Transcript Cervical cancer & pregnancy

In the name of God
Isfahan medical school
Shahnaz Aram MD
Cervical cancer & pregnancy
Definition:
in pregnancy or 12 months after delivery
Rarely invasive cancer in pregnancy
Most common cancer is genital cancer
Pregnancy complicates 3% of cervical cancers
Overall cancer rate in pregnancy
Dysplasia
is common
Abnormal pap-smear is 3%
CIN3 1.3 in 1000 pregnancies
Invasive cancer 1 in 2200, 1 in 8333
Overall survival similar in non pregnant in any stage
Screening









Pap-smear is the routine antenatal test in all
pregnancies
Evaluating pap-smears is more difficult in
pregnancy
Initial pap-smear may be normal
If ASCUS 2-3 months later repeat pap-smear
Second pap-smear if ASCUS or abnormal
colposcopy, biopsy
Colposcopic evaluation is easier in pregnancy
Accuracy of diagnostic colposcopy = 99%
Colposcopy biopsy is used liberally in pregnancy
Endocervical curettage avoided
Inadequate colposcopy examination
(ablative therapy)
 Close follow up in 2-3rd trimester
 Conization in first trimester 33% causes
abortion
Cone biopsy complication:
 hemorrhage
 Abortion
 Preterm labor

If bleeding after colposcopy
► Monsel solution
► Silver nitrate
► Vaginal packing
► Occasionally suture
If CIN1 in colposcopy
► Repeated pap-smear every 3 months during
pregnancy
► 6 week after delivery, colposcopy is the rule out
of dysplasia
► After vaginal delivery normal pap-smear
Regression rate in post partum is high
CIN2 & CIN3 in pregnancy should
 Colposcopy directed biopsy
If CIN3 should
 Be followed by cytology
 Normal vaginal delivery
 80% persistent after delivery
 Definitive management
If pap-smear is suspicious
for invasive cancer
cone biopsy is indicated
 Cone biopsy in limited situation
If conization necessary
 Prophylactic cerclage
 Wedge resection
 In second trimester

If microinvasive in cone biopsy <3mm and
margin free
 Continuing pregnancy
 Normal vaginal delivery
 6 weeks later after delivery , vaginal
hysterectomy
If margin involved (3-5mm invasion) or
lymphatic invasion
 More treatment
 Follow till term
 Classical cesarean section + modified radical
hysterectomy + pelvic lymph node dissection
If margin involved( >5mm invasion)

Treatment is according to
1.
Stage
2.
Patient’s desire
3.
Duration of pregnancy
If > 28 weeks 75% survival
If > 32 weeks 90%

Amnioscentesis for lung maturation

No later than 4 weeks

Classical cesarean section

Radical hysterectomy + pelvic lymph
node dissection
Symptoms
• Symptoms are often ignored due to
pregnancy related causes
• Vaginal bleeding
• Vaginal discharge
• Post coital bleeding
• Pelvic pain
• 20% asymptomatic
Diagnosis
Often delayed due to pregnancy
related causes
Pap-smear in all pregnant women
Punch biopsy of gross cervical lesion
Asymptomatic  evaluating abnormal
pap-smear and colposcopy
Staging
 Pregnancy complicates both staging and treatment
 Staging is difficult in pregnancy due to
1- soft tissue edema
2- collagen tissue edema
3- limitation of X-Ray
MRI for
 Tumor volume
 Spread beyond the cervix
 Detect lymphatic node
Cystoscopy, sigmoidoscopy can be performed
Management










Treatment according to stage and pregnancy duration
All management after full discuss
CIN 1 and pregnancy until 6 weeks after delivery
CIN 3 in last trimester, evaluation after delivery
Stage 1A cone biopsy + frozen section
If margin free, followed till term , NVD
More advanced ( according to stage and duration)
Before 20th week  treatment without delay
After 30th week  await fetal maturity, fetal viability
20-30 weeks no adverse effect for delay in
treatment
Route of delivery






Vaginal or cesarean section (most clinicians
prefer abdominal delivery)
No clear evidence that tumor dissemination
caused by birth process
Major risk for vaginal delivery, tearing and
bleeding
Recurrence in episiotomy reported
If lesion is removed  NVD
If no conization classical cesarean section
radiation
Stage 2-4
• Before fetal viability teletherapy
(external beam 4000-5000 c Gy)
• If not spontaneous abortion  D&C, PG,
hysterotomy, before brachytherapy or
intracavitary
If tumor is small of completely regressed:
• Modified radical hysterectomy
• Fetus viable classical C/S, postoperative
radiation
• If C/S (palpated pelvic para-aortic node)
If large node, should be exited and frozen
section If positive radiation, extension
detected by MRI and save ovary
Prognosis
• Overall prognosis is as the same as non
pregnant ( under staging)
• Stage 1 the same as non pregnant
• More advanced pregnancy can have
adverse effects
if diagnosed in first trimester its better
than third trimester.
• Survival rate is not different
• Mode of delivery has no effect on
maternal survival
• Cure rate in stage 1 is 80-90%
•
stage 2 is 60-80%
•
stage 3 is 50%