Abnormal Cytology during Pregnancy – A Retrospective Analysis of Patients in a Dysplasia Clinic

Discussion

A pregnant woman with an abnormal cervical cytological result poses a great challenge for the gynaecologists responsibility for her care. On the one hand, it is necessary to preserve the life of the unborn child, and on the other hand, to also protect the health of the mother. Interventions such as tissue biopsy during early pregnancy, as well as conisation, should be avoided where possible (1, 4). Repeated biopsies should only be performed if the colposcopy findings worsen, and colposcopical and cytological follow-up should take place at a minimum of six weeks postpartum (5). Colposcopy and tissue biopsy appear to be the safest methods of assessing an abnormal cytological smear test during pregnancy (7). The aim of care of a pregnant patient with an abnormal cytological result is to continue the pregnancy and to exclude an invasive abnormality, so that it can first be eradicated after the pregnancy is complete. The option of conservative care of dysplastic changes during pregnancy has also been shown in other studies (8-10). A retrospective analysis by Yost et al., which examined 153 women with CIN II and CIN III showed a high regression rate of 68% and 70%, respectively, and a persistence rate of 25% and 30%; 7% of the CIN II lesions tended to progress towards CIN III, but no patients developed a carcinoma (8). The concern with this study is that of the 269 patients in whom a CIN II or CIN III was diagnosed during pregnancy, 126 (47%) were lost in follow-up. Therefore, no safe conclusions can be made regarding the progress, the pregnancy or the dysplasia. The retrospective study of 58 patients by Murta et al. also showed that high-grade cervical dysplasia during pregnancy can be conservatively managed throughout (9). Another retrospective analysis by Kaplan et al. showed a mostly stable course during pregnancy, where three women were diagnosed with a microinvasive carcinoma after a postpartum conization. The mode of delivery was not investigated in that study (10). The distinctive feature of the present study is the high number of follow-up examinations, which showed that women with dysplastic changes in pregnancy, who are monitored regularly can be advised to continue the pregnancy. It also showed a remission and partial remission rate of 43.1%; remission of severe dysplasia and an ACIS even occurred in 9.3% of cases. Persistence was observed in 26.2% of patients. Progression of CIN II to CIN III was seen in one patient (1.5%), which had no therapeutic consequences for the patient, as a CIN II result as well as a CIN III result can be treated with postpartum conization. No invasion occurred in this case. Progression of a CIN III to microinvasive cervical cancer was only observed in one patient. However, it should be noted that this patient refused postpartum follow-up for a long period of time and the conization was first performed nine months postpartum. Therefore this patient cannot be compared to an otherwise regular progression with clearance of the abnormality 6-8 weeks postpartum. Furthermore, it was shown that a vaginal delivery is possible in many cases (71.1%). The Caesarean sections mentioned were performed for other reasons, such as foetal breech position, secondary to labour progression, or after individual risk assessment unrelated to the dysplasia. Patient information and explanation is important for the care of pregnant women, as is a gynaecology-colposcopy link, especially postpartum. The management of a patient with histologically confirmed cervical cancer in pregnancy is a further therapeutic challenge. In the present study, in this patient with a pT2a G3 tumour, the lesion was advanced cervical cancer in a very early week of pregnancy. After the couple had undergone detailed counselling, a Wertheim's procedure was performed with sectio parva. At the time of data collection, the patient had fortunately been relapse-free for 2.5 years. A conization/trachelectomy with cerclage where indicated would be performed for a microinvasive carcinoma in pregnancy before the 20th to 22nd week, with additional pelvic lymphadenectomy for stage pT1a2 (2, 4). A vaginal delivery can be considered after an R0 resection; a primary Caesarean section is recommended after an R1 resection. If a microinvasive cervical cancer is diagnosed in a later week of pregnancy, one should initially wait, accelerate foetal lung maturation and perform a planned Caesarean section according to the individual diagnostic findings. Stage-appropriate treatment then follows. In the case of advanced cancer in pregnancy, further treatment planning and determination of procedures must always be performed by an interdisciplinary team after the patient and couple have been extensively counselled. Based on individual case reports, pregnancy can be prolonged with chemotherapy given during the pregnancy if necessary, and thereby a viable and/or mature age can be attained for the child. Depending on the feasibility, the aim would be prolongation until the 25th week of pregnancy. Chemotherapy during the second or third trimester is likely not associated with the incidence of congenital malformations (11). Prolonging the pregnancy does not appear to have any negative effects on the prognosis (12). In summary, the monitoring and treatment of cervical cancer during pregnancy is an interdisciplinary challenge, and it should be performed at an experienced clinical centre. Dysplasia during pregnancy should be regularly monitored in a dysplasia clinic in order to detect any possible invasion. According to review of the existing literature and after evaluation of the present data, this risk can be classified as low.