The clinical course of cervical carcinoma in situ diagnosed during pregnancy

Evaluation of the effectiveness and safety of photodynamic therapy in the treatment of precancerous diseases of the cervix (neoplasia) associated with the human papillomavirus: A systematic review

This study provides an overview of the effectiveness and safety of PDT for the treatment of HPV-associated precancerous cervical conditions and contains recent findings from relevant research studies. A comprehensive literature search of MEDLINE/PubMed, Cochrane Central Library, and Google Scholar was conducted, including analytic epidemiological studies, and 11 papers were included. The narrative synthesis approach was used to summarize the results of the included studies. Studies were critically appraised using The Joanna Briggs Institute (JBI) tool for assessing the risk of bias. The results of the study demonstrate that CRR for HPV remission ranges from 66.7 % to 92.73 %, whereas for CIN1 it fluctuates from 57.1 % to 83.3 %. The frequency of recurrence of the disease ranged from 3.3 % to 8.9 % during the follow-up period of up to 2 years. Adverse events were observed in 8 (66 %) studies and the most common were cervical stenosis, abdominal pain, vaginal pain, and focal edema. Five types of topical and intravenous applications along with lasers of various wavelengths and intensities were mostly used. However, all studies demonstrated relatively similar results. According to the results, PDT has demonstrated favorable outcomes, but no impressive effect on the treatment of CIN. It should be emphasized, that the effectiveness of PDT for the treatment of HPV-associated CIN may vary depending on some variables, including the kind of PDT agent used, the dosage, duration and frequency of PDT administration, the severity and location of the lesions, and the host immunological response.

The Fate of Cervical Dysplastic Lesions during Pregnancy and the Impact of the Delivery Mode: A Review

Cervical dysplasia, also referred to as cervical intraepithelial neoplasia (CIN) or squamous intraepithelial lesion (SIL), is the precursor lesion of cervical carcinoma. Therefore, its diagnosis is vital for early detection and inhibiting the development of cervical carcinogenesis. Human papillomavirus (HPV) is the most common aetiology of cervical cancer and this infection mainly affects young women of childbearing age, thus affecting pregnant women as well. It is essential to know how CIN progresses in pregnant patients because the management of pregnant and non-pregnant patients is different (considering the safety of both mother and child in pregnancy). This review intends to highlight the studies which have assessed the rates of progression of CIN diagnosed in pregnancy throughout the antenatal period and the impact of the mode of delivery on CIN outcomes. We searched PubMed/MEDLINE and Google Scholar databases for relevant articles. Many studies indicate that the rate of progression of these lesions is very slow during the tenure of pregnancy; many also report postpartum regression of these lesions. Thus, in most of these patients, management can be safely implemented in the postpartum period while just keeping them under observation in the antenatal period. However, patients with high-grade CIN have a higher chance of developing invasive cancer and, therefore, require careful monitoring. There is a dispute regarding the role of the mode of delivery in determining the fate of cervical dysplasia. While some studies supported vaginal births over caesarean sections, others did not find any difference between the two in defining the outcome of the dysplastic lesions.

Does mode of delivery impact the course of cervical dysplasia in pregnancy? A review of 219 cases

OBJECTIVE

The prevalence of cervical intraepithelial neoplasia (CIN) in pregnancy is about 1%. The aim of this study was to analyze the regression, persistence and progression rates of cervical dysplasia in pregnancy and the impact of delivery mode.

STUDY DESIGN

In this retrospective study, data from pregnant patients with abnormal cytology findings, who presented to a colposcopic outpatient clinic of a university hospital within the last 10 years, were analyzed. Information on cytology, histology and Human Papillomavirus (HPV) status during pregnancy and postpartum and mode of delivery was collected.

RESULTS

219 women, who were assessed with cytology and /or biopsy antepartum and postpartum between January 2010 and July 2020, were included in the study. Antepartum patients presented with low grade squamous intraepithelial lesions (LSIL) in 37% and high grade squamous intraepithelial lesions (HSIL) in 53%. During pregnancy biopsy was performed in 78 patients (36%). Postpartum evaluation revealed an overall regression rate of 39%. Persistence rates were especially high in the HSIL group with 70 %. HSIL regressed in 28 %. Progression to invasive disease was rare and seen in two patients postpartum only. 141 women delivered vaginally (VD) and 51 received a cesarean section (CS). Regression rates were similar: 36 % and 47 %. There was no significant difference in progression or persistence rates.

CONCLUSION

Our study demonstrates that mode of delivery does not influence the course of SIL. SIL show high rates of regression and persistence, progression to invasive disease is rare.

