Q.1:-How
many us carry out speculum exam as a
routine & Pap smear in first ANC
visit(booking) and Post
Postpartum visit say 6weeks to 3 months
after confinement – in A) Corporate settings B) Own private clinic C) Govt or
municipal hospitals? Your practice patterns please & FOGSI / International bodies
recommendations?? Please do remember that 0.05%
of all pregnancies are complicated by cervical
cancers. To my knowledge the
Recommendation for Pap
smear screening includes screening at
first prenatal visit and again at 6 weeks
postpartum.
Q.
on Doctors Day :: Q NO 2:- Why Pap smear
in booking visit? Ans: Many Indian are denied of routine health
check up. Honestly speaking millions of Indian rural women undergo first health check up in their
life while being pregnant. Undenibaly
such check up are often carried out by ASHA
health workers. Be that it may be pregnancy
and prenatal care offer an
excellent opportunity to implement screening for premalignant disease especially in women who do not
seek routine health care.
Q.3: What is the prevalence of Invasive
Ca Cx in pregnancy?? Ans:-Whereas the incidence of invasive
cancer ranges from 1 in
1000 to 1 in 10,000 pregnancies but
alarmingly the incidence of preinvasive cancer is 1 in
750 depending on the type of population studied. One should take a note that cervical cancer remains the most common
malignancy diagnosed during pregnancy.
Q.
on Doctors Day :: Q NO 2:- Why Pap smear
in booking visit? Ans: Many Indian are denied of routine health
check up. Honestly speaking millions of Indian rural women undergo first health check up in their
life while being pregnant. Undenibaly
such check up are often carried out by ASHA
health workers. Be that it may be pregnancy
and prenatal care offer an
excellent opportunity to implement screening for premalignant disease especially in women who do not
seek routine health care.
Q.3: What is the prevalence of Invasive
Ca Cx in pregnancy?? Ans:-Whereas the incidence of invasive
cancer ranges from 1 in
1000 to 1 in 10,000 pregnancies but
alarmingly the incidence of preinvasive cancer is 1 in
750 depending on the type of population studied. One should take a note that cervical cancer remains the most common
malignancy diagnosed during pregnancy.
On Doctors
Day:-My Q to members are :Have we ever thought of “ What is the % of Cervical cancer that occur in child bearing age
making Pap smear so important in preg or P partum visits??”
Ans:-Approximately 30% cervical cancers are diagnosed during child
bearing age with 3% of cervical cancers diagnosed
during pregnancy
and only .We have to remember 0.05% of all pregnancies are complicated
by cervical cancers. Effectiveness
of Papanicolaou smear and Colposcopy
in the detection of preinvasive and early
invasive disease is well proven as we carry on our discussions on
Doctors Day.
On Doctors Day:-My second Q to learned members are Q.5:- Why do cytologist “go on leave:”- when she/ he is confronted
with a Pap slide where report proforma
along with slide sent says the “The
enclosed slide or wet smear” slide is from a pregnant woman??
What makes interpretations of diff cell kinds so difficult?? Ans:-The physiological changes in the lower genital tract secondary
to pregnancy , in many cases cause specific alternations that may
make screening a challenge
. Nevertheless an astute cytologist can
pick up and gently exclude normal preg
changes in ectocx &
endocervical changes. But the effectiveness
of Papanicolaou smear and Colposcopy
in the detection of preinvasive and early invasive disease is well proven .
On Doctors
Day:-My Q to members are :Have we ever thought of “ What is the % of Cervical cancer that occur in child bearing age
making Pap smear so important in preg or P partum visits??”
Ans:-Approximately 30% cervical cancers are diagnosed during child
bearing age with 3% of cervical cancers diagnosed
during pregnancy
and only .We have to remember 0.05% of all pregnancies are complicated
by cervical cancers. Effectiveness
of Papanicolaou smear and Colposcopy
in the detection of preinvasive and early
invasive disease is well proven as we carry on our discussions on
Doctors Day.
