Colposcopic evaluation of the abnormal Papanicolaou test in pregnancy

High-Grade Cervical Intraepithelial Neoplasia (CIN) in Pregnancy: Clinicotherapeutic Management

An increasing incidence of cervical intraepithelial neoplasia (CIN) among young women has been noticed in recent years. For this reason pregnancy might represent a peculiar opportunity to undergo cytocolposcopic examination for those women who do not take part in a screening program for cervical carcinoma. Diagnosis of CIN during pregnancy poses the question of the management of this disease and particularly of whether it is better to treat the lesion or not during pregnancy. To contribute to the solution of this issue we initiated a study on the management of high-grade CIN in pregnancy.

Material and methods

Five hundred and seventy-one pregnant women underwent cytologic, colposcopic and, when necessary, histologic examination. Those in whom a CIN was discovered in the first four months of gestation underwent laser conization. When the diagnosis of CIN was made after the sixteenth week of gestation, cytocolposcopic monitoring was performed every eighth week during pregnancy and two months after childbirth. Laser conization was performed under colposcopic guidance in the outpatient setting in all cases. All treated patients were submitted to cytologic, colposcopic and, if necessary, histologic examination every third month in the first year after treatment, every sixth month in the second year and yearly from the third year onwards.

Results

In 14 (2.4%) of the 571 examined women a CIN III was discovered, 6 of which associated with a human papilloma virus (HPV) infection. Of these, 8 patients, whose diagnosis was made within the sixteenth week of pregnancy, underwent laser conization. In one case a minor hemorrhage occurred during treatment. Two patients reported minor bleeding up to ten days after treatment. No major hemorrhages or cervical stenosis were observed. Histologic examination of the cones confirmed the preoperative diagnosis based on cervical biopsies and the lesion was entirely removed by conization in all cases. Seven of the 8 patients who underwent laser conization during pregnancy had a spontaneous delivery at term. The remaining patient, who had had a previous cesarean section, was again delivered by cesarean section. All treated patients were cured after the first-year follow-up visit. In 6 patients CIN was diagnosed after the sixteenth week of pregnancy. These women underwent cytocolposcopic examination every eighth week during pregnancy and two months after delivery, when the cervical changes associated with gestation had disappeared. Four of these patients showed persistence of CIN at postpartum follow-up and therefore underwent laser conization. In two patients spontaneous regression of the lesion was observed. In no case did progression to invasive carcinoma occur.

Conclusions

Given the increasing incidence of CIN in young women, the beginning of pregnancy may represent a peculiar opportunity for all pregnant women who do not take part in cervical screening programs to undergo a cytocolposcopic examination. In case of a diagnosis of high-grade CIN within the first 16 weeks of pregnancy, a conservative excisional treatment, which does not expose the pregnancy to any risk, should be carried out in order to confirm the intraepithelial localization of the lesion.

Clinical Trials in Cervical Intraepithelial Neoplasia: Balancing the Need for Efficacy Data with Patient Safety

OBJECTIVE.: Trial designs for novel nonsurgical, nonablative therapies for cervical intraepithelial neoplasia grades 2 and 3 (CIN 2,3) must ensure patient safety while providing sufficient time to show clinical effects. We propose an observation period based on literature and current practice. MATERIALS AND METHODS.: We reviewed 3 types of literature regarding observation of untreated CIN 2,3: 1) the management of CIN in pregnancy, perhaps the best existing model of observation; 2) the natural history of untreated CIN 2,3; and 3) the optimal means of protecting patient safety during longer-term follow-up of untreated CIN 2,3 lesions. RESULTS.: Data from both the pregnant and nonpregnant patient populations indicate that delaying treatment of CIN for periods of several weeks to several months is rarely associated with clinically significant disease progression. Screening and follow-up criteria that promote patient safety have been suggested and seem adaptable to clinical trials. CONCLUSIONS.: Careful screening and follow-up of patients with CIN 2,3 allows an observation period of at least 6 months after nonsurgical, nonablative therapy in clinical trials.