Predictive Factors Involved in Postpartum Regressions of Cytological/Histological Cervical High-Grade Dysplasia Diagnosed during Pregnancy

Objective: The aim of this study was to describe the evolution of high-grade cervical dysplasia during pregnancy and the postpartum period and to determine factors associated with dysplasia regression. Methods: Pregnant patients diagnosed with high-grade lesions were identified in our tertiary hospital center. High-grade lesions were defined either cytologically, by high squamous intraepithelial lesion/atypical squamous cells being unable to exclude HSIL (HSIL/ASC-H), or histologically, with cervical intraepithelial neoplasia (CIN) 2+ (all CIN 2 and CIN 3) during pregnancy. Postpartum regression was defined cytologically or histologically by at least a one-degree reduction in severity from the antepartum diagnosis. A logistic regression model was applied to determine independent predictive factors for high-grade cervical dysplasia regression after delivery. Results: Between January 2000 and October 2017, 79 patients fulfilled the inclusion criteria and were analyzed. High-grade cervical lesions were diagnosed by cytology in 87% of cases (69/79) and confirmed by histology in 45% of those (31/69). The overall regression rate in our cohort was 43% (34/79). Univariate analysis revealed that parity (p = 0.04), diabetes (p = 0.04) and third trimester cytology (p = 0.009) were associated with dysplasia regression. Nulliparity (OR = 4.35; 95%CI = (1.03–18.42); p= 0.046) was identified by multivariate analysis as an independent predictive factor of high-grade dysplasia regression. The presence of HSIL on third-trimester cervical cytology (OR = 0.17; 95%CI = (0.04–0.72); p = 0.016) was identified as an independent predictive factor of high-grade dysplasia persistence at postpartum. Conclusion: Our regression rate was high, at 43%, for high-grade cervical lesions postpartum. Parity status may have an impact on dysplasia regression during pregnancy. A cervical cytology should be performed at the third trimester to identify patients at risk of CIN persistence after delivery. However, larger cohorts are required to confirm these results.

Prevalence of Human Papillomavirus and Genotype Distribution in Pregnant and Non-Pregnant Women in China

Purpose

The status of human papillomavirus (HPV) infection in pregnant and non-pregnant women in China remains unclear. This study aimed to compare the prevalence and genotype distributions of HPV between pregnant and non-pregnant women in China.

Patients and Methods

A case-control study was conducted of pregnant women during the second trimester and age-matched non-pregnant women attending the Fujian Maternity and Child Health Hospital between January 1, 2017 and December 31, 2018. Participants underwent cervical cytology testing and HPV genotyping. The genotyping test was able to identify 14 high-risk HPV (HR-HPV), four possible HR-HPV, and five low-risk HPV (LR-HPV) types. Further colposcopy and a cervical biopsy were performed if indicated. The primary outcomes were HPV prevalence and genotype distribution.

Results

In total, 1077 pregnant and 1077 non-pregnant women were enrolled. Compared with non-pregnant women, pregnant women had a higher prevalence of HPV (24.2% vs 14.8%), HR-HPV (20.2% vs 11.7%), and LR-HPV (8% vs 4.5%) infection. In pregnant women, the most prevalent HPV genotypes were HPV-52 (6.0%), -16 (3.5%), -58 (2.6%), -53 (2.5%), and -51 (2.5%), while in non-pregnant women the most prevalent genotypes were HPV-52 (3.6%), -81 (1.9%), -51 (1.8%), -68 (1.4%), and -16 (1.3%). In women aged ≥35 years, HR-HPV (P=0.002) and LR-HPV (P=0.001) prevalence were significantly higher in pregnant women. However, in women aged <35 years, only HR-HPV prevalence was higher in pregnant women. Pregnant and non-pregnant women with HPV-16 and HPV-58 infection had a high prevalence of high-grade squamous intra-epithelial lesions (HSIL) (HPV-16: P<0.001 and P=0.005, HPV-58: P=0.043 and P=0.005); but with other HR-HPV genotypes, only non-pregnant women had an increased HSIL prevalence.

Conclusion

In China, the HPV prevalence is higher in pregnant women than that in non-pregnant women and is also age- and genotype-dependent. HPV-infected pregnant women aged ≥35 years and those with HPV-16 should be closely monitored to enable rapid clinical intervention.

Course of cervical intraepithelial neoplasia diagnosed during pregnancy

PURPOSE

Management of high-grade cervical intraepithelial neoplasia [CIN grade 2 or 3 (CIN2-3)] diagnosed during pregnancy is controversial. Monitoring with colposcopy and cytology every 8-12 weeks is advised by the most current guidelines.

STUDY DESIGN

This study analyzes the course of disease in pregnant women with abnormal cytologies or clinically suspicious cervixes.