On Doctors
Day:-My second Q to learned members are Q.5:- Why do
cytologist “go on leave:”- when she/ he
is confronted with a Pap slide where
report proforma along with slide sent
says the “The enclosed slide or wet smear” slide is from a pregnant
woman?? What makes interpretations of diff cell kinds so
difficult?? Ans:-The physiological
changes in the lower genital tract secondary
to pregnancy , in many cases cause specific alternations that may
make screening a challenge
. Nevertheless an astute cytologist can
pick up and gently exclude normal preg
changes in ectocx &
endocervical changes. But the effectiveness
of Papanicolaou smear and Colposcopy
in the detection of preinvasive and early invasive disease is well proven On
Doctors Day let us be duty bound:-Q.6: It is worth remembering that Pregnancy does not alter the rates of false negative results significantly ?? . Ans:-Yes,
it is admitted that diagnostic difficulties in interpretation of a smear do occur. Diagnostic
pitfalls associated with Pap Smear in pregnancy
The exaggerated ectropion in pregnancy exposes
the glandular epithelium to the
harsh vaginal environment making
inflammatory changes more common on smear,. Candida and Trichomonas are the most
common organisms in the smear .The
k exposure of endocervical
epithelium to acidic pH
increases the number of foci
of squamous metaplasia giving an erroneous
impression of dysplasia.
Q. 7:What are the physiological
changes that make interpretation and grading of CIN so difficult?? The cytologist are aware that dysplastic cells rarely have
nucleoli and have clumped chromatin which are absent in
decidual cells / decidualized chnges ecto/ endo Cx cells.
Don’t
be a fool:-Caution 9A: Firstly, decidualisation of
the cervix and endo cervix has been reported
because cytologically the decidual cells
can be confused with normal
parabasal cells and high grade
dysplastic cells but the differentiating
point is that decidual cells tend to be polygonal to round with sharp cytoplasmic
border having vacuolated
basophilic cytoplasm and large hypo chromatic centrally placed nuclei
with prominent nucleoli . By contrast
dysplastic cells rarely have
nucleoli and have clumped chromatin
On
Doctors day –No omissions are permitted, Pl be dedicated like a soldier:-Don’t be
a fool:-Caution
9B: How best to D/D
abnormal Cx cells with Trophoblast cells
which are often present in pap smear in preg?? Ans:- Trophoblast cells typically seen as multinucleated giant cells which can be shed and
picked up by Pap Smear .These cells can be differentiated from abnormal by the presence of BhCG
on immunohistochemistry from
low grade dysplasia viral infection
or any granulomatous condition
Don’t be a fool:-Caution 9 C : Which other kind of cells in may
mimick abnormal Cx cells thereby confusing cytologist about grading of CIN??:
Ans:-It is Arias Stella reaction
related cells!!! Caution from Dr Pal:à AS cells are small loosely nuclear
to cytoplasmic ratio with eccentric
nuclei and prominent cherry
red nucleoli. These mimic
high grade adenocarcinoma which is verified
on biopsy Do we recall these kinds of cells if D& C is done in
suspected EP preg cases? In the good old age when I was a final yr student
& Resident then we used to do D&C if there was clinical daig dilemma.
If curette the materials were when put in N saline –apparently looked like trophoblastic
cells flouting in N saline (backed up by negative proof puncture of POD) then
we diag that we are dealing not with a case
of EP . Be that it may coming back to
Pap in preg these A-S reacted endometrial /Cx cells are seen
as small loosely nuclear to cytoplasmic ratio with eccentric nuclei and prominent cherry
red nucleoli. These mimic
high grade adenocarcinoma which is verified
on biopsy.
On Doctors
Day let us follow / obey TRAFFIC RULES(International
recommendation on Cx Screening in Preg)
: No omissions pl: be duty bound Caution 10:-- Does Cytobrush in preg causes more
harm in context to more falsely picking up
abnormal cells? Ans:-The use of abrasive endocervical sampling device such as the Cytobrush has a
theoretical risk of significant
hemorrhage or pregnancy related remains
between the chance of detection
and complication
Caution 9:-
More false +ve prevalence of HPV
and its sequelae !! Ans:-Prevalence of HPV and its sequelae may increase
during pregnancy. Due to immune suppression the prevalence of
HPV and
its sequelae may increase during pregnancy . Several studies suggest
increased incidence of high
cancer risk viruses- HPV
type 16,18,31,35,45,51,32 and
56 compared with non pregnant woman.
