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Cervical Cancer Screening 2010 and PID in pregnancy

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

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Cervical Cancer Screening 2010 and PID in pregnancy

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

  2. 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

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

  4. Technique for cervical cancer screening

  5. Collection Methods for Pap Smear

  6. Collection Methods for Pap Smear

  7. Bethesda System 2001 • SPECIMEN ADEQUACYSatisfactory for evaluation (note presence/absence of endocervical/transformation zone component) Unsatisfactory for evaluation. . .  Specimen rejected/not processed Specimen processed and examined, butunsatisfactory for evaluation of epithelial abnormality because • GENERAL CATEGORIZATION (Optional)Negativefor intraepithelial lesion or malignancy Epithelial cell abnormality • INTERPRETATION/RESULTNegative for IntraepithelialLesion or Malignancy Organisms Trichomonasvaginalis ,   Fungal oganisms consistentwith Candida species   Shift in flora suggestiveof bacterial vaginosis  Bacteria consistent with Actinomyces species   Cellular changesconsistent with herpes simplex virus •  Other non-neoplasticfindings  Reactivecellular changes associated with    inflammation   radiation    intrauterinecontraceptive device   Glandular cells status posthysterectomy  Atrophy

  8. Bethesda System 2001 Epithelial Cell AbnormalitiesSquamouscell   Atypical squamous cells (ASC)    ofundetermined significance (ASC-US)    cannotexclude HSIL (ASC-H) Low-grade squamous intraepitheliallesion (LSIL)    encompassing: human papillomavirus/milddysplasia/cervical intraepithelial neoplasia (CIN) 1 High-gradesquamous intraepithelial lesion (HSIL)    moderate and severe dysplasia, carcinoma in situ; CIN 2 andCIN 3 Squamous cell carcinoma Glandular cell   Atypical glandular cells (AGC)   Atypicalglandular cells, favor neoplasticEndocervicaladenocarcinomain situ (AIS) Adenocarcinoma

  9. 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

  10. High prevalence of HPV infection in teenagers

  11. Most dysplasia regresses spontaneously in adolescents • A prospective study of 187 women aged 18-22 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

  12. 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 15-19 SEER 2002-2006 incidence rate of 1-2 cases per 1,000,000 females aged 15-19 (Surveillance Epidemiology and End Results)

  13. 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

  14. Management of LGSIL

  15. Abnormal Pap ASCUS-H

  16. Management of HGSIL

  17. Abnormal Pap CIN1

  18. Abnormal Pap CIN 2-3

  19. 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

  20. 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

  21. 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)

  22. 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 37.0 , 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

  23. 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

  24. 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

  25. 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)

  26. 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

  27. 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

  28. 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 • +/- Metronidazole 500 mg PO BID X 14 days • CDC STD treatment guidelines 2006 1-94

  29. Pelvic Inflammatory Disease • In House • A: • Cefotetan 2 g IV Q 12 ORCefoxitin2 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 2006 1-94

  30. 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

  31. 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

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