Is inflammation on Papanicolaou smear a risk factor for preterm delivery?

The association between cervical inflammation and histologic evidence of HPV in PAP smears and adverse pregnancy outcome in low risk population

OBJECTIVE

Recent studies suggest an association between Human Papilloma Virus (HPV) infection, cervical inflammation and obstetric complications (i.e. spontaneous preterm parturition and cervical insufficiency). It has been proposed that viral inflammation of the placenta causes changes in the mother's immune reaction to bacterial pathogens, which leads to enhanced inflammatory reaction and preterm delivery. Therefore, the aim of this population-based study was to determine the association between abnormal cervical cytology prior to pregnancy and obstetric outcomes.

STUDY DESIGN

A Retrospective population-based cohort study was designed, including all women who had a Pap smear up to two years prior to delivery or during first trimester of pregnancy (n = 15,357). Women were divided into the following groups, according to Pap smear results: group 1 - Normal PAP smear (n = 11,261); group 2 - Pap smear with evidence of an inflammatory process (n = 3895); and group 3 - Pap smear with evidence of HPV infection (n = 201). Obstetrical outcomes, gestational age at delivery, and pregnancy complications were compared among the groups.

RESULTS

The rate of HPV infection in our study population was 1.3%. The rate of preterm delivery (group 1 - 8.5%, group 2 - 8.5%, group 3 - 7%, p = 0.7), preterm PROM (group 1 - 1.7%, group 2-1.6%, group 3 - 2%, p = 0.66) and cervical insufficiency (group 1 - 0.5%, group 2 - 0.7%, group 3 - 1.5%, p = 0.11) did not differ significantly among the study groups. There was no statistical difference in the rate of premature rapture of membranes, newborn small-for-gestational-age, preeclampsia or placental abruption. Women with abnormal cervical cytology, either due to inflammation or HPV infection, had similar obstetric outcome in comparison to those with a normal cervical cytology.

CONCLUSION

This population-based retrospective cohort study indicates no association between positive HPV testing with Pap smear and obstetric complications such as preterm delivery, cervical insufficiency, placental abruption, PROM, Preterm PROM, neonatal SGA and preeclampsia, in a population with low prevalence HPV infection.

Inflammation on the cervical papanicolaou smear: evidence for infection in asymptomatic women?

Background. The significance of the possible presence of infection on the Pap smear of asymptomatic women based on cytological criteria is practically unknown. Materials and Methods. A total of 1117 asymptomatic nonpregnant women had Pap smear tests and vaginal as well as cervical cultures completed (622 with and 495 without inflammation on the Pap smear). Results. Out of the 622 women with inflammation on Pap test, 251 (40.4%) had negative cultures (normal flora present), while 371 (59.6%) women had positive cultures with different pathogens. In contrast, the group of women without inflammation on Pap test displayed significantly increased percentage of negative cultures (67.1%, P < 0.001) and decreased percentage of positive cultures (32.9%, P < 0.001). Bacterial vaginosis was diagnosed more frequently in both groups and significantly more in the group with inflammation on Pap smear compared to the group without inflammation (P < 0.02). Conclusions. A report of inflammatory changes on the cervical Pap smear cannot be used to reliably predict the presence of a genital tract infection, especially in asymptomatic women. Nevertheless, the isolation of different pathogens in about 60% of the women with inflammation on the Pap smear cannot be overlooked and must be regarded with concern.

Signs of infection in Pap smears and risk of adverse pregnancy outcome

Previous studies on whether signs of infection in Pap smears imply a risk factor for preterm delivery are conflicting. In a large population-based study, we combined information from the Swedish Medical Birth Register and the Swedish Pap Smear Screening Register to investigate whether signs of infection in Pap smears increase the risks of adverse pregnancy outcomes. Logistic regression analyses were used to estimate odds ratios (OR) for antepartum death, preterm or small-for-gestational-age delivery. The presence of Coccobacilli or Trichomonas vaginalis in Pap smears increased the risk of small-for-gestational-age delivery (OR 1.3 and 1.4, respectively). Signs of infection in Pap smears were generally not associated with an increased risk of antepartum death or preterm birth. However, the presence of Coccobacilli in Pap smears within 4 weeks before delivery was associated with a more than fourfold increase in risk of very preterm delivery (< or =31 weeks, OR 4.7). This indicates that if Coccobacilli are detected in Pap smears during the second trimester, antibacterial treatment may lower the risk of very preterm delivery.

Pap smear follow-up of possible role of mucopurulent exudate as a prognosticator of a negative pregnancy outcome

Our objective was to study a cohort of women by various means to detect sexually transmitted diseases (STD) and to correlate the presence of mucopurulent exudate (PEX) on Papanicolaou (Pap) smears with pregnancy outcome. Bacteriologic cultures taken from swabs for chlamydia and gonorrhea were correlated with Gen-Probe results. Smears were examined for trichomonas, yeast, HPV, obscuring mucopurulent exudate, and squamous intraepithelial abnormalities. There was no positive correlation between STD and negative pregnancy outcome. Mucopurulent exudate on Pap smears was very high in this population. Continuing study of this population of women is needed to see if larger cohorts will demonstrate any positive correlations between PEX and pregnancy outcome. Placing women with obscuring mucopurulent exudate in a "high-risk" category for complications may prevent adverse side effects to the birth product. The Pap smear works as well as the Gram stain for detection of bacterial vaginosis and cervicitis. Eliminating the Gram stain from routine pelvic exam results in cost savings.