Abnormal Pap smear among pregnant women - Feasibility of opportunistic cervical screening

Objective

The uptake of cervical cancer screening is poor, especially in developing countries. Thus, pregnancy represents a good opportunity to have the test done. The aim of this study is to determine the prevalence of abnormal Pap smear among pregnant women during their antenatal check-ups.

Study design

A prospective study involving five hundred and ninety-six women was recruited over a 1-year duration from 15th January 2018 until 14th January 2019 in a tertiary referral center, in Malaysia. Pap smears were performed on all consented pregnant women using liquid-based cytology and the results were obtained to evaluate the prevalence of abnormal Pap smear during pregnancy. Maternal risk factors associated with abnormal Pap smear were identified and the outcomes of abnormal Pap smear were followed up.

Results

A total of 670 participants were approached and 596 participants agreed to participate, giving a response rate of 89.0 %. Therefore, 587 participants were available for analysis. There were nine unsatisfactory smears (1.5 %). The prevalence of premalignant lesions reported on p % ap smear was 0.8 %. Three respondents had atypical squamous cells of undetermined significance (ASCUS) (0.5 %) and two respondents had low-grade squamous intraepithelial lesions (LSIL) (0.3 %). Almost one-third (30.3 %) of respondents had an infection and 24 (4.1 %) smears were reported as reactive changes associated with inflammation. Respondents between the age of 20-30 years old had a significant association with an abnormal pre-cancerous smear (p = 0.000) as well as nulliparity (p = 0.0.40). There was no significant association between height, weight, BMI, sexual partner, age of first intercourse, smoking habit, history of sexually transmitted disease and history of abnormal Pap smear.

Conclusion

The prevalence of abnormal pre-cancerous smears during pregnancy is low. However, it is desirable to perform cervical screening as it provides an opportunity to no screening at all.

Characterization and clinical management of abnormal cytology findings in pregnant women: a retrospective analysis

PURPOSE

The diagnosis of cervical intraepithelial neoplasia during pregnancy poses a great challenge to the treating clinician and the patient. According to the current guidelines, watchful waiting during pregnancy can be justified. Only in cases of invasion, immediate treatment may be indicated. However, few data are available on the management of cervical dysplasia during pregnancy. Further research is important for counselling affected women.

METHODS

Data of pregnant patients with suspected cervical dysplasia who presented to the University Women's Hospital Tübingen between 2008 and 2018 were evaluated retrospectively. Colposcopic, cytologic, and histologic assessment was performed for diagnosis. Data on remission, persistence and progression of disease based on histologic and cytologic assessment and the mode of delivery were correlated.

RESULTS

142 patients were enrolled. Cytology at first presentation was PAPIII (-p/-g) in 7.0%, PAPIIID (IIID1/IIID2) in 38.7%, PAPIVa (-p/-g) in 50.0%, PAPIVb (-p) in 2.8%, and PAPV (-p) in 1.4%. All cases with suspected invasion were recorded at the initial presentation. Complete histological or cytological remission was observed in 24.4%, partial remission in 10.4%, persistence in 56.3%, and progression in 8.9%. In two cases (1.5%) progression to squamous cell carcinoma occurred.

CONCLUSIONS

Watchful waiting for cervical intraepithelial neoplasia during pregnancy seems to be sufficient and oncologically safe. It is important to exclude invasion during pregnancy, to perform frequent colposcopic, cytologic and histologic examinations and to ensure a postpartum follow-up examination to initiate the treatment of high-grade lesions. Spontaneous delivery seems to be safe in patients with cervical dysplasia, Caesarean section is not indicated.

