Cervical cancer screening
14. Screening in pregnancy
GUIDELINE UPDATES - This guideline was last updated 9/16/2019
UPCOMING GUIDELINES - This guideline was updated and comes into practice on 7/1/2022. Download PDF
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. 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, and more women delaying pregnancy. 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).
Approximately five per cent of pregnant women will have abnormal cervical cytology. 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. 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. 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 because progression of cervical intraepithelial neoplasia (CIN) to invasive disease during pregnancy is rare, with a range of 0–3% of cases. Almost all cases are microinvasive and amenable to curative treatment.
Postpartum regression of CIN lesions is common. 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. 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.
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. Microinvasive or invasive disease was identified in a small number of cases, most of which were diagnosed post partum.
There is evidence to support the safety of colposcopy and biopsy 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.
The findings are summarised in the Technical report.
Flowchart 14.1. Management of a LBC prediction of HSIL in pregnancy
|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.
|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.
|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.
REC14.4: Referral of pregnant women with invasive disease
|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.
|REC14.6: Colposcopy during pregnancy|
Colposcopy during pregnancy should be undertaken by a colposcopist experienced in assessing women during pregnancy.
|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.
|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.
|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.
REC14.10: Vaginal oestrogen prior to postpartum colposcopy
|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.
|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.
|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. 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. Most commonly, this will be microinvasive disease, rather than a clinically apparent cancer.
Health system implications of these recommendations
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. 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.
No additional costs are anticipated.
Barriers to implementation
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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- A/Professor Alison Brand — Co-author
- Professor Ian Hammond — Co-author
- Dr Joanne Mountford — Co-author
- Dr Lara Roeske — Co-author
- Cancer Council Australia Cervical Cancer Screening Guidelines Working Party — Co-author
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