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Abnormal cervical cytology in pregnancy

자궁경부의 상처는 조기진통 및 조산으로 이어질 수 있어, 산모의 처치는 다름.

PAP
ASC-US 분만 후 재검 혹은 확대경±조직검사
ASC-H, LSIL, HSIL 확대경±조직검사
Punch Biopsy
CIN I 분만 후 재검
CIN II,III3-4개월 간격 확대경 & PAP 혹은 분만 후 재검

ASC-US

ASC-US + HPV(+) → 콜포스코피(±Bx) 혹은 분만 후 재검

Pregnant women with ASC-US + and a positive HPV test may elect to have colposcopy during pregnancy or wait until at least six weeks after delivering their baby.

The reason for this recommendation is that cervix appears somewhat different during pregnancy, which can make it difficult to determine if an area appears abnormal due to pregnancy or due to precancerous changes. In addition, most mild abnormalities resolve over time without treatment.

ASCCP 2006 consensus guideline

  • ASC-US : CIN 2 이상(15%), cervical cancer (0.2%) 이 data는 HPV 중 위험type이 positive였던 사람들의 data임
  • ASC-H : CIN2 이상 (38%) , cervical cancer (2.7%)

ASC-H

확대경±조직검사

Pregnant women with ASC-H should have a colposcopy. This is because ASC-H is more likely than ASC-US to be caused by a precancerous change. Management after colposcopy depends upon the result of the biopsy (see below).

LSIL

확대경±조직검사

Colposcopy is recommended for pregnant women with LSIL, similar to non-pregnant women. Management after colposcopy depends upon what the biopsy shows.

Management after colposcopy

  • CIN 1 — Pregnant women with CIN 1 are usually advised to defer further evaluation and treatment until at least 6 weeks after delivery of the baby. The reason for this recommendation is that most mild abnormalities will resolve over time without treatment.
  • CIN 2 or 3 — If there is evidence of CIN 2 or 3, colposcopy and cervical cytology testing may be done every 3 to 4 months during the pregnancy, or further evaluation may be deferred until at least 6 weeks after the woman delivers her baby. Treatment to remove the abnormal area is not recommended during pregnancy.

The reason for this recommendation is that CIN 2 or 3 is caused by precancerous changes that have the potential to become cancerous when untreated. This is a slow process that takes many months to years. As long as the abnormality is monitored, it is not necessary to remove the area (and increase the risk of preterm delivery or miscarriage) until after delivery.

Biopsy

The safety of cervical punch biopsy during pregnancy is well documented. Although vaginal bleeding may occur from the biopsy site, it may usually be controlled with gentle pressure and the application of topical silver nitrate or Monsel solution. Excessive bleeding that requires hospitalization or transfusion is extremely rare, and punch cervical biopsy does not appear to increase the risk of miscarriage.1)2) Furthermore, the overall risk of cervical biopsy-related complication is approximately 0.6%.3)

분만전 자궁경부 이상이 발견된 산모 중 분만후 약 63-76%가 등급이 낮아졌다. 그러므로 산모의 자궁경부 이형성증은 conservative하게 치켜보는 것이 최선이라고 하겠다. 단, 침윤성 암이 의심되는 경우 원추절제술을 시행한다.4)

ASCUS참조

1)
Orr JW, Shingleton HM: Cancer in pregnancy. Curr Probl Cancer 8:1-50, 1983.
2)
Benedet JL, Selke PA, Nickerson KG: Colposcopic evaluation of abnormal Papanicolaou smears in pregnancy. Am J Obstet Gynecol 157:932-937, 1987.
3)
Hacker NF, Berek JS, Lagasse LD, et al: Carcinoma of the cervix associated with pregnancy. Obstet Gynecol 59:735-746, 1982.
4)
Gazala Siddiqui MD Cervical dysplasia in pregnancy: progression versus regression postpartum. Mount Sinai Hospital, Finch University of the Health Sciences, the Chicago Medical School, Chicago, IL, USA

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