Imaging Cancer in Pregnancy

Pregnancy-associated cancer (PAC) is defined as cancer that is detected during pregnancy and up to 1 year postpartum. Although rare (~1:1000 pregnancies), PAC is increasing owing to postponed childbearing and advanced maternal age at conception. Cancer-related symptoms masked by physiologic gestational changes may delay diagnosis. Imaging, clinical management, and treatment require a carefully choreographed multidisciplinary team approach. The risk-benefit of every imaging modality, the strategies to balance the safety of mother and fetus, and the support of the patient and family at every step are crucial. US and MRI are preferred imaging modalities that lack ionizing radiation. Radiation dose concerns should be addressed, noting that most imaging examinations (including mammography, radiography, CT, and technetium 99m-labeled sulfur colloid sentinel lymph node staging) are performed at radiation levels below thresholds at which deterministic side effects are seen. Dose estimates should be provided after each examination. The use of iodinated intravenous contrast material is safe during pregnancy, but gadolinium-based contrast material should be avoided. Accurate diagnosis and staging combined with gestational age affect decisions about surgery and chemotherapy. Whole-body MRI with diffusion-weighted sequences is ideal to screen for primary and metastatic sites, determine disease stage, identify biopsy targets, and guide further cancer site-specific imaging. The authors provide an update of the imaging triage, safety considerations, cancer-specific imaging, and treatment options for cancer in pregnancy. An invited commentary by Silverstein and Van Loon is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Maslinic Acid Inhibits Cervical Intraepithelial Neoplasia by Suppressing Interleukin- 6 and Enhancing Apoptosis in a Mouse Model

BACKGROUND

Cervical Intraepithelial Neoplasia (CIN) directly precedes cervical cancer, and elevated proinflammatory cytokine Interleukins (IL)-6 is implicated in CIN.

OBJECTIVE

As maslinic acid exhibits anti-IL-6 property, the present study sought to determine the effect of maslinic acid on CIN in vitro and in vivo using cell cultures and mouse CIN models, respectively.

METHODS

The dose-effect of maslinic acid on HeLa cells, a human cervical cancer cell line, was first evaluated, including cytotoxicity, IL-6 secretion, IL-6 receptor (IL-6R) expression, proliferation potential and apoptosis status. A mouse model of CIN was also established, which was then subjected to increasing doses of maslinic acid treatment, followed by assessment of serum IL-6 level, cervical expression of IL-6R, and the proliferation potential and apoptosis of cervical tissues.

RESULTS

Maslinic acid dose-dependently inhibited cell growth and proliferation potential, reduced IL-6 secretion, cervical expression of IL-6R and induced apoptosis of HeLa cells in vitro. In the CIN mouse model, serum IL-6 level and cervical expression of IL-6R were elevated, which could be repressed by maslinic acid administration dosedependently. Additionally, maslinic acid treatment in the CIN mice could also restore the otherwise increased proliferation potential and reduced apoptosis in the cervical tissues.

CONCLUSION

Maslinic acid exhibits potent anti-IL-6 property in the CIN mouse model, and alleviates the diseaserelated abnormality in proliferation potential and apoptosis state of the cervical tissue cells, demonstrating its usefulness as a promising agent in treating CIN.

Natural history of histologically confirmed high-grade cervical intraepithelial neoplasia during pregnancy: meta-analysis

OBJECTIVES

This study aimed to conduct a meta-analysis of estimates of the natural history of high-grade cervical intraepithelial neoplasia (CIN) during pregnancy.

SETTING

Studies examining the clinical courses of histologically confirmed high-grade CIN during pregnancy.

PARTICIPANTS

We searched PubMed, Web of Science and Embase for eligible studies. Studies were included if they reported the data regarding the natural history of histologically confirmed high-grade CIN during pregnancy. Final estimates were from the meta-analysis of 10 eligible studies.

PRIMARY OUTCOME MEASURES

The regression rate, persistence rate and progression rate of histologically proven untreated high-grade CIN during pregnancy.

RESULTS

A total of 10 original studies were included in this meta-analysis. During pregnancy, the regression rate, persistence rate and progression rate of high-grade CIN were 40% (95% CI 35% to 45%), 59% (95% CI 54% to 64%) and 1% (95% CI 0% to 2%), respectively. There was moderate heterogeneity among the studies. The results of the subgroup meta-analysis show that the pooled rates of regression and persistence during pregnancy were 59% (95% CI 54% to 65%) and 40% (95% CI 35% to 45%) for CIN2, and 29% (95% CI 25% to 33%) and 70% (95% CI 65% to 73%) for CIN3.