Why there is
delay in diagnosis in Ca Cx in preg? What members feel about this?? Ans:-
Caution 10- Diagnosis of a cervical cancer during pregnancy are usually delayed A) Pts don’t consent or afford for Pap 2) lack of community/ Residents awareness 3)The third
cause of delayed daig are confusion of symptoms
of invasive cervical cancer
are mistaken for those of
pregnancy complications. On inspection a
senior Obstet too can miss !!! For instance a subtle preinvasive or early invasive cancer is mistaken for an A) ectropion B) cervical decidualisation B) Misc other
exaggerated changes of pregnancy
. Then what is the accepted solution?? Ans is there is a urgent need of routine
speculum examination for every abnormal
bleeding or discharge occurring in the pregnant woman & backed up by pap -> Colposcopy, If
rush at OPD is high the residents may be
asked visiting(Teacher/ Unit head) to
see such suspected cases who warrant Cx biopsy after palà Colposcopy in pregnancy .is
obvious and a cervical
smear should be taken.
On Doctors
Day let us follow / obey TRAFFIC RULES(International
recommendation on Cx Screening in Preg)
: No omissions pl: be duty bound Caution 10:-- Does Cytobrush in preg causes more
harm in context to more falsely picking up
abnormal cells? Ans:-The use of abrasive endocervical sampling device such as the Cytobrush has a
theoretical risk of significant
hemorrhage or pregnancy related remains
between the chance of detection
and complication
Caution 9:-
More false +ve prevalence of HPV
and its sequelae !! Ans:-Prevalence of HPV and its sequelae may increase
during pregnancy. Due to immune suppression the prevalence of
HPV and
its sequelae may increase during pregnancy . Several studies suggest
increased incidence of high
cancer risk viruses- HPV
type 16,18,31,35,45,51,32 and
56 compared with non pregnant woman.
Why there is
delay in diagnosis in Ca Cx in preg? What members feel about this?? Ans:-
Caution 10- Diagnosis of a cervical cancer during pregnancy are usually delayed A) Pts don’t consent or afford for Pap 2) lack of community/ Residents awareness 3)The third
cause of delayed daig are confusion of symptoms
of invasive cervical cancer
are mistaken for those of
pregnancy complications. On inspection a
senior Obstet too can miss !!! For instance a subtle preinvasive or early invasive cancer is mistaken for an A) ectropion B) cervical decidualisation B) Misc other
exaggerated changes of pregnancy
. Then what is the accepted solution?? Ans is there is a urgent need of routine
speculum examination for every abnormal
bleeding or discharge occurring in the pregnant woman & backed up by pap -> Colposcopy, If
rush at OPD is high the residents may be
asked visiting(Teacher/ Unit head) to
see such suspected cases who warrant Cx biopsy after palà Colposcopy in pregnancy .is
obvious and a cervical
smear should be taken.
On Doctors
Day may I remind my dear dignified & duty bound members –a simple query to
U , Mam & Sirs?? :- How best to diagnose Preinvasive cancer
Guidelines for managing abnormal Pap Smear
For pregnant patents with high grade squamous cell intraepithelial lesions
it is recommended that colposcopic examination should be performed by
clinicians with experience in pregnancy induced cytological changes High grade
disease or malignancy should be biopsied
Unsatisfactory colposcopic findings require repeat examination after 6-12
weeks. Post delivery repeat
cytology and colposcopy should generally be delayed for at least 6 weeks.
Then what with ab cytology?? To continue preg or
terminate?? Answer is here!!!! :- Ans: The
management of abnormal cytology
during pregnancy has
changed dramatically during the last 3
decades. The goal of evaluation
remains timely diagnosis and planning
of treatment for invasive carcinoma of cervix. Low grade
lesions are apt to regress in 36-70%
cases. The regression rates for high
grade lesions vary from 30-40 %
Therapy for preinvasive carcinoma therefore
can be postponed to postpartum
period so biopsy is avoided. The use of cone biopsy
has been significantly reduced by diligent application of colposcopy cone biopsy is necessary when colposcopy
is unsatisfactory .
Points or caution against Cx Biosy ? Limit biopsy
to worst area & counsel ahead
about àPrepare for increased biopsy site bleeding .
