A 27-year-old woman, gravida 2 para 1, at 28 weeks gestation comes to the office for follow-up of an abnormal Pap test. She feels fetal movement, has no vaginal bleeding or contractions, and has had an uneventful pregnancy to date. The patient's previous pregnancy 5 years ago was uncomplicated. She has not had a previous abnormal Pap test, but the last test was performed during her prior pregnancy. The patient has no medical issues or previous surgeries. She takes a multivitamin and an iron supplement. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 120/74 mm Hg and pulse is 82/min. Fetal heart tones are normal. Physical examination reveals a gravid, nontender uterus. The cervix is long, closed, firm, and posterior, and the fetal presenting part is high. The Pap test showed a high-grade squamous intraepithelial lesion. Which of the following is the best next step in management of this patient?

Question

A 27-year-old woman, gravida 2 para 1, at 28 weeks gestation comes to the office for follow-up of an abnormal Pap test.  She feels fetal movement, has no vaginal bleeding or contractions, and has had an uneventful pregnancy to date.  The patient's previous pregnancy 5 years ago was uncomplicated.  She has not had a previous abnormal Pap test, but the last test was performed during her prior pregnancy.  The patient has no medical issues or previous surgeries.  She takes a multivitamin and an iron supplement.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 120/74 mm Hg and pulse is 82/min.  Fetal heart tones are normal.  Physical examination reveals a gravid, nontender uterus.  The cervix is long, closed, firm, and posterior, and the fetal presenting part is high.  The Pap test showed a high-grade squamous intraepithelial lesion.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9ac_5717_bc81_4d92e5760641_MD0003_00 A Pap test is a screening examination for precancerous lesions of the uterine cervix. High-grade squamous intraepithelial lesions (HSILs) on Pap testing are concerning for underlying severe neoplasia (eg, CIN2, CIN3) or invasive cervical cancer, and all patients require evaluation with immediate colposcopy. Repeat Pap testing is not appropriate (Choice D). Colposcopy evaluates the cervix and vagina under magnification after application of acetic acid to contrast and identify abnormal (eg, aceto-white changes) from normal cells; abnormal vessels (a sign of high-grade lesions) also become more visible. Cervical neoplasia typically occurs at the transformation zone or squamocolumnar junction. If these areas are not visualized during colposcopy (eg, an "inadequate" colposcopy), an endocervical curettage is performed to evaluate the endocervical canal. Endocervical curettage is an invasive procedure and is deferred during pregnancy due to risk of miscarriage and preterm delivery. Cervical biopsy is performed even in pregnancy if a lesion has high-grade features (eg, abnormal vessels). (Choice A) Human papillomavirus (HPV) co-testing is used to triage atypical squamous cell of undetermined significance and low-grade intraepithelial lesion (LSIL) Pap tests; further evaluation with colposcopy is indicated if high-risk HPV is present. HSIL on Pap test requires colposcopy regardless of HPV status. (Choice C) HSIL lesions on Pap test can be treated with an immediate loop electrosurgical excision procedure rather than a colposcopy. However, pregnant patients first undergo colposcopy and then cervical excision only if evidence of invasive cancer is found. Immediate surgical excision based on Pap testing alone is contraindicated due to the risk of preterm delivery. (Choice E) Trichloroacetic acid therapy can be used for the treatment of vulvar or vaginal warts (condylomata acuminata) caused by low-risk HPV types 6 and 11. Educational objective: A high-grade squamous intraepithelial lesion Pap test result requires colposcopic examination and biopsy of cervical abnormalities due to a high risk of progression to cervical cancer. References: 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. (http://www.ncbi.nlm.nih.gov/pubmed/23519301) Cervical cancer screening in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/23732031)

A 27-Year-Old Woman, Gravida 2 Para 1, at 28 Weeks