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Cervical cancer screening

14. Screening in pregnancy

Clinical question

GUIDELINE UPDATES - This guideline was last updated 9/16/2019

UPCOMING GUIDELINES - This guideline was updated and comes into practice on 7/1/2022Download PDF

Background

Cervical screening during pregnancy is a special circumstance, as additional consideration needs to be given for the wellbeing of the foetus. The incidence of cervical cancer in pregnancy is low, with estimates in the literature ranging from 3.3 to 26 cases per 100,000 births.[1][2] However, early-stage cervical cancer may be more frequently encountered by clinicians caring for women during their pregnancy due to higher age-specific incidence rates in the 30–39 year age group, compared with younger ages,[3] and more women delaying pregnancy.[4] Although most cases of cervical abnormalities are likely to be asymptomatic and identified through screening, it is important to consider non-obstetric causes when a pregnant women reports vaginal bleeding (see Chapter 18. Investigation of abnormal vaginal bleeding).[5]

Approximately five per cent of pregnant women will have abnormal cervical cytology.[6] Routine antenatal care should include cervical screening when this is due or overdue. For some women, pregnancy may be the first opportunity for cervical screening and cervical cancer is more likely to be diagnosed in never screened or under-screened women.[3] The tool of choice for collection of a cervical screening specimen in pregnant women should be a broom type brush (Figure 12.1). The endocervical brush is not recommended.

Conservative management of high-grade squamous intraepithelial lesions (HSIL) is recommended during pregnancy.[7] Colposcopy is performed to exclude the presence of invasive cervical cancer, to confirm the presence of pre-invasive disease and reassure the pregnant woman that it is safe to continue with her pregnancy. When HSIL is diagnosed during pregnancy, treatment can be delayed until after delivery[8] because progression of cervical intraepithelial neoplasia (CIN) to invasive disease during pregnancy is rare, with a range of 0–3% of cases.[9][10][11][8][12] Almost all cases are microinvasive and amenable to curative treatment.

Postpartum regression of CIN lesions is common.[10][13][14] A meta-analysis of studies found that women treated for CIN during pregnancy were at an increased risk of preterm birth (< 37 weeks) and premature rupture of membranes, compared with women with untreated CIN who gave birth before treatment.[15] However, when invasive disease is suspected or confirmed in pregnancy, expert management by a gynaecologic oncologist is required due to the increased risk of poor pregnancy outcomes.


Evidence

General literature review evidence

A general literature search was conducted to identify recent studies reporting on the natural history of cervical dysplasia during pregnancy and its management.

The available evidence consists of only small studies, with somewhat diverse findings for the natural history of progression and regression of HSIL or histologically confirmed HSIL identified during pregnancy.[10][11][16][17][13][14][18][19] Microinvasive or invasive disease was identified in a small number of cases, most of which were diagnosed post partum.[10][11][16][12][19]

There is evidence to support the safety of colposcopy[10][8][13][14] and biopsy[16] during pregnancy. Biopsy of the cervix in pregnancy is associated with a small risk of excessive bleeding from the cervical biopsy site, but is considered otherwise safe.[16][12][10]

The findings are summarised in the Technical report.

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Recommendations

Flowchart 14.1. Management of a LBC prediction of HSIL in pregnancy

Consensus-based recommendation
REC14.1: Positive oncogenic HPV (not 16/18) test result with LBC negative or pLSIL/LSIL in pregnancy
Pregnant women who have a positive oncogenic HPV (not 16/18) test result with a LBC report of negative or prediction of pLSIL/LSIL should have a repeat HPV test in 12 months.
Consensus-based recommendation
REC14.2: Positive oncogenic HPV (not 16/18) test result with LBC pHSIL/HSIL or any glandular abnormality in pregnancy
Pregnant women who have a positive oncogenic HPV (not 16/18) test result with a LBC prediction of pHSIL/HSIL or any glandular abnormality should be referred for early† colposcopic assessment.

† When practical and not deferred until the postpartum period.
Consensus-based recommendation
REC14.3: Positive HPV (16/18) test result in pregnancy
Pregnant women who have a positive oncogenic HPV (16/18) test result should be referred for early† colposcopic assessment regardless of their LBC test result.

