1. In the name of God Isfahan medical school Shahnaz Aram MD

2. Cervical cancer & pregnancy Definition: in pregnancy or 12 months after delivery Definition: in pregnancy or 12 months after delivery Rarely invasive cancer in pregnancy Rarely invasive cancer in pregnancy Most common cancer is genital cancer Most common cancer is genital cancer Pregnancy complicates 3% of cervical cancers Pregnancy complicates 3% of cervical cancers Overall cancer rate in pregnancy Dysplasia is common Dysplasia is common Abnormal pap-smear is 3% Abnormal pap-smear is 3% CIN3  1.3 in 1000 pregnancies CIN3  1.3 in 1000 pregnancies Invasive cancer  1 in 2200, 1 in 8333 Invasive cancer  1 in 2200, 1 in 8333 Overall survival similar in non pregnant in any stage Overall survival similar in non pregnant in any stage

3. 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

4. Inadequate colposcopy examination (ablative therapy) Close follow up in 2-3 rd trimester Conization in first trimester  33% causes abortion Cone biopsy complication : hemorrhage Abortion Preterm labor

5. 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

6. CIN2 & CIN3 in pregnancy should Colposcopy directed biopsy Colposcopy directed biopsy If CIN3 should Be followed by cytology Be followed by cytology Normal vaginal delivery Normal vaginal delivery 80% persistent after delivery 80% persistent after delivery Definitive management Definitive management

7. If pap-smear is suspicious for invasive cancer cone biopsy is indicated cone biopsy is indicated Cone biopsy in limited situation Cone biopsy in limited situation If conization necessary Prophylactic cerclage Prophylactic cerclage Wedge resection Wedge resection In second trimester In second trimester

8. If microinvasive in cone biopsy <3mm and margin free Continuing pregnancy Continuing pregnancy Normal vaginal delivery Normal vaginal delivery 6 weeks later after delivery, vaginal hysterectomy 6 weeks later after delivery, vaginal hysterectomy If margin involved (3-5mm invasion) or lymphatic invasion More treatment More treatment Follow till term Follow till term Classical cesarean section + modified radical hysterectomy + pelvic lymph node dissection Classical cesarean section + modified radical hysterectomy + pelvic lymph node dissection

9. If margin involved( >5mm invasion) Treatment is according to 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 Amnioscentesis for lung maturation No later than 4 weeks No later than 4 weeks Classical cesarean section Classical cesarean section Radical hysterectomy + pelvic lymph node dissection Radical hysterectomy + pelvic lymph node dissection

10. Symptoms Symptoms are often ignored due to pregnancy related causes Vaginal bleeding Vaginal discharge Post coital bleeding Pelvic pain 20% asymptomatic

11. 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

12. 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

13. 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 20 th week  treatment without delay After 30th week  await fetal maturity, fetal viability 20-30 weeks  no adverse effect for delay in treatment

14. Route of delivery Vaginal or cesarean section (most clinicians prefer abdominal delivery) Vaginal or cesarean section (most clinicians prefer abdominal delivery) No clear evidence that tumor dissemination caused by birth process No clear evidence that tumor dissemination caused by birth process Major risk for vaginal delivery, tearing and bleeding Major risk for vaginal delivery, tearing and bleeding Recurrence in episiotomy reported Recurrence in episiotomy reported If lesion is removed  NVD If lesion is removed  NVD If no conization  classical cesarean section If no conization  classical cesarean section

15. 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

16. If tumor is small of completely regressed: Modified radical hysterectomy Modified radical hysterectomy Fetus viable  classical C/S, postoperative radiation Fetus viable  classical C/S, postoperative radiation If C/S (palpated pelvic para-aortic node) 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

17. 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%