Management of the abnormal cervical smear and carcinoma in situ of the cervix during pregnancy

Evidence Supporting the Current Management Guidelines for High-Grade Squamous Intraepithelial Lesion Cytology

OBJECTIVE

The study was undertaken to provide consensus guidelines for the management of women with a cytologic interpretation of high-grade squamous intraepithelial lesion (HSIL) on cytologic examination. This review article presents relevant literature supporting the proposed guidelines.

PARTICIPANTS

An independent panel of 121 experts in various aspects of the diagnosis and management of cervical cancer precursors, including representatives from 29 participating professional organizations, federal agencies, national and international health organizations, and others were invited by the American Society for Colposcopy and Cervical Pathology.

CONSENSUS PROCESS

Guidelines for the management of women with HSIL cytologic results were developed through a multistep process. Draft management guidelines were developed by the HSIL working group after formal literature reviews and obtained input from the professional community at large by way of an interactive internet-based bulletin board. At the American Society for Colposcopy and Cervical Pathology Consensus Conference, September 6 through 8, 2001, in Bethesda, Maryland, the guidelines were discussed, revised, and adopted by formal vote.

CONCLUSIONS

Evidence-based guidelines have been developed for the management of women with HSIL cytologic results.

Diagnostic significance and sequelae of cone biopsy

All cone biopsies from our institution over a 10-year period were reviewed. Two hundred seventy-one patients underwent 274 procedures. Preoperative colposcopic evaluation markedly reduced the proportion of patients with residual cervical epithelial neoplasia (CIN). No patient in our series required conization for diagnosis of frankly invasive carcinoma. Following colposcopy and conization, 8% of patients had disease extending to the surgical margins; eight of 11 such patients (72%) with adequate follow-up had no further CIN. Colposcopy and cytology underestimate the final pathologic diagnosis in many patients with incomplete visibility of the transformation zone, so conization is mandatory in this circumstance. Conization in pregnancy was associated with increased hemorrhage; colposcopy has reduced the need for this operation in gravid patients.

Colposcopy in pregnancy. A twelve year review

In a 12-year period, 195 patients with abnormal cervical cytology in pregnancy had colposcopy, of whom 73 had Grade IV cytology. Colposcopic findings in pregnancy correlated closely with the postpartum colposcopic assessment and this in turn predicted the ultimate histological diagnosis. Wedge biopsies were taken in two women in whom invasive disease could not be excluded colposcopically. Cone biopsy was avoided in all patients. No frank or occult invasive disease was missed but one patient was ultimately found to have a small focus of microinvasive disease six months post partum. Postpartum cytology gave a reasonable guide to the ultimate histology, although postpartum colposcopy was found to be of value even where cytology had by then reverted to normal.

Evaluation of abnormal cervical cytology during pregnancy with colposcopy

During a 6 1/2 year study period the authors used colposcopy to evaluate 174 pregnant patients with abnormal cervical cytology. The technique of colposcopy proved safe, accurate, and effective in determining the presence or absence of cervical cancer in the present patient's cervix. Colposcopy is mandatory for the evaluation of abnormal cervical cytology during pregancy.

Colposcopic evaluation of the abnormal Papanicolaou test in pregnancy

Colposcopy, including colposcopically directed biopsies in selected cases, was employed to evaluate over 300 pregnant patients with abnormal Papanicolaou tests suggestive of mild dysplasia or worse (Class III to V). Over half of the patients had benign disorders determined by colposcopic examination. All cases of invasive disease were diagnosed by colposcopy and biopsy, and the patients were treated accordingly. Only 3 diagnostic conizations were necessary in the antepartum period. The majority of patients with cervical intraepithelial neoplasia were seen post partum, and appropriate therapy was instituted. In the pregnant patient with an abnormal Papanicolaou test, colposcopy has proved to be a reliable and safe method of evaluation and has virtually eliminated the need for conization.