The diagnostic accuracy of colposcopy is 99%
and complication rate less than
1% . during pregnancy it is easy
to perform as the transformation zone is better exposed due to physiological eversion. Colposcopy is a safe and reliable method for evaluating pregnant patients with abnormal
cervical cytological findngs.
Daig & TR of CIN -I & II:_as pointed out by mysisterDr
Shruti:-1: It is
important however not to treat or perform a diagnostic excisional procedure
on women who are pregnant
unless invasive cancer is present or of significant concern. In case of CIN –II and III :à
Unless invasive cancer cannot
be ruled out high grade disease detected during pregnancy is generally followed until postpartum because of
the low risk of progression to invasion
and the potential to regress post delivery . Follow up is generally by cytology and colposcopy every 8-12 weeks
and 6 weeks postpartum. The
relative increase in immune response postpartum and the decrease in hormonal influences
that promote progression result in regression in 69% cases.
What is the collective
opinion on “Role of conization in pregnancy & biopsy after tying the lat Cx (lowermost part des Cx arteries) bilaterally
which feeds mostly the ectoCx ?”:-- Cone biopsy is for diagnostic
also for Tr of early lesions, We were
aware of that . But the point is that this cannot be
considered therapeutic during
pregnancy owing to the high incidence
of positive margins and residual disease on
postpartum evaluation .
Ans:-
However, not that cone should never be done but It is reserved only for cases with high
suspicion of invasive cancer. Classical conization in pregnancy can be disastrous
resulting in significant hemorrhage
necessitating vaginal packing, transfusion hospitalization miscarriage
fetal loss and increased perinatal
death rates. If absolutely indicated a cone biopsy is best
performed between 14 and 20 weeks with
or without cervical
cerclage.
How efficient is Colposcopy in pregnancy??
The challenges of performing an adequate
colposcopic examination in pregnancy are increased friability caused by relative eversion of
the columnar epithelium cervical
distortion from a low riding fetal head early effacement and obstruction of visualization by the mucus plug. Special considerations for Colposcopy in pregnancy are as follows ,Expert colposcopist should
perform the evaluation .Unsatisfactory examination
may be satisfactory in 6-12
weeks or by 20 weeks
Re
evaluate lesion with Pap smear or
colposcopy every 8 -12 weeks
Perform repeat biopsy only if lesion worsens.
Recommended
excisional biopsy only if concerned about invasive cancer. Among k patents with
the disease approximately 1% to 3% are pregnant
at the time of diagnosis. The
diagnosis of cancer evokes a multitude of feelings
ranging from denial and disbelief
to anxiety and anger. The management
of such patients can
present difficult ethical k
emotional and social considerations for the patient fetus and the health care
team.
Diagnosis and
Evaluation
Pregnancy
represents an ideal time for cervical cancer screening. A pelvic examination
including visual inspection of the cervix cervical cytology from the ecto
cervix and bimanual examination is a routine part of prenatal care .Accurate determination of the extent
of cancer is more difficult during pregnancy because indurations of base of
broad ligaments may be less prominent
during pregnancy . Such indurations in nonpregnant women characterizes tumor
spread beyond the cervix.
Symptoms are
variable and pregnancy can mask some of the common symptoms. More than 70%
are asymptomatic during
presentation .The recognition of the cancer cervix in pregnancy
may be missed through attributing vaginal bleeding directly to pregnancy
threatened abortion in early
pregnancy and placenta previa
or accidental hemorrhage in the later months . Vaginal discharge
and pain are some of the nonspecific
and less common symptoms
Suppose one
of clinically thinks that she/ he is (by speculum exam) is dealing with a case
of possible Ca CX-then what?? My ans to this problem (my approach)>::- The initial
step in the evaluation of the cancer
cervix is Pap smear. When the lesion is visible biopsy should be performed This is the only gynecological
malignancy that is clinically staged.
Staging procedure as proposed by
International Federation of
Gynecology and Obstetrics are general
physical examination systemic examination per speculum examination
per vaginum examination
chest radiograph cystoscopy
and proctoscopy Other diagnostic modality such as MRI may be useful in assessing
tumor volume and the extent of disease. MRI is a safe
and non invasive modality to
assess tumor extent and volume in pregnant patients with cervical cancer. In addition it may be
help to guide the physician in
selection of therapy and follow up
care in these patients . Pregnant patients with cervical cancer
should be staged according to
the most recent FIGO staging system.
