EPIDEMIOLOGY OF CERVICAL CANCER DURING PREGNANCY
It is rare to find invasive cancer of the uterine cervix in pregnancy. Nonetheless, cervical cancer is the most common cancer diagnosed during pregnancy. An increase in the incidence of invasive cervical cancer in younger women is suspected. Women are delaying child-bearing later than ever in history. These trends together may work together to make cervical cancer more common during pregnancy in the future. Currently, the incidence of cervical cancer varies from 1 to 15 cases per 10,000 pregnancies. The mean age of diagnosis is 34 years. The incidence of each stage at diagnosis is 83% Stage I, 10% Stage II, 3% Stage III, 2% Stage IV. Stage for stage, the prognosis is similar to that of nonpregnant patients. It is fortunate that over 80% of these cases are Stage I at presentation.

Obtaining a cervical smear is a standard component of routine antenatal care in the U.S., usually at the first prenatal visit. The objective of evaluating an abnormal cervical cytology during pregnancy is to exclude the presence of invasive cancer. Treatment of preinvasive disease is deferred until postpartum, after complete reassessment has taken place.

MANAGEMENT OF ABNORMAL CERVICAL CYTOLOGY DURING PREGNANCY
The NIH / ASCCP sponsored 2001 Consensus Guidelines for the Management of Women with Cervical Cytological Abnormalities state:

• It is preferred that the colposcopic evaluation of pregnant women with HSIL be conducted by clinicians who are experienced in the evaluation of colposcopic changes induced by pregnancy.
• Biopsy of lesions suspicious for high-grade disease or cancer is preferred; biopsy of other lesions is acceptable.
• Endocervical curettage is unacceptable in pregnant women.
• Since unsatisfactory colposcopy may become satisfactory as the pregnancy progresses, it is recommended that women with an unsatisfactory colposcopy undergo a repeat colposcopic examination in 6-12 weeks.
• In the absence of invasive disease, additional colposcopic and cytological examinations are recommended, with biopsy only if the appearance of the lesion worsens or cytology suggests invasive cancer.
• Unless invasive cancer is identified, treatment is unacceptable.
• A diagnostic excisional procedure is recommended only if invasion is suspected.
• Re-evaluation with cytology and colposcopy is recommended no sooner than 6 weeks postpartum.

COLPOSCOPIC APPEARANCE OF THE CERVIX DURING PREGNANCY
The hormonal changes of pregnancy produce dramatic alterations in the colposcopic appearance of the cervix. Increased vascularity produces a cyanotic, bluish hue.

Increased vascularity, stromal edema, and stromal hypertrophy, cause marked enlargement of the cervix.

Vaginal wall laxity and increased cervical mucus also may make visualization of the cervix more challenging.

On the other hand, progressive eversion of the squamocolumnar junction onto the ectocervix makes colposcopy satisfactory more often. Grading of lesions is more difficult than in the nonpregnant patient.

Pregnancy triggers very active squamous metaplasia which shows an exaggerated acetowhite change in response to acetic acid. Increased vascularity and stromal edema can cause a decrease in acetowhitening but an exaggeration of vascular patterns.

Decidual changes can be confusing, and may even have features consistent with invasive cancer, such as yellow coloration, topography changes, and atypical appearing vessels.

THE COLPOSCOPIC EXAMINATION DURING PREGNANCY
Colposcopy and directed biopsies are safe to perform during pregnancy. They do not increase risk of adverse pregnancy outcome. Due to less accurate lesion grading during pregnancy, and the small chance of missing an invasive cancer, directed biopsy should be considered for high-grade appearing lesions and for any lesion in the presence of a high grade cytological abnormality. Experienced colposcopists may elect to omit biopsies of low-grade appearing lesions, especially if the cervical cytology is also low-grade.

While colposcopy during very early pregnancy is not much different than in nonpregnant patients, adaptations of technique are generally needed. In the third trimester, it is wise to elevate the patient’s right hip slightly with a folded sheet to prevent supine hypotension, which can cause distressing flushing, discomfort, nausea, and vomiting in some patients. The use of a larger speculum and a vaginal sidewall retractor may be needed to provide unhindered access to the cervix. If a sidewall retractor is unavailable, a condom, latex glove finger, or ultrasound probe sheath with the tip removed may be rolled onto the speculum for better visualization. Tenacious endocervical mucus, the so-called “mucous plug,” is encountered in pregnancy. The routine application of 5% acetic acid is mucolytic and will aid in mucus removal. Doing so is in no way harmful. Use of sponge or ring forceps may also be used to carefully to remove viscous mucus. Due to progressive cervical enlargement, it may be necessary to perform colposcopy of cervical quadrants.

The increased vascularity of the cervix in pregnancy can cause bleeding even with minimal trauma, including speculum insertion and performance of the Pap test. Therefore, biopsies are expected to bleed more during pregnancy. The colposcopist should be experienced in achieving hemostasis, using sponges, pressure, and Monsel’s paste as needed. Serious bleeding requiring suturing or packing is rare (<1%), and can nearly always be avoided with prompt pressure, then a well-aimed swab with Monsel’s, to the biopsy site. Colposcopy with biopsy has not been shown to cause preterm labor, but judgement and caution should be used when performing colposcopy on patients with histories of past preterm deliveries, or when applying Monsel’s paste when the cervical os is open.

CLINICAL RESPONSE TO NEOPLASIA IN PREGNANCY
Preinvasive disease and microinvasive cancer of the cervix is not treated during pregnancy. The only indication to treat during pregnancy is histologically confirmed, frankly invasive cancer.

Historically, cervical conization was used for diagnosis and treatment of dysplasia and cancer. Fortunately, conizations are rarely indicated during pregnancy since the introduction of colposcopy. Conization in pregnant patients is associated with a 12% hemorrhagic complication rate, a 5% perinatal mortality, and a preterm labor rate of 30%. Therefore, conization is reserved for the rare cases in which invasive cancer is strongly suspected by cytology, histology, or colposcopic impression, but less invasive evaluation is inconclusive. Expert colposcopic evaluation and consultation with the pathologist are critical before the decision is made to perform cervical conization in the pregnant patient. Conization during pregnancy is not performed for unsatisfactory colposcopy, even in the presence of a high grade lesion, unless invasive cancer is suspected. Instead, colposcopy is repeated at intervals until the examination becomes satisfactory, which occurs by the second trimester in most cases.

The diagnosis of invasive cancer in pregnancy dictates referral to and management in conjunction with a gynecological oncologist. Vaginal delivery is avoided In the presence of frankly invasive cancer; the preferred method of delivery of a viable pregnancy is by cesarean section with radical hysterectomy.

POSTPARTUM REEVALUATION
The likelihood of disease progression during pregnancy is small. Regression is more likely; the incidence of this ranges widely in the literature, from approximately 12% to 70%. It is controversial whether severity of disease diagnosed and route of delivery influence postpartum persistence. Patients should be reevaluated at least six weeks postpartum to allow healing to occur. Treatment, if indicated, should be based on the grade and location of disease identified postpartum.

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