Postpartum Evolution of Cervical Squamous Intraepithelial Lesions with Respect to the Route of Delivery

OBJECTIVE.: To analyze the effect of the mode of delivery on the evolution of cervical squamous intraepithelial lesions. MATERIALS AND METHODS.: A chart review was performed of all pregnant women referred to the Northwestern Memorial Hospital Colposcopy Clinic between January 1990 and December 1998. Postpartum changes in the Pap smear and in a combined cytologic, histologic, and colposcopic impression of cervical status were evaluated. Data were analyzed using the chi, Fisher exact test, or Student t test. RESULTS.: Antepartum cytology was atypical squamous cells of undetermined significance in 23 women (7.1%), low-grade squamous intraepithelial lesions in 226 women (69.3%), and high-grade squamous intraepithelial lesions in 77 women (23.6%). Vaginal delivery occurred in 300 women (92.0%); 6 women (1.8%) had an elective cesarean section, and 20 women (6.1%) underwent a cesarean section after laboring. Of 306 women who had postpartum Pap smears, 37.9% had no change, 58.8% had improvement, and 3.3% had worsening of their cervical cytology. The rates of improvement of postpartum Pap smears were 164/285 (57.5%) following a vaginal delivery and 16/21 (76.2%) after a cesarean section (p = .81). Similarly, using a combined histologic, colposcopic, and cytologic evaluation of the cervix, the route of delivery did not affect postpartum cervical status (p = .68). CONCLUSION.: The route of delivery did not appear to influence the evolution of cervical squamous intraepithelial lesions during pregnancy and the puerperium.

Management of the abnormal papanicolaou smear during pregnancy: lessons for quality improvement

OBJECTIVE

Our goal in this study was to evaluate the management of pregnant patients with abnormal Papanicolaou smears.

MATERIALS AND METHODS

We reviewed the records of 292 patients undergoing colposcopy to evaluate abnormal cervical cytology during pregnancy.

RESULTS

A total of 32 (11%) of the subjects had Papanicolaou smears demonstrating atypical glandular cells of undetermined significance; 178 (61%) had low-grade squamous intraepithelial lesions; 69 (23.6%) had high-grade squamous intraepithelial lesions; and 2 (1%) had a malignancy. The first colposcopy was performed most commonly during gestational week 24. Colposcopy showed findings consistent with minor changes in 154 cases (53%) and with major changes in 61 (21%). Only 27 patients (9% of the total) underwent a colposcopically directed biopsy, and 51 (83.6%) of the 61 patients with a colposcopic impression of cervical intraepithelial neoplasia grade 2 or greater did not undergo biopsy. Only 24 (26%) of the 91 patients scheduled for follow-up colposcopy during pregnancy complied, and 123 of the 292 patients (42%) returned for follow-up examinations after delivery. Four patients had an invasive cervical carcinoma diagnosed in the 12 months immediately after delivery. Although the first intrapregnancy colposcopy in two of these patients noted findings consistent with cervical intraepithelial neoplasia grade 2 or greater, none of the four underwent biopsy during pregnancy.

CONCLUSIONS

Evaluation of cytological abnormalities is frequently suboptimal during pregnancy. The threshold for colposcopically directed biopsy is often modified during pregnancy in a way that may be harmful to the patient. Extra effort is needed to tailor follow-up to the patient's need and to improve patient compliance.

The effect of route of delivery on regression of abnormal cervical cytologic findings in the postpartum period

OBJECTIVES

We sought to determine whether pregnant women with abnormal antepartum cervical cytologic findings differ in their postpartum rates of regression with respect to mode of delivery.

STUDY DESIGN

Between 1990 and 1997, 446 pregnant women with antepartum abnormal cervical cytologic findings were identified. Complete demographic, clinical, and cytologic reports were available for 138 women. Papanicolaou smear data were collected and separated into three groups by use of the Bethesda classification system (atypical squamous cells of undetermined significance, low-grade squamous intraepithelial cells, and high-grade intraepithelial cells). Postpartum regression rates of antepartum Papanicolaou smears, with respect to degree of squamous epithelial cell abnormality and mode of delivery, were analyzed by Fisher's exact and Wilcoxon rank sum tests.

RESULTS

Of the 138 women, 109 (79%) were delivered vaginally and 29 (21%) by cesarean section. No statistically significant difference was found between women delivered vaginally and those delivered by cesarean section with respect to age, parity, and smoking history within the three groups (atypical squamous cells of undetermined significance, low-grade squamous intraepithelial cells, and high-grade squamous intraepithelial cells). The overall postpartum regression rate for the 59 women with antepartum high-grade squamous intraepithelial cells was 48%. Of the 47 women with high-grade squamous intraepithelial cells who were delivered vaginally, 28 showed regression in the postpartum period versus none of the 12 women delivered by cesarean section (60% vs 0%, p < 0.0002).

