Cervical Cancer Complicating Pregnancy
Cervical Cancer Complicating Pregnancy
Abstract & Commentary
Synopsis: Sood and colleagues recommend that pregnant women with cervical cancer be delivered by cesarean section.
Source: Sood AK et al. Obstet Gynecol 2000;95:832-838.
To evaluate the outcome for women diagnosed with cervical cancer during pregnancy and those whose cancer was detected within six months after delivery, Sood and colleagues conducted a matched case-control study. Fifty-six women were found to have cervical cancer during pregnancy, and 27 within six months after delivery. These patients were matched to controls on the basis of age, histology, stage, treatment, and time of treatment. In the group of women diagnosed during pregnancy, 13 cancers were found in the first trimester, 22 in the second, and 21 in the third. In women whose cervical cancer was not found until after delivery, six had not received prenatal care, 11 had a normal Pap smear, and four did not have a Pap smear. Six women in this group had an abnormal Pap smear, and three were followed with colposcopy for severe dysplasia. In the 11 women who had had a normal prenatal Pap smear, cervical cancer was recognized postpartum by an abnormal Pap smear (n = 2), a cervical lesion on postpartum exam (n = 5), and persistent bleeding after delivery (n = 4). The stage of the disease worsened with diagnosis later in pregnancy or postpartum. When cervical cancer was diagnosed in the third trimester, only three of 32 women (9%) had a vaginal delivery. However, nearly 75% of women whose cervical cancer was diagnosed postpartum had had a vaginal delivery. Vaginal delivery was a significant risk factor for recurrence of disease as was high stage. The survival of women diagnosed postpartum was significantly lower than that for women diagnosed during pregnancy.
Sood et al conclude that women found to have cervical cancer postpartum have a lower survival than those detected during pregnancy and were at greater risk for recurrent disease, especially if they were delivered vaginally. They recommend that pregnant women with cervical cancer be delivered by cesarean section.
Comment by Steven G. Gabbe, MD
Most cervical cancers are detected during pregnancy, usually by an abnormal Pap smear. Women diagnosed before 20-week’s gestation may be treated definitively with radical hysterectomy or hysterotomy and radiation therapy, while those recognized later in gestation may opt to delay treatment until the fetus is mature. For these patients, cesarean delivery has been recommended because vaginal delivery has been associated with a greater risk for hemorrhage and metastases.
This paper by Sood et al emphasizes the importance of Pap smear screening for the detection of cervical cancer during pregnancy in association with careful examination and palpation of the cervix, and confirms the benefit of delivery by cesarean section after cervical cancer has been diagnosed. Women who were diagnosed postpartum and delivered vaginally had a significantly worse prognosis in terms of stage of disease, recurrence, and survival.
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