1. Cervical Cancer Screening 2010 and PID in pregnancy
Delese LaCour M.D.
Pediatric and Adolescent Gynecology
Johns Hopkins Community Physicians
January 29, 2010

3. Cervical Cancer Screening
1943 Papanicolaou and Trout published their monograph on the use of vaginal and cervical cytology as a screening tool for cervical neoplasm
The incidence of cervical cancer has been reduced by 50%
Cervical cancer has dropped from the #2 female cancer deaths to the 13th

4. Types of Cervical Cancer
Squamous cell Approximately 80-90% of cervical cancers
Adenocarcinoma 10%
Clear cell cervical cancer
Mucinous adenocarcinoma
Adenosquamous
Glassy cell carcinoma
Stromal sarcoma
Sarcoma botryoides
Leiomyosarcoma
Lymphoma
Small cell cervical cancer
Adenoid cystic carcinoma of the cervix

5. Technique for cervical cancer screening

6. Collection Methods for Pap Smear

7. Collection Methods for Pap Smear

8. Bethesda System 2001
SPECIMEN ADEQUACY Satisfactory for evaluation (note presence/absence of endocervical/ transformation zone component) Unsatisfactory for evaluation  Specimen rejected/not processed  Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because
GENERAL CATEGORIZATION (Optional) Negative for intraepithelial lesion or malignancy Epithelial cell abnormality
INTERPRETATION/RESULT Negative for Intraepithelial Lesion or Malignancy  Organisms   Trichomonas vaginalis ,   Fungal oganisms consistent with Candida species   Shift in flora suggestive of bacterial vaginosis   Bacteria consistent with Actinomyces species   Cellular changes consistent with herpes simplex virus
 Other non-neoplastic findings   Reactive cellular changes associated with    inflammation    radiation    intrauterine contraceptive device   Glandular cells status posthysterectomy   Atrophy

9. Bethesda System 2001
Epithelial Cell Abnormalities  Squamous cell   Atypical squamous cells (ASC)    of undetermined significance (ASC-US)    cannot exclude HSIL (ASC-H)
  Low-grade squamous intraepithelial lesion (LSIL)    encompassing: human papillomavirus/mild dysplasia/cervical intraepithelial neoplasia (CIN) 1
  High-grade squamous intraepithelial lesion (HSIL)    moderate and severe dysplasia, carcinoma in situ; CIN 2 and CIN 3  Squamous cell carcinoma
 Glandular cell   Atypical glandular cells (AGC)   Atypical glandular cells, favor neoplastic   Endocervical adenocarcinoma in situ (AIS)   Adenocarcinoma

12. Cervical cancer screening
Cervical cancer screening should begin at age 21
A) High prevalence of HPV infection in teenagers
B) Most dysplasia regresses spontaneously in adolescents
C) Invasive cervical cancer is rare in those younger than 21
D) Potential for adverse effects of side effects
American College of Obstetrics and Gynecology
Practice Bulletin No 109, Dec 2009

13. High prevalence of HPV infection in teenagers

14. 1/Castle/p.225/ col 1/¶ 3
1/Castle/p.225/ col 1/¶ 3
1/Castle/p.225/ col 1/¶ 3
2/Sellors/Ch 1/p.8/ ¶ 1
2/Sellors/Ch 1/p.5/ ¶ 4
3/Rager/p.469/col 1/¶ 1
1/Castle/p.225/ col 1/¶ 3

19. Most dysplasia regresses spontaneously in adolescents
A prospective study of 187 women aged years old found that LSIL had reverted to negative in 61% after 1 year and 91% after 3 years
Only 3% progressed to CIN 3
Two smaller studies of adolescent females with biopsy confirmed CIN 2 showed 65-75% regression after 18 months and 36 months
ACOG practice bulletin 2009

23. Invasive cervical cancer is rare in those younger than 21
Only 0.1 % of cervical cancers occur before age 21 National data from 1998 through 2003 identified 14 cases of invasive cancer /year in those ages SEER incidence rate of 1-2 cases per 1,000,000 females aged (Surveillance Epidemiology and End Results)

27. Potential for adverse effects of side effects
Significantly increased risk of :
Preterm birth
Low birth weight
Neonatal intensive care admissions
For every 18 LEEPs preformed there will be an additional preterm birth
Suh-Burgmann B and Kinney W 2006 ASCCP Vol 10 , Issue 2,2006

