Re: CIN 3 in pregnancy
From: Deborah Wage (wagedj@home.com)
Thu Aug 26 17:04:47 1999
Along similar lines:
Would you colpo a lady age 36, CIN 3 4/98 with cryo, now 12 weeks EGA, PAP
with ASCUS. Smoker, BV treated at first visit. Or repeat Pap in 3 months
vs repeat Pap postpartum.
--
Deborah Wage,FNP,CNM
>In Am. J. Obstet. Gynecol 157:932-937, 1987 Benedet JL et al advocated
>colposcopically directed biopsies in pregnant women "only if the lesions
seen
>suggested possible microinvasive or invasive carcinoma" and showed that
only 2%
>had progression of cytologic abnormalities postpartum, while 39% showed
marked
>improvement. They did however suggest that women over 30 should have a
biopsy
>even if colposcopy did not suggest invasion, but that follow-up colposcopy
>postpartum was the correct management
>
>There have been several studies demonstrating that cryotherapy of CIN is as
>effective as laser cone or vapourisation, and considerably cheaper. More
>recently LLETZ has become more popular as it produces a specimen for
>histological evaluation while effectively excising the lesion, but there
has
>never been any suggestion that cryotherapy is a less adequate treatment.
The
>same author with slightly different colleagues reported on ten year follow
up
>of cryosurgically treated CIN in Am. J. Obstet. Gynecol. 157:268-273, 1987
and
>showed an 85% success rate. At 1 year the success rate was 94%. A 91%
success
>rate at 1 year was reported for LLETZ by Wright TC et al. in Obstet
Gynecol
>79: 173-178, 1992.
>
>> I have a 37 years old patient Para 1 whose pap smear showed mild
>> dyskaryosis. A colposcopy showed some acetowhite areas and a cervical
>> biopsy was performed. Diathermy of the area was also performed in the
>> same sitting.
>> The biopsy result came back as CIN3. Unfortunately she is found to be
>> 12 weeks pregnant.
>>
>> Any comments about the situation?
>> My plan now is to do colposcopic surveilliance during her pregnancy
>> making sure that there is no invasive features and then offer her LLETZ
>> post delivery.
>>
>> Questions
>> 1) Does anybody agree with above?
>> 2) Assuming that she is not pregnant, does anybody think that diathermy
>> is an adequate treatment? I would have thought that it may not be
>> adequate as you may not be sure of the depth of the lesion you destroy
>> and even the extent of it with the concept of field change. Therefore
>> excision method such as LLETZ would be more appropriate follow up
>> treatment I presume. Any comments?
>> 3) Finally any place for less extensive treatment for CIN 3 other than
>> the commonly offered LLETZ or Cone biopsy?
>>
>Based on the evidence and the experience of the last 10 years, my opinions
are
>as follows:
>1) I agree that no further treatment is required during the pregnancy, but
>suggest no need for colposcopy until postpartum 4-6/52.
>2) Ball diathermy has a lower success rate than cryo, laser or LLETZ, but
may
>still be sufficient - you're going to follow up anyway, so wait and see.
>3) Most definitely - there are, as I have shown above, good studies
confirming
>a place for cryo - the failure rate is the same no matter what grade of
CIN.
>
>I would be interested to hear other opinions and experiences. By the way I
>hate biopsying in pregnancy and go perhaps too far the other way to try to
>establish a diagnosis on colposcopy alone. So far I haven't had any
disasters,
>touch wood.
>
>Steve Raymond
>Head of O & G
>Empangeni Hospital
>SOUTH AFRICA
