Management of the abnormal papanicolaou smear during pregnancy: lessons for quality improvement

Our goal in this study was to evaluate the management of pregnant patients with abnormal Papanicolaou smears.

We reviewed the records of 292 patients undergoing colposcopy to evaluate abnormal cervical cytology during pregnancy.

A total of 32 (11%) of the subjects had Papanicolaou smears demonstrating atypical glandular cells of undetermined significance; 178 (61%) had low-grade squamous intraepithelial lesions; 69 (23.6%) had high-grade squamous intraepithelial lesions; and 2 (1%) had a malignancy. The first colposcopy was performed most commonly during gestational week 24. Colposcopy showed findings consistent with minor changes in 154 cases (53%) and with major changes in 61 (21%). Only 27 patients (9% of the total) underwent a colposcopically directed biopsy, and 51 (83.6%) of the 61 patients with a colposcopic impression of cervical intraepithelial neoplasia grade 2 or greater did not undergo biopsy. Only 24 (26%) of the 91 patients scheduled for follow-up colposcopy during pregnancy complied, and 123 of the 292 patients (42%) returned for follow-up examinations after delivery. Four patients had an invasive cervical carcinoma diagnosed in the 12 months immediately after delivery. Although the first intrapregnancy colposcopy in two of these patients noted findings consistent with cervical intraepithelial neoplasia grade 2 or greater, none of the four underwent biopsy during pregnancy.

Evaluation of cytological abnormalities is frequently suboptimal during pregnancy. The threshold for colposcopically directed biopsy is often modified during pregnancy in a way that may be harmful to the patient. Extra effort is needed to tailor follow-up to the patient's need and to improve patient compliance.