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Precancer lesions in pregnancy

Home Forums MRCPI and other exams Precancer lesions in pregnancy

This topic contains 11 replies, has 2 voices, and was last updated by Profile photo of Asma Naqi Asma Naqi 1 year, 7 months ago.

Viewing 12 posts - 1 through 12 (of 12 total)
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  • #12213
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    30 year old is found to have severe dyskaryotic smear at 14 weeks gestation. Justify your management.

    #12214
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    This woman will be worried and anxious with an abnormal smear. she must be explained the findings, reassured that cancer has not been diagnosed, she will need further investigation to be able to define abnormality and offer adequate treatment.

    -optimal counseling of the condition and MDT approach.

    -Information on her parity, her future reproductive plans, prior history of being treated  for same dyskaryosis, previous birth and MOD should be sought.

    -Refer patient for colposcopy, and that further management will depend on colposcopy findings.

    -If colposcopy shows abnormal cytology without invasion than pap smear/ colposcopy done every 8 weeks and anticipate vaginal delivery and patient be re evaluated 6/52 post partum, if patient wishes to continue with pregnancy, after being counseled on risk and benefit.

    -If colposcopy shows microinvasive cancer (diagnostic conization or wedge cervical biopsy) or malignant cytology suggesting invasion, and if invasion is less than 3 mm conservative approach as above can be taken, by regular pap smear, vaginal delivery (if no CI to SVD), and re evaluate 6/52 post partum.

    -If there is invasive cancer than it should be treated based on the stage, size of the lesion and desire to continue with pregnancy.

    -Delaying treatment carries an undefined but a small risk of disease progression, and delaying treatment to optimize fetal outcomes shows no measurable increased maternal risk, disease progression is 5% which is similar to non pregnant pts. (ACOG)

    -MOD with invasive cancer would be by classical C/S (with ovarian preservation), as there is risk of obstructing labor, risk of bleeding which could be potential life threatening and may require Em hysterectomy under less than optimal circumstances

    -Fetal lung maturity needs to be assessed to avoid potential complications of prematurity.

    -If patients Opts for a termination at 14 weeks and is found to have invasive cancer can be offered either surgical / medical TOP or primary radiation therapy with intent of TOP, however some may not abort spontaneously and may require surgical uterine evacuation.

    #12465
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    Dr. Asma any comment on this question ????

    #12475
    Profile photo of Asma Naqi
    Asma Naqi
    Moderator

    Now after you have gone through the answering techniques tutorial, do you want to read the question  again and make any changes to your answer?

    #12476
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    30 year old, severe dyskaryosis, 14 weeks

    justify: history, examination, investigation and treatment,follow up

    -Severe dyskaryotic smear is common and suggestive of CIN 2 and CIN 3and potential of malignancy evolves over long period if left untreated.

    -Confirming the diagnosis is important, which will be done by colposcopy, and once diagnosis is confirmed further management will depend on colposcopy finding and patients wish/desire, and management ideally should be MDT (gynecologist, pathologist, neonatologist in view of pre term birth, oncologist in view of futher treatment if invasive cancer ; radiotherapy or chemotherapy)

    -Information on her parity, her future reproductive plans, prior history of being treated  for same dyskaryosis (ablation, cryo, cone biopsy, LEEP) previous birth and MOD should be sought as it can influence her current management.

    – Adequate colposcopy with normal findings, take a smear and observe patient, allow for vaginal delivery provided no CI to VD and follow up 6/52 post partum with repeat smear/colposcopy.

    -Abnormal colposcopy finding needs to be treated, if shows CIN 1 it can be treated though not a usual recommendation unless persistent CIN 1 .

    – CIN 2 and CIN 3 requires entire TZ to be removed by either ablative methods or excision procedures.

    -Ablative procedures done when there is no discrepency between cytology and colposcopy, no microinvasion and satisfactory colposcopy, done with either cryotherapy or laser ablation. It is associated with copious vaginal discharge, no tissue available for histopathology and low success rate.

    -Excisional procedures, is where the abnormal area is excised using cold knife conization, LEEP/LLETZ. It is done where micro invasion is suspected, discrepency between cytology and colposcopy, recurrence after prior ablation.

    – Cold knife conization requires GA and leads to subsequent development of cervical incompetence or stenosis. patient should be aware of this complication and may need a cerclage after the procedure if pt wishes to continue with pregnancy.

    – LEEP/LLETZ is the approach of choice, as it is easy to use,  performed under LA,low cost and high success rate. However it is associated with infection, hemorrhage (though less common than cold knife), cervical stenosis, Preterm birth due to either cervical incompetence or PPROM .

    – Cold knife and LEEP associated with increased risk of preterm delivery and with ablative procedures the risk is not increased to the same degree. Fetal lung maturity needs to be assessed to avoid potential complications of prematurity. If patient continues with pregnancy than she will require steroids. neonatologist present at delivery.

    -Delaying treatment carries an undefined but a small risk of disease progression, and delaying treatment to optimize fetal outcomes shows no measurable increased maternal risk, disease progression is 5% which is similar to non pregnant pts. (ACOG)

    -Follow up requires cervical smear to be taken at 4, 10 – 12, 16- 18, and 24 month, after treatment. if normal smears than revert to annual screening

    -If high risk HPV DNA detected than colposcopy should be done till 3 negative findings than annaul F/U till 3 additional consecutive results have been documented.