RESULTS

In total, 139 pregnant women, at a median age of 31 years (range 19-49), treated at the Colposcopy Unit of the University Medical Center Hamburg-Eppendorf between 2011 and 2017 were identified. During pregnancy, at least one biopsy was performed on 70.5% of patients. In 84.7% of cases, CIN2-3 (CIN2 n = 14 (14.3%), CIN3 n = 69 (70.4%)) was detected, 7.1% (n = 7) of women were diagnosed with CIN1, while no dysplasia was found in 8.2% (n = 8) of cases. No interventions were necessary during pregnancy. Despite explicit invitation, only 72.3% of women with CIN2-3 attended postpartal consultations. While 61.7% showed persistent lesions, 5% were diagnosed with CIN1 and 33.3% with complete remission. During pregnancy, 68.7% of women with prepartal CIN2-3 were tested for HPV infection. Later, 49.1% were followed up postpartally by means of HPV testing and histology. HPV clearance was observed in 36.4% of women with complete histological remission. Postpartum conization was performed on 44.6% of patients with prepartal CIN2-3 diagnosis. CIN2-3 was histologically confirmed in 97.3% cases. Progression from persistent CIN3 to microinvasive carcinoma was observed in a single case.

CONCLUSIONS

High-grade CIN lesions, diagnosed during pregnancy, show a high rate of regression postpartum; whereas, progression to carcinoma is rare. Close and continuous monitoring rarely has any therapeutic consequences. Compliance for postpartal follow-up needs to be improved.

Cervical intraepithelial neoplasia during pregnancy

Objectives

The aim was to analyze the unaffected course of cervical intraepithelial neoplasia (CIN) in pregnant women and to compare the rates of lesion persistence, progression, and regression.

Materials and Methods

Patients with abnormal cytology included in the study underwent colposcopy, followed by a biopsy of the cervix. At the end of the postpartum period, all patients underwent Pap smear, colposcopy, and endocervical curettage to obtain tissue samples. The findings were compared to the baseline to assess the rates of persistence, regression, and progression of CIN.

Results

The study group were 53 pregnant women. CIN was confirmed in 35 (66%) of them: CIN1 (n = 8, 22.9%); CIN 2+ (n = 26, 74.3%); and stage IA1 cervical cancer (n = 1, 2.9%). At the end of the postpartum period in 50% cases, there was no change compared to the baseline. Progression was seen in 2.9% and regression in 47.1%. A tendency for persistence and spontaneous regression of the lesions was observed.

Conclusions

Although in many cases CIN tends to regress spontaneously after delivery, such outcome is not to be expected in all patients. When invasive cervical cancer has been excluded, definitive treatment for cervical dysplasia may be deferred to the postpartum period without any harm to the mother.

High-grade Cervical Squamous Intraepithelial Lesion during Pregnancy

Aims and Background

An increasing incidence of high-grade squamous intraepithelial lesion (HSIL) has been observed among young women. Consequently, an increased number of cases are being discovered during pregnancy. We analyzed the clinical and therapeutic management of HSIL during pregnancy.

Methods

A retrospective study was conducted from 1979 to 1998, and 58 registries of women with a cytological or histological diagnosis of HSIL during the pregnant-puerperal period were reviewed. Information obtained from medical records included age, gestational age at diagnosis, parity, age of first intercourse, number of sexual partners before pregnancy, tobacco use, cytologic and colposcopic findings, route of delivery, postpartum follow-up, and treatment. This information was compared with a non-pregnant control group with HSIL.

Results

The average age of pregnant women with HSIL was 27.9 ± 5.2 years. The cytologic or histologic diagnosis of HSIL was made in the first trimester in 12 (20.7%) women and in the second trimester in 30 (51.7%) women. Average parity was 2.8 ± 2 deliveries. Age of first intercourse ranged from 13 to 29 years (16.1 ± 3.3). Thirty-two women (55.1%) had more than one sexual partner before pregnancy. Thirty-seven (63.8%) refereed tobacco use. According to the aforementioned aspects, no statistical difference was found in relation to control, except to cervical ectopia, which was more frequent in pregnant women (56.9% versus 42.6%). From the total of 58 pregnant women with cytologic or biopsy HSIL diagnosis, 53 had HSIL diagnosis made on cervical biopsy directed by colposcopy performed during the pregnancy; 44 (83%) of them were submitted to conservative management. HSIL was diagnosed by cervical biopsy in postpartum evaluation in 76% pregnant women with vaginal delivery and 78.6% women who underwent cesarean section.

Conclusions

A conservative management of HSIL in pregnancy is proposed, with colposcopic evaluation during gestation and postpartum, regardless of route of delivery.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

OBJECTIVE

The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation.

METHODS

Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications.

RESULTS

In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%).

