1. Abnormal Pap in Pregnancy Alexander Burnett, MD Division Gyn Oncology, UAMS April, 2006

2. 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

3. 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

4. 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

5. 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

6. Management of abnormal Pap  Identical to non-pregnant patient  Indications for colposcopy: HSILLSILASC-H ASCUS + HPV AGUS Suspicion for cancer  ECC is never indicated during pregnancy!

7. Colposcopic challenges  Vaginal laxity  Cervical laxity  Inadequate visualization of TZ  Increased vascularity of cervix  Increased squamous metaplasia

8. 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

9. 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

10. 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

11. 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)

12. 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 weekstreat as non-pregnant > 24 weeksawait fetal viability 20 - 24 weeksindividualize

13. Pre-viable treatment  Early cervix cancer: Radical hysterectomy with nodes Radiation therapy/chemotherapy  Late cervix cancer: Chemoradiation

14. Later pregnancy therapy  Document fetal maturity  Deliver via classical C/S  Radical hysterectomy at time of C/S

15. 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

16. 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

17. 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

18. 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