High-grade cervical intraepithelial neoplasia (CIN) in pregnancy: Clinicotherapeutic management

An increasing incidence of cervical intraepithelial neoplasia (CIN) among y oung women has been noticed in recent years. For this reason pregnancy migh t represent a peculiar opportunity to undergo cytocolposcopic examination f or those women who do not take part in a screening program for cervical car cinoma, Diagnosis of CIN during pregnancy poses the question of the managem ent of this disease and particularly of whether it is better to treat the l esion or not during pregnancy, To contribute to the solution of this issue we initiated a study on the management of high-grade CIN in pregnancy. Mate rial and methods: Five hundred and seventy-one pregnant women underwent cyt ologic, colposcopic and, when necessary, histologic examination. Those in w hom a CIN was discovered in the first four months of gestation underwent la ser conization. When the diagnosis of CIN was made after the sixteenth week of gestation, cytocolposcopic monitoring was performed every eighth week d uring pregnancy and two months after childbirth. Laser conization was perfo rmed under colposcopic guidance in the outpatient setting in all cases. All treated patients were submitted to cytologic, colposcopic and, if necessar y, histologic examination every third month in the first year after treatme nt, every sixth month in the second year and yearly from the third year onw ards. Results: In 14(2.4%) of the 571 examined women a CIN III was discover ed, 6 of which associated with a human papilloma virus (HPV) infection. Of these, 8 patients, whose diagnosis was made within the sixteenth week of pr egnancy, underwent laser conization. In one case a minor hemorrhage occurre d during treatment, Two patients reported minor bleeding up to ten days aft er treatment. No major hemorrhages or cervical stenosis were observed. Hist ologic examination of the cones confirmed the preoperative diagnosis based on cervical biopsies and the lesion was entirely removed by conization in a ll cases. Seven of the 8 patients who underwent laser conization during pre gnancy had a spontaneous delivery at term, The remaining patient, who had h ad a previous cesarean section, was again delivered by cesarean section. Al l treated patients were cured after the first-year follow-up visit. In 6 pa tients CIN was diagnosed after the sixteenth week of pregnancy. These women underwent cytocolposcopic examination every eighth week during pregnancy a nd two months after delivery, when the cervical changes associated with ges tation had disappeared. Four of these patients showed persistence of CIN at postpartum follow-up and therefore underwent laser conization. In two pati ents spontaneous regression of the lesion was observed. In no case did prog ression to invasive carcinoma occur. Conclusions: Given the increasing inci dence of CIN in young women, the beginning of pregnancy may represent a pec uliar opportunity for all pregnant women who do not take part in cervical s creening programs to undergo a cytocolposcopic examination. In case of a di agnosis of high-grade CIN within the first 16 weeks of pregnancy, a conserv ative excisional treatment, which does not expose the pregnancy to any risk , should be carried out in order to confirm the intraepithelial localizatio n of the lesion.