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
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