Cervical cancer screening in pregnancy

Screening Principles - The Pregnancy Pap Protocol

• Initial Screen: Pap test at the first prenatal visit, same as for non-pregnant individuals.
• Abnormal Pap: Management depends on the cytology result.
• Colposcopy: Indicated for ASC-H, AGC, and HSIL. Can be considered for ASC-US and LSIL. Biopsies of suspicious lesions are safe.
• Deferral: Definitive excisional procedures (LEEP, cone) are deferred until postpartum unless invasive cancer is found.

⭐ ⚠️ Endocervical curettage (ECC) is absolutely contraindicated in pregnancy due to the risk of disrupting the pregnancy.

Managing Abnormal Results - Decoding the Cytology

• Primary Goal: Exclude invasive cervical cancer. Progression of Cervical Intraepithelial Neoplasia (CIN) is not accelerated by pregnancy.
• General Approach: Colposcopy is the standard next step for most abnormal results. Endocervical curettage (ECC) is contraindicated.
• Definitive treatment (e.g., LEEP, cone biopsy) is deferred until at least 6 weeks postpartum, unless invasive cancer is found.

⭐ Exam Favorite: For CIN 2 or CIN 3 diagnosed during pregnancy, management is conservative: observation with repeat colposcopy and cytology every 12 weeks. Biopsy is performed only if lesion appearance worsens or suggests invasion. Treatment is postpartum.

Management Algorithm:

Colposcopy & Biopsy - The Magnified View

• Indication: Performed for the same reasons as in non-pregnant patients (e.g., ASC-US with positive HPV, LSIL, HSIL).
• Procedure: Involves magnified visualization of the cervix after applying acetic acid. Allows for targeted biopsies.
• Biopsy: Permissible and safe. Directed only at lesions suspicious for high-grade dysplasia (CIN 2,3) or invasive cancer. Avoid random biopsies.
• ⚠️ Endocervical curettage (ECC) is absolutely contraindicated due to risk of membrane rupture and hemorrhage.

⭐ If biopsy confirms CIN 2 or 3, management is observation with repeat colposcopy and cytology each trimester. Definitive treatment is deferred until at least 6 weeks postpartum.

High‑Yield Points - ⚡ Biggest Takeaways

• Pregnancy is NOT a reason to defer routine cervical cancer screening; guidelines are the same.
• If cytology is abnormal, colposcopy is safe during pregnancy.
• Endocervical curettage (ECC) is contraindicated in pregnancy due to the risk of disrupting the pregnancy.
• Biopsy of suspicious lesions is acceptable, but definitive excisional procedures are deferred.
• Management of CIN is typically conservative, with definitive treatment postponed until at least 6 weeks postpartum.