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Abnormal Pap in Pregnancy
Alexander Burnett, MD
Division Gyn Oncology, UAMS
April, 2006
Objectives
1. Significance of Pap smears during
pregnancy
2. Problems with Pap smears
3. Management of abnormal results
4. Treatment during pregnancy
5. Post-partum evaluation
Pap smear is part of prenatal testing
 Screening opportunity
 Cervical cancer is the most common malignancy
detected in pregnancy (1-15/10,000)
 Majority of cancer patients are stage I -- 83%
 CIS detected in ~1/750 pregnancies
Cytology during pregnancy
Technique:
Cervical brush for LBM
Ayre spatula + cytobrush
Cotton swab is inadequate
Endocervical component absent in 55% of
Paps that utilized cotton swabs
Pregnancy effects on Pap
 0.5% - 3.0% of Paps abnormal
 Mimics of HSIL:
Degenerated decidual cells
Cytotrophoblast
Arias-Stella reaction (confuse
with adenocarcinoma)
Immature reactive metaplasia
 Mimics of LSIL:
Syncytiotrophoblast
Multinucleated cells
Management of abnormal Pap
 Identical to non-pregnant patient
 Indications for colposcopy:
HSIL
LSIL
ASC-H
ASCUS + HPV
AGUS
Suspicion for cancer
 ECC is never indicated during pregnancy!
Colposcopic challenges
 Vaginal laxity
 Cervical laxity
 Inadequate visualization of TZ
 Increased vascularity of cervix
 Increased squamous metaplasia
Frequency of colposcopy
 Recommended each trimester for visual
inspection of dysplasia
 Inadequate transformation zone will often
become adequate with cervical eversion over
gestation
 “Clearance” for delivery
 No need to repeat the Pap smear at each
colposcopy
Biopsy in pregnancy
 Should be performed for suspicion of HSIL
or invasive disease
 Directed biopsy with immediate application
of pressure, silver nitrate, and/or Monsel’s
 Safe to perform at any stage in pregnancy
 Do not repeat biopsy at later colposcopy
unless significant change is seen
Cone biopsy
 Indicated if biopsy suggests microinvasion
 Associated with increased bleeding (> 500 cc
in 10%), preterm labor, infection,
spontaneous abortion in first trimester.
 LEEP can be performed, similar
complications reported as cold-knife
 ONLY done in surgical suite setting
Management of SIL in pregnancy
 Pre-invasive disease should not be treated in
pregnancy
 Repeat colposcopy to follow patient with
biopsy if a significant change is noted
 Re-evaluate in the post-partum period (at
least 6-8 weeks)
Cervical cancer in pregnancy
 Pregnancy does not appear to significantly
alter the course of disease
 Management is based on gestational age at
time of diagnosis:
< 20 weeks
treat as non-pregnant
> 24 weeks
await fetal viability
20 - 24 weeks
individualize
Pre-viable treatment
 Early cervix cancer:
Radical hysterectomy with nodes
Radiation therapy/chemotherapy
 Late cervix cancer:
Chemoradiation
Later pregnancy therapy
 Document fetal maturity
 Deliver via classical C/S
 Radical hysterectomy at time of C/S
Planned delay in therapy
 Numerous reports of patient opting for
delays
 Follow closely, increased bleeding risk
 Chemotherapy has been utilized in rapidly
growing cervix cancers
 Outcome generally good, but numbers are
small
 Deliver via C/S
Dysplasia management
 Delivery route should be for obstetric
indications
 Several reports have suggested high rate of
regression post-partum, particularly if a
vaginal delivery has occurred
 6-8 weeks post-partum, reasonable to
perform PAP, colposcopy, biopsies and ECC
Other management considerations
 If colposcopy is difficult or suspicious for
HSIL or microinvasion, consider referral to
expert colposcopist to determine need for
biopsy
 Vascular lesions with negative Pap smears,
consider referral, close monitoring to
determine if this is dysplastic/malignant
versus physiologic
Condylomas during pregnancy
 Can rapidly grow during gestation
 Increased risk of trauma at delivery
 Increased risk of Respiratory Papillomatosis
in offspring. Not prevented by C/S or wart
therapy
 Treatment:
TCA, cryo for small lesions
Cautery, LEEP, laser for large areas