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

High-grade Cervical Squamous Intraepithelial Lesion during Pregnancy

Aims and Background

An increasing incidence of high-grade squamous intraepithelial lesion (HSIL) has been observed among young women. Consequently, an increased number of cases are being discovered during pregnancy. We analyzed the clinical and therapeutic management of HSIL during pregnancy.

Methods

A retrospective study was conducted from 1979 to 1998, and 58 registries of women with a cytological or histological diagnosis of HSIL during the pregnant-puerperal period were reviewed. Information obtained from medical records included age, gestational age at diagnosis, parity, age of first intercourse, number of sexual partners before pregnancy, tobacco use, cytologic and colposcopic findings, route of delivery, postpartum follow-up, and treatment. This information was compared with a non-pregnant control group with HSIL.

Results

The average age of pregnant women with HSIL was 27.9 ± 5.2 years. The cytologic or histologic diagnosis of HSIL was made in the first trimester in 12 (20.7%) women and in the second trimester in 30 (51.7%) women. Average parity was 2.8 ± 2 deliveries. Age of first intercourse ranged from 13 to 29 years (16.1 ± 3.3). Thirty-two women (55.1%) had more than one sexual partner before pregnancy. Thirty-seven (63.8%) refereed tobacco use. According to the aforementioned aspects, no statistical difference was found in relation to control, except to cervical ectopia, which was more frequent in pregnant women (56.9% versus 42.6%). From the total of 58 pregnant women with cytologic or biopsy HSIL diagnosis, 53 had HSIL diagnosis made on cervical biopsy directed by colposcopy performed during the pregnancy; 44 (83%) of them were submitted to conservative management. HSIL was diagnosed by cervical biopsy in postpartum evaluation in 76% pregnant women with vaginal delivery and 78.6% women who underwent cesarean section.

Conclusions

A conservative management of HSIL in pregnancy is proposed, with colposcopic evaluation during gestation and postpartum, regardless of route of delivery.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

OBJECTIVE

The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation.

METHODS

Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications.

RESULTS

In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%).

CONCLUSIONS

The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

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.

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.

Studies on the prevalence of human papillomavirus in pregnant women in Japan

AIMS

In order to evaluate the prevalence of human papillomavirus (HPV) in the pregnant population in Japan.

METHODS

We examined cervical swabs of 1,183 pregnant women for HPV DNA using a PCR-RFLP method during October, 2000 and February, 2001. The overall prevalence of HPV in 1,183 pregnant women was analyzed and stratified by age.

RESULTS

The overall prevalence of HPV in pregnant women was 12.5% (148 of 1,183 cases). The prevalence in pregnant women younger than 25 years (22.6%, 28 of 124 cases) was significantly higher compared with that in pregnant women > or =25 years (11.3%, 120 of 1057 cases, P< 0.0005).

CONCLUSIONS

The data indicate a significantly higher prevalence of HPV infection in younger pregnant Japanese women.

Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.