Brief discussion on patients diagnosed as cervical cancer during pregnancy. It includes diagnosis and treatment of the same.

1. Dr Swati Shah MS, DNB
Robotic Pelvic (Uro & Gynec)
& Musculoskeletal Oncosurgeon
HCG Cancer Centre, Ahmedabad

2. Incidence
1/3rd of cervical
cancer occur in
reproductive age
Jacobs IA, Chang CK, Salti GI. Coexistence of
pregnancy and cancer. Am Surg.2004;70(11).
3% cervical cancer
diagnosed during
pregnancy
Traen K, Svane D et al. stage Ib cervical cancer
during pregnancy. Eur J Gynaecol
Oncol.2006;27(6)
1 case of ca cervix for
every 1000-5000
pregnancies
Nguyen C, Montz FJ, Bristow RE. management
of stage I cervical cancer in pregnancy. Obstet
Gynecol Surv.2000;55(10)
76% of the lesions
diagnosed during
pregnancy are in
stage Ib

3. Staging at time of diagnosis of
cervical cancer in pregnant and
non pregnant women
Staging Pregnant Non - pregnant
Stage I 70-80% 42%
Stage II 11-20% 35%
Stage III 3-8% 21%
Stage IV 0-3% 2%
Van calsteren K, Vergote I, Amant F. cervical neoplasia during pregnancy:
diagnosis, management and prognosis. Best Pract Res Clin Obstet Gynaecol.2005;19(4)

4. Clinical features
Most common symptom = vaginal bleeding (50%)
Advanced stages – hematuria, lumbar pain
Eltan R, Abu-Rustum NR. Management of cervical cancer diagnosed during pregnancy.
Primary care update for Ob/Gynae.2003;10(4).
Pelvic Examination
Cervix triple in size by end of pregnancy
Transformation Zone becomes exuberant due to
eversion of SCJ
May be confused with neoplastic lesions

5. Cytological changes during
pregnancy
Glandular hyperplasia, presence of decidual cells,
Arias – stella reaction
Immature metaplasia ( reparative reactions due to
infections, change in vaginal pH) that may be
confused with cellular atypia
Increase false positive if pathologist not informed
that specimen is from pregnant woman
In experienced hand, incidence of these changes is same in
pregnant and non pregnant i.e. 0.6%
Sarkar S, Yousif S, Egan D. Cervical screening during pregnancy. Ir Med J.2006;99(9)

6. Colposcopy
Inreased
vascularisation of
cervix during
pregnancy
Prominent reaction
of metaplastic
epithelium to acetic
acid
Suspicion of more
severe lesion
He GF, Bian ML, Wang Y. Cervical cytology during pregnancy – comparison with
non pregnant women and management of pregnant woman with abnormal cytology.
Fukushima J Med Sci.2002;48(1)

7. COLPOSCOPY

8. Biopsy
Sensitivity = 83%
Specificity= 95%
Complications of cervical
biopsy during pregnancy
1. Excessive Bleeding
2. Preterm labour
3. Chorionic amniorrhexis
Conization is reserved for cases
in which cytological tests reveal
high grade lesion and
colposcopy is unsatisfactory
Postpone till postpartum and if
required should be done at 14–
20wks
EndoCervicalCurret
age contraindicated
due to risk of
premature rupture
of membranes &
preterm delivery

9. Imaging
CECT
Dose allowed to fetus
is 10-15cGY
Pavlidis NA. co existence of
pregnancy and malignancy.
Oncologist.2002;7(4)
Dose of 1 ct scan is just 1
cGY, so it canbe done
USG/MRI
To assess the tumour
Size, adjacent
organs(parametria/blad
der/rectum),
LymphNode metastasis
Method of choice
for staging in
pregnant women

11. Treatment

12. Treatment – precursor lesions
Monitor
3-6 mnthly during
pregnancy using
cytology and
colposcopy
Re-evaluate
6-8wks after delivery
using same methods.
Biopsy if suscpicion.
Low grade lesions
Regress 48-62%
Unchanged 29-38%
Progression to severe
lesions is infrequent
during pregnancy (6%)
Vlahos G, Rodolakis A. conservative management of CIN 2-3 in pregnancy.
Gynecol Obstet Invest.2002;54(2)

13. Treatment – invasive Ca cervix
depends on
Gestational age at time of
diagnosis
Stage of disease and size of lesion
Pts wish to maintain pregnancy
and fertility

14. Microinvasive Ca cervix (Ia1)
Colposcopy every 2 months
during pregnancy
Re-evaluate at 6wks after delivery
with cytology & colposcopy
Biopsy if suspicion
Simcock B, Shafi M. Invasive cancer of the cervix. Obs, Gynecol,
reproductive medicine. 2007;17(6).

