportsPregnancy and cervical cancer—what are the options?
2023, GynakologieCervical cancer in the pregnant population
2023, Abdominal Radiology