    -If margins are positive, f/u with cytology, colposcopy, biopsy, especially in women who are compliant with frequent monitoring.

    -Hysterectomy as a treatment option can be offered to women who request for it, satisfied parity, margins positive for CIN 3, poor compliance to F/U, persistence or recurrence of CIN 2 and CIN 3.

    -Rate of recurrence is 5 – 17% despite ablative or excisional treatment

    – Overall treatment choice will be influenced by patients desire for future pregnancy, if pt wishes for a TOP at  14 weeks , she should be counselled of the pro and cons of termination (medical vs surgical) and offer her TOP and treatment of severe dyskaryosis.

    #12477
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    while answering the above the following questions came to mind:

    If patient continues with pregnancy and undergoes excisional treatment (cold knife/LEEP) for CIN2/3 at 14 weeks GA, is there a role of cervical cerclage? and if there is a role of Cerclage than what should be the MOD? SVD vs C/S?

    should the delivery of such pt be in a tertiary center?

     

    #12590
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    Dr. Asma any comment on the answer ?

    #13559
    Profile photo of Asma Naqi
    Asma Naqi
    Moderator

    Before I can comment on your answer, what is the word length of essays allowed in your exam?

    #13563
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    i have been told we need to write maximum of 2 page a4 not more than that and a page and half is preferable

    #13741
    Profile photo of Asma Naqi
    Asma Naqi
    Moderator

    Alright!

    So your first answer was more like a management plan but it lacked the justification part. Whereas, the the second you have tried to justify your actions but looks like a complicated lengthy piece of text. Use clear words e.g. History instead of information, diagnostic investigations instead of diagnosis is important etc. Just keep it simple and stay systematic, pick all four components of ‘management’ and justify which information of that component is important and why. Just stick to the relevant information and keep your language simple.

    I have emailed you an image of the skeleton that you need to make in less than a minute before cracking on to answer. Use that image and then try again!

     

     

    #13752
    Profile photo of Nusraat Gangat
    Nusraat Gangat
    Participant

    Severe dyskaryotic smear is suggestive of CIN2 and 3, and potential for malignancy evolves over long period of time if left treated.

    – further history is needed in this pt as it determine her eventual plan of Mx. such as desire for future reproduction, parity, previous treatment for dyskaryosis which indicated recurrence, other associated symptoms such as vaginal discharge or PVB, and also to rule out potential risk of malignancy.

    -physical examination to identify the lesion and to rule out any spread of the lesion by doing a BME, and andexal mass though may not be accurate due to garvid uterus.

    – following this investigation have to be undertaken to confirm the diagnosis, exclude possibilty of malignancy and routine investigation for the pregnancy. relavant investigation will be a colposcopy, for the severe dyskaryosis and others for the pregnancy sucah as Pelvic U/S, FBC,Urine m/c/s, FBS, and alike.

    – once diagnosis is confirmed, treatment will be tailored according to pts wish and involve MDT. Treatment options are conservative and surgical, pt need to counselled adequately with risk and benefits of the options available.

    *Delaying treatment carries an undefined but a small risk of disease progression, and delaying treatment to optimize fetal outcomes shows no measurable increased maternal risk, disease progression is 5% which is similar to non pregnant pts. In this case pregnancy can reach and pt can deliver  SVD if no Contraindication without risk of preterm labour and its associated complication of  prematurity. F/U required 6 weeks postpartum by a coploscopy and smear.

    *Severe dyskaryotic lesion requires removal of TZ either by ablation or excision procedure. Ablation using cryo or laser and is associated with copiuos vaginal discharge and low success rate. Excisional procedure: LEEP/LLETZ is the approcah of choice, as it is easy to perform, done under LA, low cost anf high success rate. However it is associate with infection, hemorrage, Cervical stenosis, incompetence, preterm birth and prematurity and  patient may require cervical cerclage (which has a risk of membrane rupture and preterm birth) after procedure. Rate of recurrence despite ablation or excision is 5 to 17%. If patient goes into preterm labour neanatologist should be available with NICU facilities at the Centre. there will be need to give pt antenatal steriods for fetal lung maturity.

    * TOP can be offered if patient has satidfied parity but she needs to be conselled on the pros and cons of TOP medical vs surgical and after TOP treat the dyskaryosis using either ablative or excision options.

    *Hysterectomy can be offered, if the pt requests, has satisfied parity and there is persistance or recurrence dyskaryosis.

     

     

    #13883
    Profile photo of Asma Naqi
    Asma Naqi
    Moderator

    Superb!!

    So now you can see your answer is precise and covers every aspect of the question asked.
    That’s a very simple trick of making a skeleton of your answer no matter how simple you think it is but when you keep that skeleton in your view while answering an essay or a SAQ, there is no way of missing any point. And you can answer even the most unknown question and be sure you will pass that answer.

    For next time, before you answer any further essays, go through the essay writing techniques tutorial, spend a good time skeletonizing (if that’s a word) the question and then answer it. Repeat this each time you write an essay and within no time you will master the technique.

    Good luck!!

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