† When practical and not deferred until the postpartum period.
Consensus-based recommendation*

REC14.4: Referral of pregnant women with invasive disease
Pregnant women should be referred and seen within 2 weeks by a gynaecological oncologist/gynaecological cancer centre for multidisciplinary team review and management in the following situations:

  • LBC prediction of invasive disease
  • colposcopic impression of invasive or superficially invasive squamous cell carcinoma of the cervix
  • histologically confirmed diagnosis of invasive or superficially invasive squamous cell carcinoma of the cervix.
Consensus-based recommendation*
REC14.5: Colposcopy during pregnancy
The aim of colposcopy in pregnant women is to exclude the presence of invasive cancer and to reassure them that their pregnancy will not be affected by the presence of an abnormal cervical screening test result.
Practice point
REC14.6: Colposcopy during pregnancy
Colposcopy during pregnancy should be undertaken by a colposcopist experienced in assessing women during pregnancy.
Consensus-based recommendation*
REC14.7: Cervical biopsy in pregnancy is usually unnecessary
Biopsy of the cervix is usually unnecessary in pregnancy, unless invasive disease is suspected on colposcopy or reflex LBC predicts invasive disease.
Consensus-based recommendation*
REC14.8: Defer treatment until after pregnancy
Definitive treatment of a suspected high-grade lesion, except invasive cancer, may be safely deferred until after the pregnancy.
Practice point
REC14.9: Follow-up assessment after pregnancy
If postpartum follow-up assessment (colposcopy and/or HPV test and reflex LBC if necessary) is required, it should be done no less than 6 weeks after delivery and preferably at 3 months. This interval is optimal to reduce the risk of reflex LBC interpretation difficulties or unsatisfactory reflex LBC.

The cervical sample (for HPV test and reflex LBC if necessary) could be collected at the time of postpartum check or at the time of the colposcopic assessment.
Practice point

REC14.10: Vaginal oestrogen prior to postpartum colposcopy
For women who are breastfeeding, the use of intra-vaginal oestrogen cream or pessary† prior to colposcopy may improve visualisation of the cervix and the quality of any cervical sample for LBC.

†Daily for two weeks and cease approximately 3 days before colposcopy.

Practice point
REC14.11: Cervical screening in pregnancy
Routine antenatal and postpartum care should include a review of the woman’s cervical screening history. Women who are due or overdue for screening should be screened.
Practice point
REC14.12: Cervical screening in pregnancy
A woman can be safely screened at any time during pregnancy, provided that the correct sampling equipment is used. A cytobrush or combi-brush should not be inserted into the cervical canal because of the risk of associated bleeding, which may distress women.
Practice point
REC14.13: Self-collection in pregnancy
Self-collection for HPV testing may be considered during pregnancy in never screened or under-screened women, following counselling by a health care professional regarding the risk of bleeding.


Benefits and harms

Biopsy is not recommended in pregnancy but may be required, especially when there is suspicion of invasive disease. There is evidence that it is safe to biopsy the cervix during pregnancy, although there may be a risk of excess bleeding.[16][12][10] However, the risk of an undiagnosed cervical cancer in pregnancy outweighs the risk of bleeding from a biopsy.

Deferring treatment of pre-invasive high grade lesions during pregnancy will prevent possible complications of pregnancy loss and excessive bleeding. There is a small risk of progression to invasive cervical cancer during pregnancy, although an Australian case series showed no cases of progression.[20] Most commonly, this will be microinvasive disease, rather than a clinically apparent cancer.

See Chapter 5. Benefits, harms and cost-effectiveness of screening in the renewed NCSP.


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Health system implications of these recommendations

Clinical practice

The recommendations are consistent with current clinical practice. However changes to the cervix in pregnancy make colposcopic assessment more challenging. Although the squamocolumnar junction and the transformation zone (TZ) are more exposed during pregnancy, complete visualisation of all four quadrants of the cervix is often hindered by oedema, cyanosis, vaginal wall protrusion and thick mucus production.[9] Although colposcopy is safe to perform during pregnancy, an experienced colposcopist should perform the examination owing to the difficulty in differentiating between changes occurring as a result of pregnancy and those due to cervical pathology. A lack of experience could potentially lead to an overestimation of the severity of dysplasia, a mistaken diagnosis of invasive disease and unnecessary investigation during pregnancy.[21]

Resourcing

No additional costs are anticipated.

Barriers to implementation

None.

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Figure 12.1. Collection tools for cervical screening in pregnant women

Figure 12.1.1. Cyto-broom: recommended for use in pregnant women to collect a cervical screening specimen

Image source: Victorian Cytology Services Limited.

Figure 12.1.2. Endocervical brush: not recommended for use

Image source: Victorian Cytology Services Limited.

