Cervical cancer in pregnancy
- Amer Karam, MD
Amer Karam, MD
- Clinical Associate Professor
- Associate Director and Director of Outreach
- Division of Gynecologic Oncology
- Department of Obstetrics and Gynecology
- Stanford University School of Medicine
- Section Editors
- Vincenzo Berghella, MD
Vincenzo Berghella, MD
- Section Editor — Obstetrics
- Director, Maternal-Fetal Medicine
- Professor, Obstetrics and Gynecology
- Thomas Jefferson University
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Head of Women's Cancers, Lifespan Cancer Institute
- Director of Medical Oncology, Rhode Island Hospital
- Associate Professor of Medicine, Warren Alpert Medical School of Brown University
- Deputy Editors
- Sadhna R Vora, MD
Sadhna R Vora, MD
- Deputy Editor — Oncology
- Instructor in Medicine
- Harvard Medical School
- Vanessa A Barss, MD, FACOG
Vanessa A Barss, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Associate Clinical Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
One to 3 percent of women diagnosed with cervical cancer are pregnant or postpartum at the time of diagnosis [1,2]. About one-half of these cases are diagnosed prenatally, and the other half are diagnosed in the 12 months after delivery . Cervical cancer is one of the most common malignancies in pregnancy, with an estimated incidence of 0.8 to 1.5 cases per 10,000 births [3-6].
Most patients are diagnosed at an early stage of disease [7,8]. This is probably a result of routine prenatal screening, but it is also possible that advanced stage disease interferes with conception. Stage for stage, the course of disease and prognosis of cervical cancer in pregnant patients are similar to those of nonpregnant patients [8,9].
There are no data from large randomized trials upon which to base recommendations for the care of pregnant patients with cervical cancer. Therefore, management is based upon evidence from randomized trials in nonpregnant women, findings from observational studies of pregnant women, and the unique medical and ethical considerations underlying each individual case. Treatment should be individualized and based on the stage of cancer, the woman's desire to continue pregnancy, and the risks of modifying or delaying therapy during pregnancy.
Cervical cancer is often first suspected when a screening test for the disease is abnormal . While they have not been studied directly, the performance characteristics of the Papanicolaou (Pap) test do not appear to differ significantly between pregnant and nonpregnant women . Overall, the rate of significant cytological abnormalities among obstetrical patients has been reported to be 5 to 8 percent and is similar to that of the nonpregnant population [1,7].
Symptoms and signs of cervical carcinoma in pregnancy are dependent upon the clinical stage and lesion size. In two series, all pregnant patients with stage IA and 50 percent of those with stage IB carcinoma were asymptomatic at the time of diagnosis and had their disease detected by routine cancer screening (table 1) [6,11]. Patients with symptomatic stage IB disease presented with abnormal vaginal bleeding or discharge; patients with more advanced disease also presented with pelvic pain, sciatica-type leg pain, flank pain, chronic anemia, and shortness of breath. Since many of these symptoms are similar to those associated with a normal pregnancy, the diagnosis of cervical cancer may be delayed in pregnant women.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Nguyen C, Montz FJ, Bristow RE. Management of stage I cervical cancer in pregnancy. Obstet Gynecol Surv 2000; 55:633.
- Creasman WT. Cancer and pregnancy. Ann N Y Acad Sci 2001; 943:281.
- Smith LH, Dalrymple JL, Leiserowitz GS, et al. Obstetrical deliveries associated with maternal malignancy in California, 1992 through 1997. Am J Obstet Gynecol 2001; 184:1504.
- Smith LH, Danielsen B, Allen ME, Cress R. Cancer associated with obstetric delivery: results of linkage with the California cancer registry. Am J Obstet Gynecol 2003; 189:1128.
- Demeter A, Sziller I, Csapó Z, et al. Outcome of pregnancies after cold-knife conization of the uterine cervix during pregnancy. Eur J Gynaecol Oncol 2002; 23:207.
- Duggan B, Muderspach LI, Roman LD, et al. Cervical cancer in pregnancy: reporting on planned delay in therapy. Obstet Gynecol 1993; 82:598.