28. Management of LGSIL

29. Abnormal Pap ASCUS-H

30. Management of HGSIL

31. Abnormal Pap CIN1

32. Abnormal Pap CIN 2-3

33. How often to screen Frequency of cervical cytology screening
Every 2 years for women aged 21-29
Women aged 30 or older with three consecutive negative pap smears can be followed every three years
More frequent screening for
HIV infected women
Immunosuppressed women
Women exposed to DES
Women with previously treated CIN2, CIN 3 , or cancer

34. How often to screen Frequency
Women with HIV should be screened every 6 months in the first year of diagnosis, then every year
Women treated in the past for CIN2, CIN3, or cancer are at risk for 20 years for recurrence or persistence, annual screening

35. Special Notes The frequency of those with same sex partners
Penetrative sex at an early age
Same screening in those who have been vaccinated against HPV ( ACOG press release 11/09)

37. Pelvic Inflammatory disease in pregnancy
A 23 year old P2032 at 8 weeks and 6 /7 days presents to ER with complaint of nausea, vomiting, and abdominal pain
Past Medical history : NC
Past Surgical history : TAB x 3
Social history : positive marijuana use
Gyn/OB history: new partner, history of Chlamydia, Trich, PID in past, SVD times two
Vitals , RR 20, P 65, BP 97/59
PE: moderate distress
Abdomen soft, no rebound or guarding,
Pelvic: Yellow vaginal discharge, cervical motion tenderness
Sonogram: 8 week fetus with fetal HMS

38. Pelvic Inflammatory disease in pregnancy
Labs: WBC 4.9, Hct 39.9, Positive culture for chlamydia, Trich on wet prep
Hospital course: pt was admitted with diagnosis of PID in pregnancy, Treated 48 hours with IV Gentamycin and Clindamycin , po Azithomycin
Discharge Home with Clindamycin for ten days

39. Pelvic Inflammatory Disease
Most of the times multi-organism
Can range from endometritis to pelvic abcesses
300,000 cases per year
16-20% in Adolescents
Clinical diagnosis overestimated and difficult

40. Pelvic Inflammatory Disease
Empiric treatment warranted if suspected because of long term effects if untreated
Begin treatment if sexually active and
Uterine tenderness
Adnexal tenderness
Cervical motion tenderness (CMT)

41. Pelvic Inflammatory Disease
Additional Criteria:
Temp > 101 F (38.3 C)
Mucopurulent cervical discharge
WBC on microscopy
Increased erythrocyte sedimentation rate
Increased C-reactive protein
Positive culture for N. gonorrhea or Chlamydia

43. Pelvic Inflammatory Disease
Treat in hospital if:
Surgical emergency cannot be excluded
Pregnancy (rare 1: 1000 to 1:25000)
No initial clinical response
Does not tolerate PO
Severe illness
Tubo-Ovarian abscess

44. Pelvic Inflammatory Disease
Rx. Outpatient: A:
Ofloxacin 400 mg PO BID X 14 days OR
Levofloxacin 500 mg PO QD X 14 days
+/- Metronidazole 500 mg PO BID X 14 days B:
Ceftriaxone 250 mg IM X 1 dose OR
Cefoxitin 2 g IM X 1 dose + Probenecid 1 g PO OR
Other third generation cephalosporin
Plus Doxycycline 100 mg PO BID X 14 days
CDC STD treatment guidelines

45. Pelvic Inflammatory Disease
In House A:
Cefotetan 2 g IV Q 12 OR Cefoxitin 2 g IV Q 6H
Plus Doxycycline 100 mg IV or PO Q12 H B:
Clindamycin 900 mg IV q8h
Plus Gentamicin 2mg/kg loading f/u 1.5 mg/kg Q8H C:
Ofloxacin 400 mg IV Q6h or Levofloxacin 500 mg QD
+/- Metronidazole 500 mg IV Q8H or Unasyn 3 g IV Q6H
Plus Doxycycline 100 mg PO IV Q12H
CDC STD treatment guidelines

46. Pelvic Inflammatory Disease
Pregnancy:
Multiple reports in the literature (1:1000-1:25000)
Easily confused with ectopic pregnancy
Associated with fetal wastage and poor outcomes
Etiology confusing:
Sperm carrying bacteria?
Infection prior to 12 weeks and membrane apposition?
Reactivation of latent disease?
Hematogenous or Lymphatic spread?
Lara-Torre E et al JRM 2002;47:959-61

47. Pelvic Inflammatory Disease
Pregnancy (cont):
Aggressive antibiotic treatment warranted prior to uterine evacuation
Conservative treatment may maintain pregnancy to term
Delay in diagnosis because of pregnancy may worsen outcomes
Decrease immune response in pregnancy may worsen presentation and progression