CONCLUSIONS

During pregnancy, the majority of histologically confirmed high-grade CIN would be persistent or regressed to lower grade CIN or normal. However, it is still worth noting that a small percentage of high-grade CIN would progress to cervical cancer during pregnancy.

Midwives' practices related to cervical cancer screening during pregnancy: A vignette-based study

OBJECTIVE

To describe midwives' practices related to cervical cancer screening and women's eligibility for screening during pregnancy.

STUDY DESIGN

Cross-sectional vignette-based study of French midwives during February-May 2018.

MAIN OUTCOME MEASURES

Participants were asked to complete an internet-based questionnaire: a clinical case-vignette about a woman eligible for cervical cancer screening during pregnancy and a short self-administered questionnaire.

RESULTS

We obtained 273 complete questionnaires from eligible midwives. Of those responding, 15% reported that they never screened for cervical cancer during pregnancy, 63.7% did so for women 25 years or older, and 51% adhered to the recommended intervals between tests. Overall, 110 (40%) midwives adhered to the complete screening protocol (age at initiation and interval). In this clinical case vignette of a woman meeting the criteria for screening, only 29% of midwives reported they would perform a Pap test at 25 weeks of gestation, while 91% would at 10 weeks.

CONCLUSION

Midwives' practices of cervical cancer screening and their determination of women's eligibility during pregnancy vary, especially according to gestational age; Nevertheless, pregnancy is an appropriate time to screen women who meet the criteria for cervical cancer screening, especially if they are not receiving regular gynaecological care.

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.

Invasive and in situ cervical cancer associated with pregnancy: analysis from the French cancer network (CALG: Cancer Associé à La Grossesse)

PURPOSE

To describe the oncologic and obstetric outcomes of patients diagnosed with invasive cervical cancer (ICC) and in situ adenocarcinoma (ISA) during pregnancy or during the year following delivery.

METHODS

This retrospective observational study involved a cohort of 28 patients diagnosed with invasive cervical cancer (20 patients) or in situ adenocarcinoma (eight patients) during pregnancy or during the year following delivery who received expert opinion from physicians of the Cancer Associé à La Grossesse (CALG) network between 2005 and 2018. Descriptive results were expressed in median, range and interquartile range (IQR).

RESULTS

Between 2005 and 2018, 20 patients with ICC and eight with ISA received expert opinion from physicians of the CALG network. Both ICC and ISA were mostly diagnosed during pregnancy with a median term at diagnosis of 23.3 weeks of gestation (WG) for ICC and 7.3 WG for ISA. Overall, the median age at diagnosis for both ICC and ISA was 33 years. Most ICCs (n = 9) had FIGO stage ≥ IB2 and five underwent neoadjuvant chemotherapy at a median term of 22.5 WG. Seventeen patients with ICC underwent surgery. Three patients had medical termination of the pregnancy. Two patients experienced recurrence and three died. Median time of follow-up was 59.3 months (IQR 30.5-129.2).

CONCLUSION

Management of cervical cancer during pregnancy is challenging especially in terms of maternal outcomes with a relative poor prognosis requiring a multidisciplinary expert advice.

Diagnosis and treatment of cervical cancer in pregnant women

In recent years, the incidence of gynecological malignant tumors during pregnancy has increased, mainly due to the increased number of old age pregnancy. The most common gynecological malignant tumors in pregnancy are cervical cancer, accounting for 71.6%, followed by ovarian malignant tumors, accounting for 7.0%. The incidence of cervical cancer in pregnancy is itself not very high, and the symptoms are easily confused with other diseases in pregnancy. During pregnancy, gynecological examination is limited, and therefore, the rate of misdiagnosis is higher. The treatment of cervical cancer during pregnancy is related to many factors, such as tumor size, pathological type, period of gestation, lymph node involvement, and patients' willingness to maintain pregnancy. As a reason of these factors, it is difficult to determine the optimal treatment. This article reviews the research progress on the diagnosis and treatment principles of cervical cancer in pregnancy, in order to strike a balance between effective treatment of tumors and protection of fetal health, and avoid delays in treatment and preterm delivery.