CONCLUSIONS

The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

Natural history of cervical intraepithelial neoplasia in pregnancy: postpartum histo-pathologic outcome and review of the literature

Background

To study the natural history of cervical intraepithelial neoplasia (CIN) during pregnancy and to compare the rates of persistence, progression and regression of CIN by colposcopically guided biopsy (CGB) during pregnancy with outcome in non-pregnant-women.

Methods

A retrospective analysis of all pregnant women diagnosed with CIN at our outpatient clinic between 2005 and 2010 was performed. A CGB for histo-pathological analysis was obtained in all participants and observational management was performed. The histo-pathologic findings of initial and postpartum visits were collected. Rates of persistence, progression and regression of CIN were assessed. Results were compared to a matched control group of non-pregnant women where observational management was performed for at least three months. In addition a review of the literature and pooled analysis of published data was performed.

Results

A total of 51 pregnant women with CIN were included into analysis. CIN 1, 2, and 3 was diagnosed by CGB in 33.3, 13.7 and 52.9 % of all pregnant women, respectively. The postpartum histo-pathologic evaluation of the pregnant cohort revealed a significantly higher tendency to spontaneous regression (56.9 versus 31.4 %, p = 0.010) and a considerably, but not significantly higher complete remission rate (41.2 versus 27.5 %, p = 0.144) when compared to the non-pregnant cohort. In addition, we observed a significantly lower CIN persistence rate than in the non-pregnant cohort (39.2 versus 58.8 %, p = 0.048). The progression rate was notably low in the pregnant cohort (3.9 %) and no progression to invasive cancer was observed.

Conclusions

CIN lesions show considerably high spontaneous regression rates postpartum. Once presence of invasive cancer is ruled out definitive treatment can be deferred to the postpartum period.

Premalignant disease in the genital tract in pregnancy

Cervical intraepithelial neoplasia (CIN) is the most common premalignant disease of the lower genital tract encountered during pregnancy. As in the non-pregnant state, abnormal cytology should be referred for colposcopy. However, the role of colposcopy in pregnant women is to exclude invasive cancer by visual inspection and defer biopsy and definitive treatment until the post-partum period. Colposcopic exclusion of invasive disease is the only absolute indication for conisation in pregnancy. It is now evident that treatment for CIN outside of pregnancy, that involves >15 mm deep excision is associated with an increased risk of preterm delivery. Vulval intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VaIN) rarely present in women of childbearing age; nevertheless, medical management should be postponed until after delivery, unless symptoms are particularly severe.

Risk of Human Papillomavirus (HPV) Infection and Cervical Neoplasia after Pregnancy

BACKGROUND

Parity is well established as a risk factor for cervical cancer. It is not clear, however, how pregnancy influences the natural history of HPV infection and cervical neoplasia. Our objective was to study the risk of HPV infection and cervical squamous intraepithelial lesions (SIL) after pregnancy.

METHODS

We used the Ludwig-McGill cohort study which includes 2462 women recruited in Sao Paulo, Brazil in 1993-97 and followed for up to 10 years. Cellular specimens were collected every 4-6 months for Pap cytology and HPV detection and genotyping by a polymerase chain reaction protocol. Study nurses recorded pregnancy occurrence during follow-up. HPV and Pap results from pregnant women were available before and after, but not during pregnancy. The associations between pregnancy and post-partum HPV infection/SIL were studied using generalized estimating equation models with logistic link. Adjusted odds ratios (OR) were estimated with empirical adjustment for confounding.

RESULTS

We recorded 122 women with a history of pregnancy during follow-up. Of these, 29 reintegrated the cohort study after delivery. No association between HPV and pregnancy was found. A single SIL case (high grade SIL) occurred post-partum. Likewise, there was no association between pregnancy and risk of low grade SIL or any-grade SIL at the next visit (adjusted OR = 0.84, 95 % CI: 0.46-15.33) after controlling for confounders.

CONCLUSIONS

No associations were found between pregnancy and HPV or LSIL. The single observed case of HSIL post-partum was more than would be expected based on the rate of these abnormalities among non-pregnant women. As this association was found with only one case, caution is required in the interpretation of these results.

p16/Ki-67 dual-stained cytology testing may predict postpartum outcome in patients with abnormal papanicolaou cytology during pregnancy

OBJECTIVE

To evaluate the use of a new immunocytochemical dual-staining protocol, which allows for the detection of coexpression of the p16(INK4a) (p16) and Ki-67 biomarkers in prenatal care. It was hypothesized that dual-staining cytology may predict postpartum outcome in patients with abnormal cervical Papanicolaou (Pap) smears during pregnancy.

STUDY DESIGN

In this retrospective pilot study, 27 abnormal Pap smears collected from women during early pregnancy were destained and subsequently stained for p16/Ki-67. RESULTS were correlated with histologic outcome collected during postpartum follow-up.

