Colposcopy in pregnancy. A twelve year review

Management of the minimally abnormal papanicolaou smear in pregnancy

OBJECTIVE

To evaluate the effectiveness of colposcopy of the uterine cervix in pregnant patients with minimally abnormal Papanicolaou smears.

METHODS

Two hundred, indigent, pregnant patients with atypical cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesions (LGSIL) on Papanicolaou smear underwent colposcopy and endocervical evaluation. Directed biopsies were performed on 64 patients. One hundred thirty-five patients were compliant with postpartum Papanicolaou smears or colposcopy with endocervical evaluation.

RESULTS

One hundred eighty-seven pregnant patients had satisfactory prenatal Papanicolaou smears, colposcopy and endocervical brushings. High-grade intraepithelial lesions were found in 2.1% of prenatal endocervical brushings, 4.7% of prenatal biopsies, 0.8% of postpartum Papanicolaou smears, 2.2% of postpartum endocervical brushings, and 7.9% of postpartum biopsies. No invasive cervical cancer was detected.

CONCLUSION

Antepartum colposcopic evaluation did not add in the management of minimally abnormal Papnicolaou smears in this population of pregnant women.

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.

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.

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.

Prepregnancy and early pregnancy care

There is ample evidence to support the familiar message offered to women early in pregnancy that they should stop smoking, limit their alcohol intake to less than two units daily, avoid all unnecessary drugs and eat a normal well-balanced diet. They may continue to take exercise and work (in almost all occupations) without any risk to the fetus. For doctors the challenge is to balance their wish to pass on the scientific evidence with the obligation to address the concerns and needs of their individual patients. Routine screening in early pregnancy should be continued for syphilis and rubella, but the benefits do not justify it for other infectious illness, including urinary tract infection. The arguments for screening for toxoplasmosis in pregnancy are finely balanced; if more effective treatment were available then screening might become worthwhile. Provided a full screening programme for cervical cancer is achieving reasonable coverage for the adult female population, there is no need for additional screening in pregnancy. Unplanned and unwanted pregnancy is a substantial problem in the United Kingdom and will continue to be so. For those that request it, termination is a safe procedure with low morbidity, especially when carried out early on. Women with unplanned pregnancies are entitled to advice from their doctors in order to help them decide whether they want a termination or not.

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.

Selective screening for cancer of the cervix uteri in South Indian women

In India, the need exists for a scheme of selective screening for women at high risk of developing cervical carcinoma. In this study, the incidence of abnormal cervical cytology amongst 500 pregnant south Indian women (gravida 3, para 2 or more) who were booked under the Post Partum Programme of the Government of India was compared to that of 200 primi and second gravidas from the same out patient clinic population. Abnormal cytology was detected in 3.6% of the women in the study group which was significantly higher (P less than 0.05) than that in the control (0.5%), indicating that the former are at higher risk of developing cervical cancer. Within the study group, abnormal cytology was not found to correlate with increasing age and gravidity or with any clinical parameter. The study and follow up could be carried out using existing facilities and manpower. Using existing personnel involved in the Post Partum Programme, a follow up rate of 67% could be achieved from among women with abnormal cervical cytology. The cost-effectiveness of this scheme of selective screening is borne out by the extremely modest additional cost incurred.