Management of High Risk Pap Smears in Pregnancy: A Case of a Near Miss

Kassandra Whitfield; H James Williams; Krista S Pfaendler

Management of High Risk Pap Smears in Pregnancy: A Case of a Near Miss

by Kassandra Whitfield¹, H James Williams², Krista S Pfaendler^3*

¹Department of Obstetrics and Gynecology/West Virginia University, Morgantown, WV, United States

²Department of Department of Pathology, Anatomy & Laboratory Medicine/ West Virginia University, Morgantown, WV, United States

³Department of Obstetrics and Gynecology, Gynecologic Oncology/West Virginia University, Morgantown, WV, United States

^*Corresponding author: Krista S Pfaendler, Department of Obstetrics and Gynecology, Gynecologic Oncology/West Virginia University, Morgantown, WV, United States.

Received Date: 14 December 2023

Accepted Date: 18 December 2023

Published Date: 20 December 2023

Citation: Whitfield K, Williams HJ, Pfaendler KS (2023) Management of High Risk Pap Smears in Pregnancy: A Case of a Near Miss. Ann Case Report 08: 1561. https://doi.org/10.29011/2574-7754.101561

Abstract

Cervical cancer screening should be included during routine prenatal care and the American Society for Colposcopy and Cervical Pathology guidelines should be followed for the management of abnormal cervical cytology. Cervical cancer is the most common gynecologic malignancy diagnosed in pregnancy with treatment varying significantly depending on stage of disease. Diagnostic work-up and treatment of cervical cancer should be provided during pregnancy. We report the case of a 33-year-old G4P3104 who was diagnosed with squamous cell carcinoma of the cervix during third trimester pregnancy. Her first trimester pap smear demonstrated high grade squamous intraepithelial lesion, but no biopsy was performed. Invasive squamous cell carcinoma was identified on third trimester biopsy. Patient underwent Cesarean radical hysterectomy, bilateral pelvic lymphadenectomy, and bilateral oophoropexy followed by adjuvant radiation for International Federation of Gynecology and Obstetrics (FIGO) stage IB2 squamous cell carcinoma of the cervix.

Keywords: Cancer and Pregnancy; Cervical Cancer; Cervical Cancer Screening; Colposcopy

Introduction

Prenatal care involves screening and treatment of medical conditions that affect maternal and fetal health, including infectious diseases, genetic abnormalities, and cervical cancer. Cervical cancer screening is completed via the Papanicolaou (Pap) smear and/or Human Papillomavirus (HPV) testing. A Pap smear involves collection and cytological examination of ectocervical and endocervical cells. Women aged 30-65 should be screened with the addition of HPV co-testing per the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. If abnormalities are detected during screening, prompt evaluation and treatment should be performed. In the setting of early-stage cervical cancer, surgical management can be performed at the time of Cesarean section delivery. We report a case of International Federation of Gynecologic Oncology (FIGO) stage IB2 squamous cell carcinoma of the cervix diagnosed during third trimester pregnancy with possible missed opportunity for earlier diagnosis.

Case

A 33-year-old Caucasian, now G4P3104, presented for routine prenatal care. A Pap smear collected at 14w4d demonstrated High Grade Squamous Intraepithelial Lesion (HSIL) with features suggestive of endocervical gland involvement. High risk Human Papillomavirus (HPV) testing was negative. The patient was instructed to follow up in 2-4 weeks for a prenatal visit and colposcopy.

Colposcopy at 16w5d demonstrated acetowhite changes on the cervix at 5-7 o’clock with fine punctations (Figure 1A). No biopsies were obtained at that time, but the impression was noted to be HSIL. Recommendation was made for repeat colposcopy during third trimester, which was performed at 31w5d. Gross cervical changes were noted with an ulcerative lesion described (Figure 1B). Acetowhite changes, punctuation, mosaicism, abnormal blood vessels, and raised borders were present. Biopsies were taken at 12 o’clock. The colposcopic impression was severe dysplasia. Pathology reported Cervical Intraepithelial Neoplasia 3 (CIN 3). The obstetrician then referred the patient to Gynecologic Oncology for further evaluation given concern for malignancy.