- Van Calsteren K, Vergote I, Amant F. Cervical neoplasia during pregnancy: diagnosis, management and prognosis. Best Pract Res Clin Obstet Gynaecol 2005; 19:611.
- Zemlickis D, Lishner M, Degendorfer P, et al. Maternal and fetal outcome after invasive cervical cancer in pregnancy. J Clin Oncol 1991; 9:1956.
- Hopkins MP, Morley GW. The prognosis and management of cervical cancer associated with pregnancy. Obstet Gynecol 1992; 80:9.
- Morimura Y, Fujimori K, Soeda S, et al. Cervical cytology during pregnancy--comparison with non-pregnant women and management of pregnant women with abnormal cytology. Fukushima J Med Sci 2002; 48:27.
- Lee RB, Neglia W, Park RC. Cervical carcinoma in pregnancy. Obstet Gynecol 1981; 58:584.
- Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol 2013; 121:829.
- Moscicki AB, Shiboski S, Hills NK, et al. Regression of low-grade squamous intra-epithelial lesions in young women. Lancet 2004; 364:1678.
- Economos K, Perez Veridiano N, Delke I, et al. Abnormal cervical cytology in pregnancy: a 17-year experience. Obstet Gynecol 1993; 81:915.
- Baldauf JJ, Dreyfus M, Ritter J, Philippe E. Colposcopy and directed biopsy reliability during pregnancy: a cohort study. Eur J Obstet Gynecol Reprod Biol 1995; 62:31.
- Colposcopy-Cervical Pathology: Textbook and Atlas, 3rd, Burghardt E, Pickel H, Girardi F (Eds), Thieme, 1998.
- Fader AN, Alward EK, Niederhauser A, et al. Cervical dysplasia in pregnancy: a multi-institutional evaluation. Am J Obstet Gynecol 2010; 203:113.e1.
- Kaplan KJ, Dainty LA, Dolinsky B, et al. Prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions diagnosed during pregnancy. Cancer 2004; 102:228.
- Serati M, Uccella S, Laterza RM, et al. Natural history of cervical intraepithelial neoplasia during pregnancy. Acta Obstet Gynecol Scand 2008; 87:1296.
- Robinson WR, Webb S, Tirpack J, et al. Management of cervical intraepithelial neoplasia during pregnancy with LOOP excision. Gynecol Oncol 1997; 64:153.
- Douvier S, Filipuzzi L, Sagot P. [Management of cervical intra-epithelial neoplasm during pregnancy]. Gynecol Obstet Fertil 2003; 31:851.
- Muller CY, Smith HO. Cervical neoplasia complicating pregnancy. Obstet Gynecol Clin North Am 2005; 32:533.
- Clinical Gynecologic Oncology, 6th, DiSaia PJ, Creasman WT (Eds), Mosby, 2002.
- Goldberg GL, Altaras MM, Block B. Cone cerclage in pregnancy. Obstet Gynecol 1991; 77:315.
- Palle C, Bangsbøll S, Andreasson B. Cervical intraepithelial neoplasia in pregnancy. Acta Obstet Gynecol Scand 2000; 79:306.
- Hannigan EV. Cervical cancer in pregnancy. Clin Obstet Gynecol 1990; 33:837.
- Averette HE, Nasser N, Yankow SL, Little WA. Cervical conization in pregnancy. Analysis of 180 operations. Am J Obstet Gynecol 1970; 106:543.
- Reznek RH, Sahdev A. MR imaging in cervical cancer: seeing is believing. The 2004 Mackenzie Davidson Memorial Lecture. Br J Radiol 2005; 78 Spec No 2:S73.
- Van Calsteren K, Hanssens M, Moerman P, et al. Successful conservative treatment of endocervical adenocarcinoma stage Ib1 diagnosed early in pregnancy. Acta Obstet Gynecol Scand 2008; 87:250.
- Alouini S, Rida K, Mathevet P. Cervical cancer complicating pregnancy: implications of laparoscopic lymphadenectomy. Gynecol Oncol 2008; 108:472.
- Hertel H, Possover M, Kühne-Heid R, Schneider A. Laparoscopic lymph node staging of cervical cancer in the 19th week of pregnancy. A case report. Surg Endosc 2001; 15:324.
