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In the name of God

In the name of God. Isfahan medical school Shahnaz Aram MD. Cervical cancer & pregnancy. Definition: in pregnancy or 12 months after delivery Rarely invasive cancer in pregnancy Most common cancer is genital cancer Pregnancy complicates 3% of cervical cancers

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In the name of God

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

  2. Cervical cancer & pregnancy Definition: in pregnancy or 12 months after delivery Rarely invasive cancer in pregnancy Most common cancer is genital cancer Pregnancy complicates 3% of cervical cancers Overall cancer rate in pregnancy Dysplasia is common Abnormal pap-smear is 3% CIN3 1.3 in 1000 pregnancies Invasive cancer 1 in 2200, 1 in 8333 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 2-3rd 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 If CIN3 should • Be followed by cytology • Normal vaginal delivery • 80% persistent after delivery • Definitive management

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

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

  9. If margin involved( >5mm invasion) • Treatment is according to • Stage • Patient’s desire • Duration of pregnancy If > 28 weeks 75% survival If > 32 weeks 90% • Amnioscentesis for lung maturation • No later than 4 weeks • Classical cesarean section • 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 20th 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) • No clear evidence that tumor dissemination caused by birth process • Major risk for vaginal delivery, tearing and bleeding • Recurrence in episiotomy reported • If lesion is removed  NVD • 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 • Fetus viable classical C/S, postoperative radiation • 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%

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