Management of gynecological cancer in pregnant patients

INTRODUCTION

Cancer during pregnancy is a rare but challenging condition. More women delay childbearing and consequently the incidence of cancer during pregnancy is constantly increasing.

EVIDENCE ACQUISITION

An extensive electronic search was performed in PubMed and Scopus. Only studies written after 1985 were considered eligible for this review. Abstracts, conference papers, book chapters, animal studies, commentaries as well as editorials articles were excluded from this review.

EVIDENCE SYNTHESIS

Cancer treatment during pregnancy is possible, but both maternal and fetal conditions need to be preserved. Randomized clinical trials are not feasible and current evidence are mainly based on case-series, small case reports and expert opinion. Cervical and ovarian cancers are the most common gynecological cancers diagnosed during pregnancy. Surgery and chemotherapy after the first trimester seem to be relatively safe for the newborn. Platinum-based chemotherapy administered during the 2nd-3rd trimester showed comparable adverse effects in newborns to those in the general population. Babies exposed to antenatal chemotherapy might be more likely to develop small for gestational age and NICU admission, than babies not exposed.

CONCLUSIONS

Management of pregnant women with cancer should be performed in specialized cancer centers and all cases should be discussed with a multidisciplinary approach. In the present review, we discuss the current recommendations for the management of pregnancies complicated by cancer and neonatal outcomes.

Cervical intraepithelial neoplasia in pregnancy: Interference of pregnancy status with p16 and Ki-67 protein expression

To date, there are evidence-based guidelines available for cervical dysplasia diagnosed in pregnancy. Certain functional biomarkers have proven useful in the prediction of regressing and non-regressing cervical intraepithelial neoplasia (CIN) lesions in non-pregnant women. In the present study, Ki-67 and p16 immunostaining were evaluated in different grades of CIN lesions diagnosed in pregnant or non-pregnant women with the aim to identify any differences in order to better understand the behavior of CIN in pregnancy. The current retrospective case-control study included 17 pregnant patients that conceived naturally with first-time onset of CIN occurring at no later than 16 gestational weeks. The control group included 17 non-pregnant patients matched for age, parity and number of previous sexual partners. Exclusion criteria included previous cervical treatment, immunocompromised status, chronic hepatitis B and/or C and cigarette smoking. p16 and Ki-67 protein expression were respectively detected using the CINtec Histology kit and monoclonal antibodies against Ki-67. p16 and Ki-67 staining were analyzed using a classification system based on the distribution of positivity on a semi-quantitative three point-scale. p16 and Ki-67 immune reactivity correlated positively with the grade of epithelial dysplasia in the total cohort of pregnant and non-pregnant patients; expression increased linearly from CIN1 to CIN3. Furthermore, the association between p16 immunostaining and CIN grade was significant in non-pregnant patients but not in pregnant patients. In pregnant patients, positivity for Ki-67 was less intense than in non-pregnant patients. These results appear to suggest that pregnancy status interferes with the expression of cellular proteins involved in cell-cycle regulation and the carcinogenic process induced by high-risk human papilloma virus, exhibiting increased variability in their staining.