- Stan C, Megevand E, Irion O, et al. Cervical cancer in pregnant women: laparoscopic evaluation before delaying treatment. Eur J Gynaecol Oncol 2005; 26:649.
- Amant F, Halaska MJ, Fumagalli M, et al. Gynecologic cancers in pregnancy: guidelines of a second international consensus meeting. Int J Gynecol Cancer 2014; 24:394.
- Maikranz P, Lindheimer M, Coe F. Nephrolithiasis in pregnancy. Baillieres Clin Obstet Gynaecol 1994; 8:375.
- O'mahony S. Endoscopy in pregnancy. Best Pract Res Clin Gastroenterol 2007; 21:893.
- Ackermann S, Gehrsitz C, Mehlhorn G, Beckmann MW. Management and course of histologically verified cervical carcinoma in situ during pregnancy. Acta Obstet Gynecol Scand 2006; 85:1134.
- Yost NP, Santoso JT, McIntire DD, Iliya FA. Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions. Obstet Gynecol 1999; 93:359.
- Paraskevaidis E, Koliopoulos G, Kalantaridou S, et al. Management and evolution of cervical intraepithelial neoplasia during pregnancy and postpartum. Eur J Obstet Gynecol Reprod Biol 2002; 104:67.
- Ahdoot D, Van Nostrand KM, Nguyen NJ, et al. The effect of route of delivery on regression of abnormal cervical cytologic findings in the postpartum period. Am J Obstet Gynecol 1998; 178:1116.
- Vercellino GF, Koehler C, Erdemoglu E, et al. Laparoscopic pelvic lymphadenectomy in 32 pregnant patients with cervical cancer: rationale, description of the technique, and outcome. Int J Gynecol Cancer 2014; 24:364.
- Takushi M, Moromizato H, Sakumoto K, Kanazawa K. Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment. Gynecol Oncol 2002; 87:185.
- Yahata T, Numata M, Kashima K, et al. Conservative treatment of stage IA1 adenocarcinoma of the cervix during pregnancy. Gynecol Oncol 2008; 109:49.
- Hannigan EV, Whitehouse HH 3rd, Atkinson WD, Becker SN. Cone biopsy during pregnancy. Obstet Gynecol 1982; 60:450.
- Hunter MI, Monk BJ, Tewari KS. Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease. Am J Obstet Gynecol 2008; 199:3.
- Bisseling KC, Bekkers RL, Rome RM, Quinn MA. Treatment of microinvasive adenocarcinoma of the uterine cervix: a retrospective study and review of the literature. Gynecol Oncol 2007; 107:424.
- Herod JJ, Decruze SB, Patel RD. A report of two cases of the management of cervical cancer in pregnancy by cone biopsy and laparoscopic pelvic node dissection. BJOG 2010; 117:1558.
- Rydzewska L, Tierney J, Vale CL, Symonds PR. Neoadjuvant chemotherapy plus surgery versus surgery for cervical cancer. Cochrane Database Syst Rev 2012; 12:CD007406.
- Cardonick E, Bhat A, Gilmandyar D, Somer R. Maternal and fetal outcomes of taxane chemotherapy in breast and ovarian cancer during pregnancy: case series and review of the literature. Ann Oncol 2012; 23:3016.
- Cardonick E. Chemotherapy in the treatment of pregnant women with cancer. In: Cancer and Reproductive Health, Kehoe S, Jauniaux E, Maretin-Hirsch P, Savege P. (Eds), RCOG Press, London 2008.
- Karam A, Feldman N, Holschneider CH. Neoadjuvant cisplatin and radical cesarean hysterectomy for cervical cancer in pregnancy. Nat Clin Pract Oncol 2007; 4:375.
- van der Vange N, Weverling GJ, Ketting BW, et al. The prognosis of cervical cancer associated with pregnancy: a matched cohort study. Obstet Gynecol 1995; 85:1022.
- Method MW, Brost BC. Management of cervical cancer in pregnancy. Semin Surg Oncol 1999; 16:251.
- Lee JM, Lee KB, Kim YT, et al. Cervical cancer associated with pregnancy: results of a multicenter retrospective Korean study (KGOG-1006). Am J Obstet Gynecol 2008; 198:92.e1.