What will be
the Management of Ca Cx after biopsy & review of slide by another senior
person ??
Treatment varies for each patient depending on the A) stage
of disease and duration of pregnancy and B) the woman’s
/ couples desire to continue the pregnancy .C) multidisciplinary
Counseling and formulation of treatment plan:-
. Treatment for micro
invasive disease follows guidelines
similar to those for intra epithelial disease . In general
continuation of
pregnancy and vaginal delivery
are considered safe and
definitive therapy is provided
postpartum.
What about Invasive cancer?? Ans:-Invasive cancer demands relatively prompt therapy . During the first half of the pregnancy Immediate treatment may be advisable. During the latter half of
pregnancy a reasonable option is to wait
for not only fetal viability but also fetal maturity. There are issues
regarding the safety of a
planned delay in treatment . With recent
advances in neonatal care the definition of fetal viability has been
lowered. The survival k of
neonates born at earlier gestations has
improved with steroids surfactant
and contemporary neonatal intensive care. Antepartum
steroids should be given to
enhance fetal lung maturity Accurate dating of pregnancy is important to determine the timing of
delivery . Delivery should be
considered as soon as fetal
viability can be expected with
minimal anticipated neonatal morbidity.
Mode of
delivery
Cesarean
section is the recommended mode of delivery
although studies suggest that survival
after vaginal delivery is not
significantly different from after
abdominal delivery .
Other concerns
include hemorrhage and obstructed
labor associated with vaginal delivery in pregnant patients with cervical cancer. Episiotomy site recurrence may be associated with high
mortality Recurrences at the
episiotomy site most likely
occur from direct tumor spillage and
implantation during vaginal delivery. Owing
to these concerns cesarean delivery
should be the mode of delivery .
Pregnant
women diagnosed with cervical cancer in the first or second trimester who require immediate treatment
with radiation should be allowed to deliver vaginally Hysterotomy during the second trimester usually requires a vertical
uterine incision and can result
in large blood loss Thus in patients
in who a planned delay in treatment is not possible radiation
should be given without exposing
the patients to the high morbidity
associated with hysterotomy
Surgical Treatment
Radical hysterectomy and lymphadenectomy are widely accepted as the preferred therapy for early stage
cervical cancer in pregnant and non pregnant women
Pregnant women are most likely to benefit from surgical treatment
because of their young age as the
ovarian function can be preserved.
Except for the increased blood loss in conjunction with cesarean section the studies reported that the outcome for radical hysterectomy with the fetus in situ or
after cesarean delivery did
not differ significantly from that of radical hysterectomy in the non
pregnant state. There were also
no differences in operative
morbidity and major
complication rates. Thus the
surgical management of cervical
cancer complicating
pregnancy seems to be safe
and effective with morbidity rates
comparable with those for
nonpregnant patients.
Before
20 weeks gestation radical hysterectomy can usually be performed with
the fetus in situ if the fetal age is
> 20 weeks or better visualization is needed the fetus can be delivered via hysterotomy
through a fundal incision or classic
cesarean section superior to hysterectomy The lower uterine segment and the cervix should be avoided during fetal delivery,
Intra
operatively surgery should not be abandoned on the basis of enlarged pelvic and Para
aortic lymph nodes because node
hypertrophy can occur with pregnancy
alone. Physiologic decidual cell reactions in lymph nodes as a result of pregnancy can be confusing and histological
evaluation should be carefully
performed.
Radiation Treatment
Treatment for stage IIB and higher
stages cervical cancer is usually limited to radiation therapy
In addition woman at high risk
for surgical morbidity and mortality should also be treated primarily
with radiotherapy When the fetus is viable delivery should be
performed via cesarean section prior to
the initiation of therapy ./ If the fetus is not viable external
beam radiation therapy can be
started prior to delivery. The mean radiation
dose at which abortion occurs in 34
cy/ thus teletherapy is a
safe and effective modality for evacuating the uterus
prior to brachytherapy . If spontaneous
abortion does not ensure curettage
is performed .
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