RESULTS

Fourteen of 20 abnormal Pap smears during pregnancy showed a positive p16/Ki-67 dual-stained cytology result, whereas 6 specimens tested negative. Seven cases were excluded due to technical reasons. All 14 patients who were positive for p16/Ki-67 dual stain had cervical intraepithelial neoplasia (CIN) on postpartum histology. In contrast, 5 out of 6 patients negative for p16/Ki-67 dual-staining had a negative histology postpartum and during follow-up, and the remaining patient showed a CIN1 (p < 0.001).

CONCLUSION

p16/Ki-67 dual-stained cytology may provide a valuable novel approach to identify pregnant women with persistent or progressing CIN disease and may help improve the management of abnormal Pap cytology results during pregnancy.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

Cervical intraepithelial neoplasia 2, 3 in pregnancy: time to consider loop cone excision in the first trimester of pregnancy?

OBJECTIVES

To report the outcome of patients diagnosed with cervical intraepithelial neoplasia 2, 3 (CIN 2, 3) during pregnancy, who were treated by large loop excision of the transformation zone (LLETZ) in the first trimester or were followed up conservatively and treated after delivery.

METHODS

Patients diagnosed with CIN 2, 3 during pregnancy who were treated with LLETZ or were conservatively followed up were included. Complications of the LLETZ, pathologic results, and pregnancy outcome of both groups were examined after delivery.

RESULTS

Thirty-one patients were included in the study. Eighteen were conservatively followed up and 13 underwent LLETZ during the first 14 weeks of pregnancy. Four patients (12.9%) in the study group were diagnosed with invasive cervical cancer. From women who underwent LLETZ, 9 patients continued their pregnancy, 7 of which had term normal deliveries and 2 had late preterm deliveries. No complications of severe bleeding or miscarriage were reported in any of the treated patients.

CONCLUSIONS

Large loop excision of the transformation zone procedure in the first trimester of pregnancy is a safe procedure, with the advantage of treating definitively CIN 2, 3 lesions and preventing the devastating consequences of undiagnosed cervical cancer. We suggest that LLETZ should be performed more liberally in the first trimester of pregnancy.

The management of women with abnormal cervical cytology in pregnancy

The management of women with abnormal cytology in pregnancy represents both a diagnostic and a therapeutic challenge for colposcopists. The emphasis should be on diagnosis and confirmation of cervical precancer (Cervical intraepithelial neoplasia (CIN) or Adenocarcinoma in situ (AIS), thus excluding invasive cancer). Following an initial assessment, careful follow-up is essential. This must include colposcopy and take into account the physiological changes of the cervix during pregnancy and the puerperium. The management of women with invasive cancer diagnosed during pregnancy depends on the gestation at diagnosis and requires careful assessment and multidisciplinary planning.

European guidelines for clinical management of abnormal cervical cytology, part 2

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. The first part of the same chapter was published in a previous issue (Cytopathology 2008;19:342-54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.

Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease

Cervical cancer screening is an essential component of prenatal care. The diagnosis and management of cervical intraepithelial neoplasia (CIN) during pregnancy are challenging, and sufficient information does not exist to allow for a definitive evidence-based approach. The American Society for Colposcopy and Cervical Pathology has recently published guidelines regarding the evaluation of abnormal Papanicolaou tests and the treatment of CIN in this setting. Many techniques traditionally recommended in the evaluation of abnormal cervical cytology and the treatment of CIN in the nonpregnant woman, such as colposcopy, cervical biopsy, and electrosurgical excision, can be applied to the pregnant patient with important exceptions. The vascular cervix associated with the gravid condition and the risk of premature pregnancy loss mandates deviation from existing consensus guidelines in screening for cervical cancer in pregnancy and treating associated CIN. In the present review, current guidelines regarding cervical cancer screening are reviewed, and data from studies of pregnant populations are summarized.

Gynaecological malignancies in pregnancy

PURPOSE OF REVIEW

To review the management of gynaecological cancers occurring in association with pregnancy. To consider the impact of the cancer on the pregnancy, and the impact of the pregnancy on the cancer.

RECENT FINDINGS

The management of gynaecological cancers in pregnancy remains, fortunately, a rare problem for the gynaecological oncology team. This inevitably means that many management decisions will be informed by relatively small case series and case reports. There have been interesting reports where pregnancy has been prolonged to achieve fetal viability in both cervix and ovary cancer in pregnancy, and these are discussed below.

SUMMARY

Any cancer in pregnancy is a catastrophic event for the woman and her partner, and poses great challenges for the multidisciplinary team responsible for her care. Gynaecological cancers in pregnancy are even more stressful as the woman will naturally worry about the survival of her baby, and the implications for her future fertility. Fortunately the outcome for most women and their babies is favourable.

Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: The cochrane colposcopy & cervical cytopathology collaborative group (C5 group) approach

This overview presents the up-to-date evidence on colposcopy practice and other diagnostic modalities such as HPV DNA test and cytology for cervical intraepithelial neoplasia (CIN). Current evidence supports the use of colposcopy for the detection of intraepithelial lesions as a second line tool. CIN treatment involves either excisional or destructive techniques, usually performed under local anesthesia. Although a debate exists about the most efficient approach, the currently available evidence reveals no differences in efficacy among the available conservative methods of treatment. New evidence supports treatment by destructive rather than excisional techniques, at least for low grade lesions in women wishing future childbearing, as they appear to have no apparent pregnancy-related morbidity. Treatment failures rates might increase in cases of involved excision margins, older age or glandular involvement. There is no worldwide consensus on the optimal follow-up policy, interventions or frequency in surveillance after treatment. HPV DNA test combined with either colposcopy or cytology is a promising combination for the early detection of treatment failures due to residual disease. Existing guidelines should probably be updated incorporating the new information emerged from recently published work.

Lésions cervicales utérines pendant la grossesse : diagnostic et prise en charge

OBJECTIVES

To define a practical attitude for the management of pregnant women with cervical intraepithelial neoplasia (CIN) and cervical cancer.

MATERIALS AND METHODS

Review of the literature indexed in Medline.

RESULTS

The prevalence of the HPV infections is unchanged among pregnant women with infection by low risk viruses. The viral load increases at the time of the pregnancy, and decreases in the post-partum period. Cervical cytology is easily to perform with reliable results: among the 5% of pathological cervical smears, low grade lesions predominate. The high grade smears require colposcopic exploration, usefully completed by directed biopsies to rule out invasive lesions. Surveillance of high grade CIN is required during pregnancy with post-partum control; most regress. In France during the year 2000, 189 cancers of the uterine cervix were detected during 774.782 pregnancies. Clinical diagnosis is delayed by the non specific clinical signs and the histological aspects of the lesions which are identical with those observed in young woman. The intrinsic outcome of cancer is not modified by pregnancy, and the cesarean section is often preferred (vaginal delivery likely facilitates vascular dissemination). For fetal reasons, a therapeutic delay can be proposed for small sized lesions with a favourable histological subtype and no progression after 20 weeks of gestation.

CONCLUSION

Pregnancy offers the opportunity to perform cervical smears in women not regularly followed. A conservative attitude with a revaluation in postpartum can be proposed in the event of diagnosis of CIN during pregnancy. Pregnancy has little influence on invasive cervical cancers. Management decisions must be made on a case-by-case basis.

Assessing the accuracy of colposcopy at predicting the outcome of abnormal cytology in pregnancy

OBJECTIVE

To determine the accuracy of colposcopic and cytological assessment at predicting final histological diagnosis in women referred with abnormal cervical smears during pregnancy; to use this data as a basis for a follow up protocol for pregnant patients referred with abnormal cervical cytology.

STUDY DESIGN

Retrospective analysis of women referred to Queens Medical Centre, Nottingham, UK with abnormal cytology whilst pregnant between 1994 and 2003.

RESULTS

Forty-nine patients in total were included in the study. Colposcopic assessment in the antenatal period had a concordance with final histological diagnosis in 60% of patients and a concordance of 68% when undertaken in the post-natal period. Cytological concordance was lower at 58%. In only six percent of patients was a cervical biopsy undertaken and there were no complications as a result. There was a fall in colposcopically assessed high-grade cervical intraepithelial neoplasia between the antenatal and post-natal period. No cases of invasive cancers were diagnosed antenatally.

CONCLUSION

A policy of conservative management of pregnant patients during the antenatal period is supported by this data. A suggested protocol of one colposcopic assessment at the time of the index abnormal smear followed by a post-partum colposcopy, and appropriate treatment is suggested.

Cervical neoplasia during pregnancy: Diagnosis, management and prognosis

Pregnancy represents an exceptional opportunity for the early diagnosis of cervical cancer since visual inspection, cytological examination and bimanual palpation are considered to be part of routine antenatal care. An abnormal cervical smear should generally be managed as in the non-pregnant state. However, colposcopy and biopsies are mainly intended to exclude invasive disease because a conservative approach is preferred in cases of pre-invasive disease. The only absolute indication for conization in pregnancy is to rule out (micro-)invasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing or mode of delivery. Overall, earlier stages of cervical cancer are encountered during pregnancy compared with the general population. Although stage of disease and gestational age will largely influence the timing of the interventions, treatment of invasive cervical cancer is similar to the non-pregnant state. In strongly desired pregnancies, the use of neo-adjuvant chemotherapy in order to obtain fetal maturity should be considered and discussed with the patient. Although good evidence supports short-term safety, long-term data regarding the in-utero exposure of cytotoxic drugs need to be consolidated. After stratifying for stage, the outcome is similar to the non-pregnant state.

