Regression of a CIN lesion is common during pregnancy or postpartum. In a study of 1079 pregnant women with cervical dysplasia in which biopsy correlated with colposcopic findings, 61 percent of lesions reverted to normal postpartum (Fader, 2010). In another study, Yost and colleagues (1999) reported postpartum lesion regression in 70 percent of women with CIN 2 or 3. And, although 7 percent of women had CIN 2 lesions that progressed to CIN 3, no lesion progressed to invasive carcinoma. In another study of 77 women with carcinoma in situ (CIS) diagnosed during pregnancy, a third had postpartum regression of their lesion, two thirds had persistent CIS, and only two women had microinvasive cancer on cone biopsy after delivery (Ackermann, 2006).
Adenocarcinoma in situ (AIS) is managed similarly to CIN 3 (Dunton, 2008). hus, unless invasive cancer is identified, treatment of AIS is not recommended until 6 weeks postpartum.
Cervical Conization. If invasive epithelial lesions are suspected, conization is indicated and may be done with loop electrosurgical excisional procedure (LEEP) or by cold-knife conization. However, the epithelium and underlying stroma within the endocervical canal cannot be extensively excised without the risk of membrane rupture. Logically, residual disease is common. Of 376 cone biopsies during pregnancy, Hacker and aWomen aged 30+ years.
bEndocervical curettage and endometrial sampling are contraindicated in pregnancy.
adenoCA = adenocarcinoma; AGC = atypical glandular cells; AIS = adenocarcinoma in situ; ASC-H = atypical squamous cells, cannot exclude high-grade squamous intraepithelialrlesion; ASC-US = atypical squamous cells of undetermined significance; HPV = human papillomavirus;
HSIL = high-grade squamous intraepithelialrlesion; LSIL = low7grade squamous intraepithelial lesion; NILM = negative for intraepithelialrlesion or malignancy; SCCA = squamous cell carcinoma. Adapted from American Society for Colposcopy and Cervical Pathology (ASCCP) 2012 Consensus Guidelines; Massad, 20lr3.
Table summarized and used with permission from Dr. Claudia L. Werner.
associates (1982) found residual neoplasia in 43 percent of subsequent specimens. In addition, nearly 10 percent of 180 pregnant women required transfusion after conization (Averette, 1970). hus, if possible, conization is avoided in pregnancy because of its higher risks for abortion, membrane rupture, hemorrhage, and preterm delivery.
Women with CIN treated bore pregnancy may also encounter pregnancy complications. First, cicatricial cervical stenosis is uncommon but may follow conization, LEEP, or laser surgery. Cervical stenosis almost always yields during labor. A so-called conglutinated cervix may undergo almost complete intrapartum efacement without dilation, and the presenting part is separated from the vagina by only a thin layer of cervical tissue. Spontaneous dilation usually promptly follows firm pressure with a ingertip, although instrumented dilation or cruciate incisions may be required.
Second, preconceptional cold-knife conization is associated with cervical insuiciency and preterm birth. That said, the relationship between preterm birth and LEEP continues to be debated (Castanon, 2012; Conner, 2014; Stout, 2015; Werner, 2010). he size of tissue excised seems to be directly related to adverse outcomes (Weinmann, 2017).