Increased prominence of vascular patterns
Decreased prominence of acetowhite epithelium
Immature metaplasia difficult to distinguish from low-grade squamous lesion
Decidual changes – atypical vascular pattern, polypoid, less intense acetowhite staining
Fine punctation and mosaic pattern within metaplasia, leading to misdiagnosis of lesion
13.4.1 Increased Vascularity of the Cervix (Figs. 13.1 and 13.2)
Fig. 13.1
Increased vascularity of pregnant cervix
Fig. 13.2
Cervix as seen through green filter
Increased vascularity of the cervix and vasodilatation result in prominent vascular patterns of mosaic and punctation which can lead to an overestimation of the degree of atypia.
Vasodilatation causes intraepithelial blood vessels to be larger so that patterns of mosaic and punctation appear coarser, thereby adding to the confusion.
13.4.2 Increased Prominence of Acetowhite Epithelium
There is progressive eversion of lower endocervical canal epithelium due to increased interstitial fluid. When this everted columnar epithelium is exposed to the acidic milieu of the vagina, it undergoes squamous metaplasia which progresses throughout pregnancy. Towards the end of the first trimester, this produces area of fusion of columnar villi with islands of immature metaplastic epithelium (Fig. 13.3a, b). This process rapidly progresses through the second trimester, producing a layer of smooth, opaque squamous metaplasia that appears acetowhite after application of acetic acid. The acetowhiteness is further exaggerated by the bluish hue of the cervix due to increased vascularity. This immature metaplasia often causes diagnostic difficulty with low-grade lesion.
Fig. 13.3
Increased acetowhiteness (a) and non-uptake of Lugol’s iodine (b) at colposcopy
In the third trimester, eversion and progressive metaplasia continue until 36 weeks of gestation and then stops. This area of metaplasia either returns to its endocervical position in the puerperium or matures into squamous epithelium.
In the subsequent pregnancy, the preexisting area of metaplasia may again get everted but not as dramatically as in the first pregnancy.
13.4.3 Diminished Acetowhitening
Edema of the cervix during pregnancy makes acetowhite epithelium look less intense, and the lesions can appear less severe than they actually are.
13.4.4 Cyanosis of Stroma
Cyanosis of stroma causes a dusky appearance (Fig. 13.4), and normal capillaries have a ring of acetowhite decidualized stroma surrounding them, which causes a “starry sky” appearance.
Fig. 13.4
Congested and cyanosed appearance of pregnant cervix
13.4.5 Decidual Changes
These changes are due to high levels of circulating progesterone in pregnancy. They are usually focal and can affect the endo- or ectocervix in the form of cuffing of gland openings or decidual polyps. Decidual polyps can appear as raised plaques or polypoidal with a yellowish appearance and no covering epithelium. They regress spontaneously in the postpartum period.
13.4.6 Condylomas
Condylomas can become extremely florid and enlarged in pregnancy (Fig. 13.5). Their benign nature can be confirmed on colposcopy. Their treatment can be safely postponed until postpartum by which time they would have decreased in size.
Fig. 13.5
Condyloma in pregnant patient
13.4.7 Microglandular Endocervical Hyperplasia
It results from stimulation of the columnar epithelium by progesterone. So, it is also seen in women on oral contraceptive pills. Though they are generally microscopic but if florid, can appear polypoidal with covering columnar epithelium.
13.5 Colposcopic Technique in Pregnant Women
Position
In early pregnancy, no changes in patient positioning are needed. But as pregnancy progresses, women may develop supine hypotension syndrome during colposcopic examination, and it is helpful to place folded sheets to wedge the hip off the table.
Visualization of the Cervix
A large-sized speculum is needed to visualize the cervix in pregnant women owing to cervical hypertrophy and lax vaginal walls. If this does not provide adequate exposure, a condom can be placed on the speculum and opened at the distal end, or lateral vaginal wall retractors can be used. Effacement and dilatation of the cervix which occur late in pregnancy further make visualization difficult. So, colposcopy in late gestation should be limited to women most likely to have invasive cancer.
It is easier to carry out colposcopy after 16–18 weeks of gestation because of the eversion of the endocervical columnar epithelium (Figs. 13.6 and 13.7). As a result of this physiologic eversion, the transformation zone (TZ) becomes more accessible.
Fig. 13.6
Inadequate colposcopy in early pregnancy
Fig. 13.7
Eversion seen before (a) and after acetic acid application (b) in late pregnancy
Removing Cervical Mucus
Cervical mucus during pregnancy is usually thick, opaque, and tenacious (Fig. 13.8). Pulling onto the mucus to remove it is generally not successful. It can be twisted around a dry cotton swab to be mobilized and removed or one can also use a sponge forceps to remove it.
Fig. 13.8
Thick tenacious mucus covering the cervix
Applying Acetic Acid
More liberal application of acetic acid is required for the acetowhitening to take place (Fig. 13.9). As the cervix is friable, care must be taken to spray or dab the acetic acid rather than rubbing it on the cervix and traumatizing it (Fig. 13.10).
Fig. 13.9
Acetowhitening seen on the posterior lip of the cervix
Fig. 13.10
Small bleeding vessels after acetic acid application
Also, pregnant women experience more burning sensation with acetic acid application than nonpregnant women.
13.5.1 Applying Lugol’s Iodine
After application of acetic acid, Lugol’s iodine is applied to the cervix. The areas of dysplasia do not stain brown and remain unstained or take up iodine patchily.
13.5.2 Colposcopic-Directed Biopsy
Due to increased vascularity and edema of the pregnant cervix and its tendency to bleed excessively, biopsy is generally avoided during pregnancy. Cervical biopsy is indicated when the lesions are suspicious for microinvasion or invasive cancer, and the results can potentially impact management options.
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