Effect of delivery route on natural history of cervical dysplasia

OBJECTIVE

This study was undertaken to determine the (1) impact of delivery route on the natural history of cervical dysplasia and (2) overall regression rates of cervical dysplasia in pregnant women.

STUDY DESIGN

A retrospective analysis was performed on 705 pregnant women with abnormal Papanicolaou tests who presented for prenatal care at the Kapiolani Medical Center Women's Clinic in Honolulu, Hawaii, between 1991 and 2001. Data collection included demographics, delivery route, and cervical pathology.

RESULTS

Two hundred one patients met the inclusion criteria. Regression rates for vaginal and cesarean section groups were as follows: atypical squamous cells (64% vs 70%, P = .32), low-grade squamous intraepithelial lesion (58% vs 42%, P = .073), and high-grade squamous intraepithelial lesion (53% vs 25%, P = .44). Of the total population, 30% of lesions persisted postpartum, 58% regressed, and 12% progressed.

CONCLUSION

Mode of delivery does not influence the natural history of dysplastic lesions. Gravid and nongravid women have similar regression rates.

Gynaecological malignancies in pregnancy: a review

Gynaecological malignancies frequently occur in women of reproductive age and are estimated to complicate approximately one in 1000 pregnancies. The incidence of gynaecological malignancies during pregnancy is expected to rise as more women delay childbearing into their later reproductive years, and maternal age is the most powerful predictor of cancer risk. Pregnancy-associated malignancies present significant challenges as a result of the conflict between optimal maternal therapy and fetal well-being. The lack of prospective randomised treatment studies has prevented the development of clinical guidelines for most of the issues complicating the management. In the present review, recent diagnostic and treatment strategies for cervical, ovarian, vulvar and endometrial carcinomas during pregnancy are presented.

Prise en charge d’une néoplasie intra-épithéliale du col de l’utérus en cours de grossesse

Approximately 30% of women diagnosed with cervical cancer are in their childbearing years. Prenatal care provides an excellent opportunity for cervical cancer screening. The incidence of abnormal Pap smear has been reported in 5-8% of pregnant women. But we must know that Pap smears have cytologic modifications because of pregnancy. All abnormal smears have to be referred to colposcopic examination. The squamocolumnar junction is visualized in almost 100% of cases. The sensitivity of colposcopy is nearly 87% with complete concordance in 72.6%. Colposcopically directed biopsies have a good correlation with the final diagnosis with very minimal risks for both mother and fetus. The high rate of complications (hemorrhage, abortion, premature labor) and residual lesions in half of cases do not encourage conization during pregnancy. The final treatment is carried out after delivery. The only absolute indication for conization in pregnancy is to rule out microinvasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing of delivery but also when there is a no satisfactory colposcopy and a high-grade Pap smear. In these cases conization is performed for diagnostic and not therapeutic purpose. We must be aware of the high rate of loss of follow-up (6-33%).

Cancer in pregnancy: maternal-fetal conflict

The occurrence of malignancies during pregnancy has increased over the last decades. They complicate approximately 1 per 1000 pregnancies. The most common malignancies associated with pregnancy include malignant melanoma, malignant lymphomas and leukemia, and cancer of the cervix, breast, ovary, colon and thyroid. Since it is impossible for prospective randomized clinical trials to be conducted in this field, relevant data have been generated from case reports and matched historical cohort studies in order to evaluate the treatment outcomes and the issues complicating the management of malignancy in the pregnant patient. There is almost always a conflict between optimal maternal therapy and fetal well-being. The maternal interest is for an immediate treatment of the recently diagnosed tumor. However, the optimal therapy, be it chemotherapy, radiotherapy or surgery, may impose great risks on the fetus. Consequently, either maternal or fetal health, or both, will be compromised. Therefore, both the pregnant patient and her physician are often in a dilemma as to the optimal course. On the basis of the medical facts, we discuss the issues raising potential ethical conflicts and present a practical ethical approach which may help to increase clarity in maternal-fetal conflicts. We review the available data informing the incidence and impact of the most common malignancies during pregnancy and their treatment on both the pregnant woman and her fetus. The optimal therapy for the tragic diagnosis of cancer in pregnancy requires a collaborative and interdisciplinary approach between gynecologists, oncologists, obstetricians, surgeons, neonatologists, psychologists, nursing staff and other disciplines. The purpose of this article is not to answer specific questions or to construct management schemes for specific tumors but to provide a framework for approaching some of these complex issues.