CONCLUSION

Postpartum spontaneous regression of Papanicolaou smears consistent with high-grade squamous intraepithelial cells occurs with increased frequency among women who are delivered vaginally versus by cesarean section.

Noninvasive cervical cancer complicating pregnancy

The management of abnormal cytology during pregnancy has changed dramatically during the last 3 decades. The goal has been and remains timely diagnosis of and treatment planning for invasive carcinoma of the cervix. Because therapy for preinvasive disease can safely be postponed until the postpartum period, the ability to distinguish CIN from invasive cancer without cone biopsy has been a major step forward in the management of cervical disease in pregnancy. The data presented herein demonstrate the safety and accuracy of the more conservative approach of colposcopy and biopsy. The use of cone biopsy during pregnancy, associated with substantial morbidity, has been significantly reduced by the diligent application of colposcopy. As is true in the nonpregnant state, cone biopsy is necessary when colposcopic examination is nonsatisfactory. Cone biopsies cannot be considered therapeutic during pregnancy owing to the high incidence of positive margins and residual disease on postpartum evaluation. For this reason, the importance of postpartum reevaluation cannot be overemphasized.

Abnormal cervical cytology in pregnancy: experience of 811 cases

This paper reviews our hospital's experience spanning 15 years and involving 811 women referred with abnormal cervical cytology in pregnancy. It supports the safety and accuracy of managing dysplasia in pregnancy with colposcopy, directed punch biopsy and deferral of treatment until the postpartum period. The histologically-proven progression in pregnancy to a higher grade of dysplasia postpartum was 7%. None of the women are known to have developed microinvasive or invasive cancer between antenatal assessment and postpartum review. Of these 811 women, 16% were lost to follow-up, 1 of whom subsequently represented 4 years later with invasive cervical cancer.

Colposcopy and directed biopsy reliability during pregnancy: a cohort study

The reliability of cytology, colposcopy, and directed biopsy were assessed in pregnancy and compared with that observed in a matched non-pregnant control group in order to evaluate the influence of pregnancy. One hundred and seventeen gravidas in which the final pathology could be ascertained and 234 control patients were examined by the same colposcopist. Concordance between cytology and final diagnosis was complete or within one degree of severity in 55.6% and 77.8% of patients, respectively. Unsatisfactory colposcopy was significantly less frequent in pregnant patients than in controls (12.8% vs. 23.1%, P = 0.023). In pregnant patients, colposcopy provided concordance, overestimation and underestimation of the final diagnosis in 72.6%, 17.6% and 9.8%, respectively. In the same group, the concordance between the histologic findings of directed biopsy and final diagnosis was complete or within one degree of severity in 83.7% and 95.9%, respectively. The reliability of cytology, colposcopy and directed biopsy was not related to pregnancy. These data show that the physiological changes which occur in pregnancy do not significantly alter the reliability of colposcopy and directed biopsy, if the colposcopist is aware of the peculiar difficulties and does not overreact to the accentuated patterns that may occur during pregnancy.

Conservative management of cervical intraepithelial neoplasia during pregnancy

Conservative treatment of a pregnant woman with moderate dysplasia that progressed to microinvasive carcinoma within 6 months is presented along with a review of the relevant literature to date. Pregnancy does not necessarily create special difficulties for the detection and diagnosis of cervical lesions as long as the patient is followed carefully. In this case, close observation using cytology and colposcopy along with colposcopically directed excisional biopsy postponed the need for more aggressive intervention, while minimizing possible disruption of the pregnancy and danger to the mother and infant. A simple hysterectomy performed 6 weeks postpartum proved successful and the cancer has not recurred.