Glycodelin expression in pregnant patients with cervical intraepithelial neoplasia: a case-control study

We aimed to evaluate glycodelin immunostaining in pregnant women with a first diagnosis of cervical intraephitelial neoplasia (CIN) and to correlate the expression of CIN with Ki-67 and glycodelin immunostaining. A retrospective case-control study was performed including 20 patients with natural pregnancy and with first time onset of CIN occurring not later than 16 gestational weeks. The control group included 20 non-pregnant patients matched for age, parity, smoking status and number of previous sexual partners. Exclusion criteria included previous cervical treatment, immunocompromised status and chronic hepatitis B and/or C. Staining for Glycodelin and for Ki-67 was expressed using a classification based on the distribution of positivity on a semi-quantitative three-point scale. An inverse relationship was observed between glycodelin immunostaining and CIN grade in pregnant patients (p = 0.01), with a significantly higher expression in CIN1 than in CIN2 and CIN3, but not in non-pregnant patients (p = 0.81). Positivity for Ki-67 was less intense in pregnant than in non-pregnant patients. A significant inverse relationship was observed between glycodelin immunostaining and Ki-67 expression (p = 0.02). We suggest that the higher expression of glycodelin in pregnancy is related to a lower proliferative activity in CIN, which is probably associated to hormonal status of pregnancy. Further clinical studies are needed to support these findings.

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.

Management of cervical cancer during pregnancy

Cervical cancer (CC) is the most common gynaecological cancer during pregnancy. The rarity of the disease and lack of randomised control studies have prevented the establishment of treatment guidelines. The management of CC mainly follows the guidelines for the non-pregnant disease state, expert opinions and limited case reports. Although the management of CC diagnosed during pregnancy appears to be a significant dilemma for the patients and specialists, the prognosis of CC is not influenced by pregnancy. The treatment decision should be made collaboratively with a multidisciplinary team consisting of an obstetrician, gynaecologist, oncologist and paediatrician. The concerns of the patient should be taken into account.

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.

Cervical cancer screening in pregnancy

Cervical cancer is the most commonly diagnosed malignancy during pregnancy with an incidence of 1.5 to 12 per 100,000 pregnancies. In the United States between 2% and 7% of all pregnant women will have an abnormal Pap test. The management of these abnormal results during pregnancy can present a challenge to the practitioner. This article reviews recently published guidelines and current evidence for evaluation and management of abnormal cervical cytology and cervical cancer in pregnancy.

Gynaecological cancers in pregnancy

Cervical and ovarian cancers are the most common gynaecological cancers diagnosed during pregnancy. In early-stage cervical cancer during the first and at the beginning of the second trimester, the two main considerations for management of the patient are the tumour size (and stage) and nodal staging. MRI and laparoscopic lymphadenectomy are useful for clinicians planning a potentially conservative approach. The management of patients with locally advanced cervical disease is controversial and should be discussed on a case-by-case basis according to the tumour size, radiological findings, the term of pregnancy, and the patient's wishes. Different histological types of malignant ovarian diseases arise during pregnancy and their management depends on the diagnosis (histological subtypes, tumour differentiation, and nodal status), the tumour stage, and the trimester of the pregnancy. In patients with peritoneal spread or high-risk early-stage disease, neoadjuvant chemotherapy with pregnancy preservation could be appropriate.

Cervical dysplasia in pregnancy: a multi-institutional evaluation

OBJECTIVE

This study was undertaken to identify the prognostic indicators associated with postpartum regression of cervical dysplasia diagnosed in pregnancy.

STUDY DESIGN

A retrospective cohort study of pregnant women referred for colposcopy from 2004-2007 at four academic centers.

RESULTS

One thousand seventy-nine patients were identified. Colposcopic impression by cervical cytology is detailed later in the text. Of patients who underwent biopsy, results correlated with or were less severe than colposcopic impression in 83% with CIN 1 and 56% with CIN 2/3. Fifty-seven percent had follow-up postpartum, with 61% reverting to normal. Resolution of cervical dysplasia was inversely associated with smoking (P = .002). No progression to cancer occurred during pregnancy.

CONCLUSION

Colposcopic impression in pregnancy correlated with cervical biopsy results and postpartum colposcopic findings when performed by expert colposcopists. A high proportion of cervical dysplasia regressed postpartum. Cervical biopsies in pregnancy may not be necessary unless invasive cancer is suspected.

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.

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.

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.