- Germann N, Haie-Meder C, Morice P, et al. Management and clinical outcomes of pregnant patients with invasive cervical cancer. Ann Oncol 2005; 16:397.
- Van den Broek NR, Lopes AD, Ansink A, Monaghan JM. "Microinvasive" adenocarcinoma of the cervix implanting in an episiotomy scar. Gynecol Oncol 1995; 59:297.
- Baloglu A, Uysal D, Aslan N, Yigit S. Advanced stage of cervical carcinoma undiagnosed during antenatal period in term pregnancy and concomitant metastasis on episiotomy scar during delivery: a case report and review of the literature. Int J Gynecol Cancer 2007; 17:1155.
- Tewari K, Cappuccini F, Gambino A, et al. Neoadjuvant chemotherapy in the treatment of locally advanced cervical carcinoma in pregnancy: a report of two cases and review of issues specific to the management of cervical carcinoma in pregnancy including planned delay of therapy. Cancer 1998; 82:1529.
- Köhler C, Oppelt P, Favero G, et al. How much platinum passes the placental barrier? Analysis of platinum applications in 21 patients with cervical cancer during pregnancy. Am J Obstet Gynecol 2015; 213:206.e1.
- Zemlickis D, Klein J, Moselhy G, Koren G. Cisplatin protein binding in pregnancy and the neonatal period. Med Pediatr Oncol 1994; 23:476.
- Weisz B, Meirow D, Schiff E, Lishner M. Impact and treatment of cancer during pregnancy. Expert Rev Anticancer Ther 2004; 4:889.
- http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/125085s308lbl.pdf (Accessed on May 18, 2015).
- Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol 2004; 5:283.
- Zagouri F, Sergentanis TN, Chrysikos D, Bartsch R. Platinum derivatives during pregnancy in cervical cancer: a systematic review and meta-analysis. Obstet Gynecol 2013; 121:337.
- Monk BJ, Montz FJ. Invasive cervical cancer complicating intrauterine pregnancy: treatment with radical hysterectomy. Obstet Gynecol 1992; 80:199.
- Dalrymple JL, Gilbert WM, Leiserowitz GS, et al. Pregnancy-associated cervical cancer: obstetric outcomes. J Matern Fetal Neonatal Med 2005; 17:269.
- Stensheim H, Møller B, van Dijk T, Fosså SD. Cause-specific survival for women diagnosed with cancer during pregnancy or lactation: a registry-based cohort study. J Clin Oncol 2009; 27:45.
- Bigelow CA, Horowitz NS, Goodman A, et al. Management and outcome of cervical cancer diagnosed in pregnancy. Am J Obstet Gynecol 2017; 216:276.e1.
- Pettersson BF, Andersson S, Hellman K, Hellström AC. Invasive carcinoma of the uterine cervix associated with pregnancy: 90 years of experience. Cancer 2010; 116:2343.
- Dildy GA 3rd, Moise KJ Jr, Carpenter RJ Jr, Klima T. Maternal malignancy metastatic to the products of conception: a review. Obstet Gynecol Surv 1989; 44:535.
- CLINICAL PRESENTATION
- DIAGNOSTIC EVALUATION
- Women with clinical findings
- Women with abnormal cervical cytology
- - Colposcopy
- Indications for and performance of conization
- Physical examination
- Imaging studies
- MANAGEMENT OF PREINVASIVE DISEASE
- MANAGEMENT OF INVASIVE DISEASE
- Pregnancy termination
- Pregnancies not terminated
- - Gestational age less than 22 to 25 weeks at diagnosis
- No evidence of nodal involvement
- - Microinvasive disease (Stage IA1)
- - Stage IA2 to IB1 tumor <2 cm
- - Stage IB1 (Tumor 2 cm or larger) and higher
- Positive nodal involvement
- - Gestational age 22 to 25 weeks or later
- Stage IA to IB1 tumor <2 cm
- Stage greater than IB1 (Tumor 2 cm or larger)
- - Surveillance during pregnancy
- - Considerations about delivery
- - Definitive treatment for cervical cancer
- WOMEN WITH METASTATIC DISEASE
- SYSTEMIC THERAPY IN PREGNANCY
- SUMMARY AND RECOMMENDATIONS