15. Invasive ca cervix
 No evidence that pregnancy accelerates disease
progression
 Survival doesn`t depend on trimester at diagnosis
 Postponing treatment for fetal maturity doesn`t
affect recurrence rate (5%)
Jacobs IA, Chang CK, Salti GI. Coexistence of pregnancy and cancer. Am Surg.2004;70(11
Traen K, Svane D et al. stage Ib cervical cancer during pregnancy. Eur J Gynaecol Oncol.2006;27(6)

16. Invasive carcinoma Ia2, Ib, Iia
diagnosed at < 20wks gestational
age
Immediate and definite treatment
Radical Hysterectomy (fetus in situ)+
B/L Pelvic Lymphadenectomy
EBRT which leads to spontaneous abortion or MTP(
if reqd) + brachytherapy
Complications – vaginal fibrosis, cystitis, enteritis

17. Classical Cesarian section + RH + B/L PLND
In Locally advanced cases – Neoadjuvant chemotherapy
(cisplatin) followed by surgery
Chemotherapy should be avoided in 1st trimester due to fetal
malformations
In other trimesters it may cause Low birth weight (40%),
Prematurity, IUGR, intrauterine death
Chemo is avoided after 35 wks as delivery may occur in
immunosupressed state
If diagnosed between 28- 34 wks – corticosteroids given for fetal
lung maturity before definitive t/t
Invasive carcinoma Ia2, Ib, IIa
> 20wks
Cardonick E, Iacobucci A. use of chemotherapy during pregnancy. Lancet Oncol. 2004;5(5).

18. Invasive carcinoma – IIb, III, IV
Rare during pregnacy
Immediate t/t
CT(cisplatin) +RT
Adding chemo increases 5yr survival by 12%
Van Calsteren K, Vergote I, Amant F. Cervical neoplasia during pregnancy;
diagnosis, management and prognosis. Best Pract Res Clin Obstet Gynecol. 2005;19(4)

19. Fertility preservation
Oocyte cryopreservation – standard
treatment but delays t/t by 6 wks
Ovary cryopreservation – upcoming
Ovary transposition to areas far from
site of RT allows subsequent retreival of
oocyte for IVF
Covens AL, van der Putten HW, Fyles AW. Laparoscopic ovarian transposition.
Eur J Gynecol Oncol.1996;17(3)

20. Route of delivery
Choice is based on type and grade of lesion
Vaginal delivery is safe in precursor lesion as it
may also lead to regression
In Advanced lesions cesarean is preferred

21. Vaginal
delivery
Preferred in
- Ia1
-CIS
-microinvasion <3mm
? Promotes disease
progression by
lymphovascular
dissemination
? Implantation at episotomy
site
Ceasarian
section
Preferred in
advanced cases as
bleeding/laceration/obstructio
n of birth canal may occur in
vaginal delivery
Increase hospital stay
Increased risk of neonatal
prematurity
Increase mortality
Increase cost
Route of delivery

22. Prognosis – maternal
Diagnosed usually in early stages
Better than non pregnant ca cervix
-prognosis is Not affected if postponed
for fetal lung maturity

23. Prognosis - fetal
Acc. To gestational age and type of t/t
Increase neonatal morbidity & mortality may
occur due to LBW, IUGR
Chemotherapy may cause toxic effect on fetus

24. Conclusion
Antenatal checkup provides opportunity for
early detection
Precursor & microinvasive lesions can be
monitored and managed postpartum
Invasive lesions
<20wks – immediate and definitive t/t
>20wks – may wait for fetal lung maturity
followed by delivery and definitive treatment

25. Thank you