Fig. 12.1, 12.2 and 12.3
Condom over the Cusco’s speculum preventing the vaginal walls from coming in the field
Cervical mucus plug is copious and tenacious in pregnancy (due to hormonal stimulation) and may be difficult to remove.
The vascular changes and features of squamous metaplasia appear exaggerated during pregnancy and may lead to difficulty in differentiating it from low-grade dysplasia (Fig. 12.4).
Fig. 12.4
Hyperemia of the cervix showing prominent vessels but maintaining the normal pattern
Deciduosis in pregnancy may mimic high-grade lesions or malignancy. It appears colposcopically as dense acetowhite areas around lacy superficial capillaries. Normal capillaries may also have thin acetowhite areas all around due to decidualized stroma called as “starry sky appearance.”
Cervical ectropion (Fig. 12.5) is a normal finding in pregnancy. This makes visualization of the squamocolumnar junction (SCJ) and transformation zone (TZ) easier. If however colposcopy in the first trimester is inadequate, it should be repeated in the second trimester when visualization of SCJ junction and TZ becomes easier.
Fig. 12.5
Hypertrophied endocervical mucosa
If a pregnant woman requires colposcopic or cytological examination after treatment for CIN or follow-up of untreated CIN, her review can safely be postponed until after delivery, unless it is the first clinical review following treatment for CIN 2/CIN 3 with involved or uncertain margin status. If repeat cytological examination is due and the woman has defaulted from a follow-up appointment prior to pregnancy, consideration should be given to her undergoing cytological or colposcopic examination during pregnancy.
12.4.3 Cervical Biopsy
Biopsy should only be performed in pregnancy for high-grade CIN or invasive lesions. When invasive disease is suspected, conventional punch biopsies may not be adequate as they may fail to give a representative sample and microinvasion cannot be ruled out with certainty. Multiple punch biopsies are also not advisable as they may cause trauma and significant bleeding [18]. Therefore, a wedge biopsy from the suspicious area identified colposcopically is taken. This procedure should be done in the operating theater as there is a significant risk of hemorrhage; silver nitrate or Monsel’s paste can be applied for hemostasis. In case of excessive bleeding, suturing or vaginal packing may also be done. Endocervical curettage (ECC) is not recommended in pregnancy [19]. Decisions regarding the need for a wedge biopsy and the procedure itself should be performed by an experienced clinician with relevant expertise.
12.5 Management of Abnormal Cytology During Pregnancy
- 1.
Atypical squamous cells of undetermined significance (ASC-US)
Management options for pregnant women with ASC-US are identical to those described for nonpregnant women, with the exception that deferring colposcopy until 6 weeks postpartum is acceptable [20]:
For young women between 21 and 24 years of age, repeat cytology at 1 year is preferred.
For women >24 years of age, HPV testing is preferred, and if HPV is negative, then co-testing at 3 years is recommended. If HPV is positive, then colposcopy is to be performed (this can be deferred until 6 weeks postpartum).
For women with ASC-US cytology and no HPV result, repeat cytology at 1 year is acceptable.
For pregnant women who have no cytologic, histologic, or colposcopically suspected CIN 2+ at the initial colposcopy, postpartum follow-up is recommended.
ECC is not to be performed for inadequate colposcopy.
- 2.
Atypical squamous cells–cannot exclude high-grade squamous intraepithelial lesions (ASC–H)
Women with ASC-H should undergo a colposcopic examination in pregnancy as the risk of CIN 2/CIN 3 on colposcopic-directed biopsy is as high as 50 % [21].
- 3.
Low-grade squamous intraepithelial lesion (LSIL)
- (a)
For pregnant women aged 21–24 years with LSIL, follow-up with cytology at 12-month interval is recommended; colposcopy is not recommended. At 12-month follow-up, women with ASC-H or HSIL are recommended for colposcopy. If cytology is ASC-US or LSIL, then repeat cytology at 12 months is recommended. For women with ASC-US or worse at the 24-month follow-up, colposcopy is recommended. For women with two consecutive negative results, return to routine screening is recommended.
- (b)
For pregnant women >24 years with LSIL, colposcopy is preferred, but deferring colposcopy till 6 weeks postpartum is acceptable. ECC is not to be performed even if the colposcopy is inadequate or no lesion is identified.
If there is no cytologic, histologic, or colposcopically suspected CIN 2+ at the initial colposcopy, postpartum follow-up is recommended. Additional colposcopic and cytologic examinations during pregnancy are unacceptable for these women.
- (a)
- 4.
High-grade squamous intraepithelial lesions (HSIL)(Fig. 12.6)
Fig. 12.6
Colposcopy showing mosaic pattern and CIN 2 lesion
Pregnant women with HSIL should undergo colposcopy with biopsy of any lesion suspicious of CIN 2/CIN 3 or cancer. Women without CIN 2/CIN 3 on biopsy do not require further evaluation during pregnancy; however, ECC is not to be performed in pregnancy.
- 5.
Atypical glandular cells or cytologic adenocarcinoma in situ (AGC or cytologic AIS)
Pregnant women should be evaluated with colposcopy and biopsy, but endocervical curettage or endometrial sampling is not to be performed because of the risk of pregnancy-related complications. Studies have suggested that 9–38 % of women with a Pap showing AGC have high-grade CIN or adenocarcinoma in situ and an additional 3–17% of women have invasive cancer.
- 6.
CIN 1
Pregnant women with CIN 1 on histology need to be followed up without any treatment.
- 7.
CIN 2/3
In women remote from term and with absence of any invasive disease, follow-up with repeat colposcopy and cytology at an interval of 12 weeks is recommended. Repeat biopsy is to be performed only if the appearance of the lesion worsens or if cytology suggests invasive cancer. However, deferring reevaluation until 6 weeks postpartum is also acceptable. At postpartum follow-up, a repeat cytology and colposcopy should be done to account for any regression of lesions.
12.5.1 Excisional Biopsy and Treatment During Pregnancy
A diagnostic excisional procedure/LEEP is recommended only if invasion is suspected as it leads to increase in preterm births and also increases the risk of cesarean deliveries. If required, it should preferably be performed in the second trimester of pregnancy under general anesthesia.
A recent meta-analysis has estimated twofold increase in risk of preterm deliveries and other pregnancy complications after excisional procedures in pregnancy [22]. There is also an excessively high risk of incomplete excision and disease persistence [23, 24]. Therefore, special consideration should be given to young women between 21 and 24 years age and to women who have not completed childbearing.
12.5.2 Glandular Lesions During Pregnancy
The natural history and implications of glandular atypia in pregnancy are poorly understood. In nonpregnant women, glandular atypia is often associated with squamous lesions; therefore, these women require a close follow-up with colposcopy during pregnancy, and biopsy of suspicious areas should be taken in the postpartum period [20].
Line diagram 1 shows the outline of management of abnormal smear during pregnancy
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