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Author(s):

References

  1. Al-Halal H, Kezouh A, Abenhaim HA. Incidence and obstetrical outcomes of cervical intraepithelial neoplasia and cervical cancer in pregnancy: a population-based study on 8.8 million births. Arch Gynecol Obstet 2013 Feb;287(2):245-50 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23053308.
  2. Pereg D, Koren G, Lishner M. Cancer in pregnancy: gaps, challenges and solutions. Cancer Treat Rev 2008 Jun;34(4):302-12 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18291591.
  3. Australian Institute of Health and Welfare. ACIM (Australian Cancer Incidence and Mortality) reports. Cervical Cancer. Canberra: AIHW; 2015 Available from: http://www.aihw.gov.au/acim-books.
  4. Nguyen C, Montz FJ, Bristow RE. Management of stage I cervical cancer in pregnancy. Obstet Gynecol Surv 2000 Oct;55(10):633-43 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11023204.
  5. Kärrberg C, Rådberg T, Holmberg E, Norström A. Support for down-staging of pregnancy-associated cervical cancer. Acta Obstet Gynecol Scand 2015 Jun;94(6):654-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25845736.
  6. Blomfield P. Cervical neoplasia in pregnancy. Cancer 2012;14(1):34-5.
  7. National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. Canberra: NHMRC; 2005.
  8. Guijon F. Colposcopy in pregnancy analysis of 1182 patients with abnormal cervical cytology. J Low Genit Tract Dis 2010;14(3):260-61.
  9. Origoni M, Salvatore S, Perino A, Cucinella G, Candiani M. Cervical Intraepithelial Neoplasia (CIN) in pregnancy: the state of the art. Eur Rev Med Pharmacol Sci 2014;18(6):851-60 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24706310.
  10. Wu YM, Wang T, He Y, Song F, Wang Y, Zhu L, et al. Clinical management of cervical intraepithelial neoplasia in pregnant and postpartum women. Arch Gynecol Obstet 2014 May;289(5):1071-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24196304.
  11. Coppolillo EF, DE Ruda Vega HM, Brizuela J, Eliseth MC, Barata A, Perazzi BE. High-grade cervical neoplasia during pregnancy: diagnosis, management and postpartum findings. Acta Obstet Gynecol Scand 2013 Mar;92(3):293-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22880637.
  12. Siddiq TS, Twigg JP, Hammond RH. Assessing the accuracy of colposcopy at predicting the outcome of abnormal cytology in pregnancy. Eur J Obstet Gynecol Reprod Biol 2006 Jan 1;124(1):93-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16029922.
  13. Fader AN, Alward EK, Niederhauser A, Chirico C, Lesnock JL, Zwiesler DJ, et al. Cervical dysplasia in pregnancy: a multi-institutional evaluation. Am J Obstet Gynecol 2010 Aug;203(2):113.e1-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20522409.
  14. Serati M, Uccella S, Laterza RM, Salvatore S, Beretta P, Riva C, et al. Natural history of cervical intraepithelial neoplasia during pregnancy. Acta Obstet Gynecol Scand 2008;87(12):1296-300 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18951206.
  15. Danhof NA, Kamphuis EI, Limpens J, van Lonkhuijzen LR, Pajkrt E, Mol BW. The risk of preterm birth of treated versus untreated cervical intraepithelial neoplasia (CIN): a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2015 May;188:24-33 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25770844.
  16. Kärrberg C, Brännström M, Strander B, Ladfors L, Rådberg T. Colposcopically directed cervical biopsy during pregnancy; minor surgical and obstetrical complications and high rates of persistence and regression. Acta Obstet Gynecol Scand 2013 Jun;92(6):692-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23590574.
  17. Cubo-Abert M, Centeno-Mediavilla C, Franco-Zabala P, Merced-Vázquez C, Castellví J, García A, et al. Risk factors for progression or persistence of squamous intraepithelial lesions diagnosed during pregnancy. J Low Genit Tract Dis 2012 Jan;16(1):34-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22126830.
  18. Frega A, Scirpa P, Corosu R, Verrico M, Scarciglia ML, Primieri MR, et al. Clinical management and follow-up of squamous intraepithelial cervical lesions during pregnancy and postpartum. Anticancer Res 2007 Jul;27(4C):2743-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17695441.
  19. Kaplan KJ, Dainty LA, Dolinsky B, Rose GS, Carlson J, McHale M, et al. Prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions diagnosed during pregnancy. Cancer 2004 Aug 25;102(4):228-32 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15368314.
  20. Woodrow N, Permezel M, Butterfield L, Rome R, Tan J, Quinn M. Abnormal cervical cytology in pregnancy: experience of 811 cases. Aust N Z J Obstet Gynaecol 1998 May;38(2):161-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9653851.
  21. Freeman-Wang T, Walker P. Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause. Best Pract Res Clin Obstet Gynaecol 2011 Oct;25(5):653-65 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21843974.

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