Chapter 7 A gynecologic examination is indicated in early pregnancy if the patient has not recently had one. This should include a Pap smear and, we believe, colposcopy. The scenario of cervical cancers diagnosed in pregnancy (usually in women without standard gynecologic care) has become uncommon. The most prominent colposcopic finding seen in pregnancy is the increase in size and number of the blood vessels, leading to hyperemia of the cervix. The stroma is softened and edematous, and the cervix becomes enlarged. The endocervical mucosa is hyperplastic. Proliferation of the columnar cells leads to enlargement and ramification of the glandular crypts, with formation of numerous secondary clefts and tunnels. The endocervical mucosa becomes velvety as a result of deeper extension into the stroma. The end result is a honeycomb appearance of the gland field. Another characteristic change in pregnancy is a decidual reaction of the stroma. This can be limited and focal or quite extensive and can on occasion produce polypoid lesions referred to as decidual polyps (Figs. 7.1–7.3). An ectocervix completely covered by squamous epithelium will not change much during the course of the pregnancy. However, occasionally, a pregnant woman can develop ectopy, or a preexisting ectopy can increase in size as a result of the increased volume of the cervix. (Outside pregnancy ectopy does not develop de novo.) It is also possible to produce pseudoectopy during the later stages of pregnancy by everting the cervical lips during speculum examination. Fig. 7.1 Gravida 3, 20 weeks’ gestation. Deciduosis. Grayish, solid formation at the external os. The formation is covered by fibrin, not epithelium. Histology showed a decidual reaction of the stroma. Fig. 7.2 Gravida 2, 8 weeks’ gestation. Two decidual polyps in the cervical canal. Their surface is covered with fibrin, which obscures the epithelium. Note the vascular pattern, which is typical for decidual polyps. Fig. 7.3 Gravida 2, 16 weeks’ gestation, decidual polyp in the cervical canal. The cervix is livid. The cervical mucus undergoes characteristic changes during pregnancy, becoming viscous and cloudy, whitish or yellowish, and containing threads or particles (Figs. 7.4 and 7.5). The mucus can be more difficult to remove with acetic acid than in the nonpregnant patient. Apart from lesions such as decidual polyps (Fig. 7.1), there are no colposcopic findings specific for pregnancy. The changes occurring during pregnancy are the same as those described in Chapter 6. The same applies to reactive changes, inflammation, and infections. In the past, there has been lively debate as to whether squamous intraepithelial lesion (SIL; also known as cervical intraepithelial neoplasia [CIN]) can develop during pregnancy and regress after the puerperium. Of course, low-grade squamous intraepithelial lesion (LSIL) can regress independently of pregnancy. In contrast, a number of studies have shown that high-grade squamous intraepithelial lesion (HSIL; CIN 3) detected during pregnancy does not regress postpartum. Systematic examination of the cervices of women in early pregnancy has even shown a surprisingly high incidence of persisting HSIL (CIN 3). These results are of interest from the epidemiologic point of view and underline the importance of standard gynecologic care during pregnancy. Lividity of the cervicovaginal mucosa was a clinical sign of pregnancy long before ultrasound and immunologic tests were developed. Lividity is due to the increased vascularity of the pelvic organs, especially the venous plexuses. Marked fluid retention gives the cervix a soft consistency, and it becomes softer as the pregnancy advances. Increased fragility and a tendency toward contact bleeding are observed with introduction of the speculum, especially when taking a smear or biopsy. Fig. 7.5 (a) Gravida 2, 18 weeks’ gestation. There is a clearly circumscribed, almost unstructured area within an otherwise unremarkable transformation zone on the anterior lip. (b) After application of acetic acid, a few gland openings and a fine mosaic appear within the area described. Histology showed metaplastic epithelium. Fig. 7.7 Gravida 1, 8 weeks’ gestation. Transformation zone, with a whitish reaction to acetic acid. Cuffed gland openings. Flat condylomas between 12 o’clock and 2 o’clock positions. Fig. 7.8 Gravida 1, 11 weeks’ gestation. After acetic acid, a white area with fine mosaic and punctation appears on the anterior and posterior lip inside the transformation zone. The border with the slightly livid original epithelium is sharp. Histology showed metaplastic epithelium. The lividity and softness bring about background changes in the colposcopic appearance. In contrast to the nonpregnant state, these are coarse and may give even benign changes a suspicious and alarming aspect (Figs. 7.5–7.9). This applies especially to the response to acetic acid. The effect of acetic acid is more pronounced during pregnancy, so that whitening even of benign lesions can appear suspicious (Figs. 7.5b, 7.7, and 7.9b). Thus, the response to acetic acid can be difficult to interpret during pregnancy.
Colposcopy in Pregnancy
7 Colposcopy in Pregnancy
7.1 Effects of Pregnancy on Colposcopic Findings
7.1.1 Acetic Acid Test
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