It is rare to find invasive cancer of the uterine cervix in pregnancy, but there is a trend toward an increasing incidence of invasive cervical cancer in younger women.

• incidence of approximately 1 to 15 cases per 10,000 pregnancies
• women are delaying child bearing later than at any time in history
• obtaining a cervical smear is standard practice in routine antenatal care, usually at the first antenatal visit

• complicates up to 5% of pregnancies
• in the United States, most women will have low-grade disease
• high-grade SIL is occuring with increasing frequency in this age group
• a woman with advanced stage or large cervical cancers will usually not become pregnant
• a significant degree of expertise and experience is required in the
• colposcopic triage of the abnormal pap smear in pregnancy
• the most important aspect of abnormal pap smear triage in pregnancy is to exclude invasive cancer

Pregnancy produces dramatic alterations in the colposcopic appearance of the cervix.

• the most significant changes are a result of the high estrogen status in pregnancy
• the increased vascularity produces a bluish hue
• the acetic acid reaction of the metaplastic epithelium in pregnancy is exaggerated by the bluish hue
• the increased estrogen produces a significant increase in cervical volume through hypertrophy of the fibromuscular stroma

• begins during the early weeks of pregnancy and usually will be clearly apparent in the early second trimester
• in later pregnancies, there is less eversion, but gaping of the endocervical canal is often present
• the everted epithelium, exposed to the acidity of the vaginal environment, usually produces a high degree of squamous metaplasia
• this metaplasia is important because HPV needs active cellular machinery to reproduce and transform the cells
• this is the stage of greatest risk for initiation of dysplasia

• toward the end of the first trimester, eversion and metaplasia produce areas of fusion of columnar villa and distinct islands or fingers of immature metaplastic epithelium
• this process progresses through the second trimester, producing a layer of squamous metaplasia
• in addition, tenacious endocervical mucus develops, which further hinders examination
• in the third trimester, eversion and progressive metaplasia continues until about 36 weeks gestation

• shows stromal edema, increased vascularity, enlargement of glandular structures, and acute inflammatory response
• stromal decidualization may occur in the second and third trimesters; these changes may appear suspicious to the inexperienced observer

Colposcopy in pregnancy is difficult

• often reserved for the most experienced colposcopist
• the patient may experience a degree of anxiety in relation to her pregnancy and the possible effects of the examination
• although colposcopic assessment will not impair the pregnancy or the baby, the patient needs reassurance of this fact
• the increased laxity of the lateral vaginal walls produces prolapse
• the use of a lateral wall retractor will often permit unhindered access to the cervix
• a large vaginal speculum will usually be necessary
• a condom, latex glove finger, or ultrasound probe sheath with the tip removed may be rolled onto the speculum for better visualization

• the application of 5% acetic acid is mucolytic and will aid in mucus removal
• careful use of sponge forceps to remove viscous mucus
• great care must be used since the increasingly vascularity causes easy bleeding

• extensive immature metaplasia frequently causes an acetowhite effect
• increased vascularity of the cervix exaggerates this effect
• a fine punctation and mosaicism may be seen within metaplasia
• the appearance may lead to overcalling lesions

• if possible, only 1 directed biopsy is done to establish the histological level of disease
• if invasive disease is excluded, management of CIN consist of conservative follow-up
• repeat sampling, if performed, should be done if the lesion appears to markedly advance
• definitive diagnostic workup and treatment is planned for 1 to 2 months postpartum

• the risks of hemorrhage associated with the biopsy are significantly less than those associated with failed diagnosis of early invasive cancer
• a Tischler or baby Tischler biopsy forceps should be used
• cotton tipped applicators should be placed immediately above the cervical epithelium
• the applicators are pressed firmly onto the bleeding site with the off hand as soon as the biopsy is taken (Monsel's solution may be used)
• the patient should avoid vigorous activity for 48 hours
• spotting and Monsel's-type discharge may continue for several days

With high-grade disease, follow the patient at 8 to 10 weeks intervals with repeat colposcopy.

• if the lesion remains stable, the patient should be recalled for definitive diagnosis and treatment at 8 to 12 weeks post partum
• at the post-partum colposcopic examination, a complete new evaluation with biopsy and ECC is performed
• if the patient is a good follow-up candidate, treatment can be avoided
• the patient should be assessed by cytology and/or colposcopy at six-month intervals for two years before returning to yearly Pap smears

• histologic confirmation should be necessary only if a suspicion of more significant disease exists
• if the lesion remains stable, the patient should be recalled for definitive diagnosis and treatment at 8 to 12 weeks post partum as noted above