Cancer and pregnancy: recent developments

PURPOSE OF REVIEW

Breast carcinoma, cervical dysplasia and cervical carcinoma are some of the most common forms of precancerous and malignant changes seen in pregnancy due to their prevalence in reproductive age women. The impact of pregnancy on these diseases is complex and needs to be carefully considered for appropriate clinical management.

RECENT FINDINGS

Recent studies indicate a relationship between hormone levels during pregnancy and subsequent breast cancer risk. For women who have already been diagnosed with breast cancer, retrospective studies show no adverse outcomes on maternal mortality with subsequent pregnancy. Prospective studies are needed to further elucidate these relationships. Recent research evaluating human papilloma virus in pregnant women indicates a similar prevalence of disease among pregnant and nonpregnant patients. Increased rates of human papilloma virus clearance postpartum may be related to an increased immune response within the cervix secondary to the trauma of labor. For women with early stage cervical cancer desiring to preserve future fertility, new trends in treatment allow for preservation of reproductive function. Few recent studies have been conducted regarding the use of chemotherapy during pregnancy, but one study reports increased rates of prematurity after the use of chemotherapy.

SUMMARY

Continued research is needed regarding the management of breast and cervical cancer during pregnancy in order to optimize treatments and to further our understanding of these disease processes.

Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment

OBJECTIVE

To investigate patients with invasive cervical carcinoma associated with pregnancy, with special reference to the maternal and neonatal outcomes after planned treatment delay to improve fetal maturity.

METHODS

The medical records of 28 patients with invasive cervical carcinoma diagnosed during pregnancy or within 1 month after pregnancy were retrospectively reviewed.

RESULTS

Twenty-two patients (79%) had Stage I disease and 6 (21%) had Stage II or III disease. Tumor histology revealed squamous cell carcinoma in 27 cases and adenocarcinoma in 1. Twenty cases were diagnosed before 22 weeks gestation, 4 between 22 and 36 weeks, 1 after 36 weeks gestation, and 3 were diagnosed postpartum. In the immediate treatment group (n = 16), the diseases were Stage IA in 3 cases, IB in 7, and II or III in 6. In 11 patients, hysterectomy was performed after therapeutic abortion or with fetus in situ. In 2 patients, cesarean section was followed by hysterectomy or radiotherapy. Three patients diagnosed postpartum were treated with either hysterectomy or radiotherapy. Fifteen patients were free of disease during the follow-up of 27 to 114 months. In the delayed treatment group (n = 12), the diseases were Stage IA1 in 8 cases, IA2 in 1, IB1 in 2, and IB2 in 1 case. In 8 patients with Stage IA1 tumor, the treatment was deferred until term with a delay of 6 to 25 weeks, and hysterectomy or therapeutic conization was performed after delivery. In 4 patients with Stage IA2, IB1 or IB2 tumor, the treatment was postponed until after 30 weeks gestation with a delay of 6 to 15 weeks. No disease progression was documented. Cesarean delivery was followed by hysterectomy in these patients. All patients were free from disease during the follow-up of 70 to 156 months and their babies were well with no sequelae.

CONCLUSION

Delay in treatment to allow for fetal maturity is safe in patients with early Stage I cervical carcinoma associated with pregnancy.

Cervical cancer during pregnancy

Cervical cancer is one of the most devastating conditions that can complicate a pregnancy. Stage for stage, treatment for squamous cell cervical cancer is the same as that given in the non-pregnant patient. Radical surgery is the treatment of choice for the early stages of the disease. Although a planned delay in therapy may be considered for up to 20 weeks, for stages IA and IB1, it should be implemented cautiously and with the patient's full awareness of the risks. If delay is considered for higher stages, the patient must be aware of the paucity of data to support this plan. Chemoradiation is the standard treatment for advanced cancer of the cervix. When acceptable fetal maturity has been reached, a classical Caesarean section is usually performed prior to definitive treatment.

Management of the pregnant mother with malignant conditions

A malignancy discovered in pregnancy is often difficult to manage; the optimal maternal therapy has to be balanced with the fetal well-being. Generally, the cancer is managed as though the patient is not pregnant. For the various site-specific cancers, surgery is the main modality of treatment; this should be individualized. Chemotherapeutic agents are highly teratogenic in the first trimester, with some adverse effects when used after 12 weeks' gestation. The overall survival rate for pregnancy-associated breast cancer is poor; the reasons for this are discussed. For cervical cancer, delivery by caesarean section appears to be the method of choice, with significantly better survival rates compared with those who deliver vaginally. Other gynaecological and non-gynaecological malignancies are discussed.

Loop electrosurgical excision procedure (LEEP) during first trimester of pregnancy

Loop electrosurgical excision procedure (LEEP) during pregnancy can be performed safely as in non-pregnant women and can replace traditional cone biopsy when performed in the first trimester.