Colposcopic evaluation of abnormal Papanicolaou smears in pregnancy

Colposcopy was used to examine 401 pregnant patients with cytologic or clinical abnormalities of the cervix to determine if routine biopsy could be safely omitted except where the colposcopic impression was one of possible invasive carcinoma. A comparison of the antepartum colposcopic impressions with the postpartum histologic diagnosis revealed agreement to within one degree in 87% of patients, with 3% of patients showing a more advanced lesion than that anticipated. Only 2% of patients showed a progression of cytologic abnormalities at postpartum examination; 39% showed marked improvement. Four of nine patients with invasive carcinoma were diagnosed at antepartum colposcopy, with an additional two patients recognized as having invasive cancer at the postpartum colposcopic examination. The omission of routine biopsy is less than ideal if only one antepartum colposcopy is performed, since a considerable period of time may elapse before the patient is seen again postpartum. Those situations in which it may be omitted, together with guidelines for the management of pregnant patients with abnormal cervical cytologic findings, are presented.

Clear cell adenocarcinoma (CCA) of the vagina and cervix in association with pregnancy

The effect of pregnancy on patients with CCA of the vagina and cervix was evaluated based upon a review of 503 cases. Eighty-five had been pregnant (24 at diagnosis), 408 had never been pregnant, and the pregnancy history was unavailable in 10 cases. All of the 24 patients pregnant at diagnosis were over 16 years of age; 14 were in the first trimester, 6 in the second, and 4 in the third trimester. By FIGO criteria, 15 were stage I, 7 stage II, and 2 were stage III. The 24 pregnant and 408 never pregnant (age corrected) cases were compared with regard to maternal hormone history, symptoms, stage, location, predominant histologic or cell type, greatest tumor diameter, surface area, depth of invasion, grade, and number of mitoses. No significant differences were detected. Twelve of the 24 pregnant patients had radical hysterectomy with or without irradiation (9 stage I, 3 stage II); of the 7 treated by local therapy (5 stage I, 2 stage II), 3 required additional therapy due to persistent disease; 4 had radiotherapy alone (1 stage I, 2 stage II, and 1 stage III); one had teletherapy followed by exenteration (stage III). Six of the 24 died 2 to 12 years after diagnosis (1 stage I, 3 stage II, 2 stage III). Eighteen are alive at 1 to 17 years. The overall 5 and 10 year actuarial survival rates (age adjusted) for the group pregnant at diagnosis (86 and 68%) do not differ significantly from the never pregnant group. Pregnancy does not seem to adversely affect the outcome of CCA. Guidelines are presented to treat pregnant patients with CCA.

The value of colposcopy in follow-up care of the treated gynecologic oncology patient

The diagnostic value of colposcopy for primary gynecologic malignancies is well accepted. This study was conducted to determine the value of colposcopy in follow-up examinations of treated gynecologic oncology patients. The original gynecologic malignancies included carcinomas of the cervix, endometrium, ovary, vulva, vagina, fallopian tubes, and uterine sarcomas. Distinct colposcopic changes could be identified secondary to radiation therapy, granulation tissue, surgery, and recurrent disease. One-hundred eight treated gynecologic oncology patients were colposcopically examined. Twenty-four of the one-hundred eight patients developed recurrent disease. Thirteen of twenty-four patients had recurrent disease in the vagina, on the cervix, or the vulva. The recurrent disease in these 13 patients was colposcopically diagnosed.

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.

Colposcopy in the management of the pregnant patient with abnormal cervical cytology

Thirty patients with abnormal cervical cytology had a colposcopy during pregnancy. Their management during and after pregnancy is described and supports the contention that the introduction of a colposcopy service safely permits a greater selectivity in management without recourse to operative intervention during pregnancy. In one patient a preclinical invasive squamous carcinoma of the cervix was diagnosed by colposcopy, and in another three, in whom colposcopy could not exclude the presence of invasion, a wedge biopsy under anaesthesia and two punch biopsies without anaesthesia had to be performed. In the remaining 26 patients, the possibility of invasion could be excluded by colposcopy and further treatment deferred until after pregnancy.

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 pregnant patients with abnormal cervical smears

Colposcopic examination and biopsy were used to assess 123 pregnant patients presenting with abnormal cervical smears. Eighty-seven per cent were 30 years of age or less and 95 (77 per cent) had had one or no previous children. Two patients were found to have microinvasive carcinoma and, in an additional 95 patients, either severe dysplasia or carcinoma in situ was present. Fifty-five patients (45 per cent) had subsequent conization or hysterectomy and in no instance was the histological diagnosis more serious than that anticipated from the colposcopic evaluation. Only three patients (1-6 per cent) had a cone biopsy during pregnancy; only one minor complication occurred. Colposcopic examination is the choice method of evaluating patients with abnormal cervical smears in pregnancy.