Queensland Health Guidelines: Cervical Screening and the
Management of Screen-Detected Abnormalities in Pregnancy
Within Queensland Health thin layer technology (ThinPrep®) is offered as an adjunctive test to conventional Pap smears. Use is indicated as per the following protocol.
Cervical Screening Guideline
A Pap smear for cervical cytology should be
offered to every woman booking for antenatal
care who:
• has not had cervical screening within the past two years, and
• has a history of abnormal symptoms,
cytology reports and/or treatment of
cervical abnormalities who has not
been followed up in accordance with
the national guidelines.
Rationale
Pregnancy and a request for antenatal care
may be the only reason a woman presents
to a health professional, and thus at the
time of booking, or a later visit, may be the
only occasion on which she can be offered
cervical screening. In line with the practice of
opportunistic screening Pap smears should be
offered to all women presenting for antenatal
care who have not had a previous Pap smear
or have not had a Pap smear in accordance
with national guidelines.
In general, pregnancy is not a contraindication to performing a Pap smear. It is
recommended that Pap smears be offered to
women where appropriate:
• until at least 28 weeks of pregnancy
• in selected women into the third trimester, (if it appears likely that they may have difficulty presenting for screening in the postnatal period).
Pap smears have not been associated with
increased rates of miscarriage or pre-term
labour but a woman with such a history
in previous pregnancies, or of threatened
miscarriage in the current pregnancy,
may believe this to be the case and be
understandably reluctant to agree to a Pap
smear in pregnancy.1,2 In such cases the
Pap smear provider should emphasise to
the woman the importance of having a Pap
smear performed as soon as the pregnancy
is safely established. It is also recommended
that every woman with unexplained bleeding
in early pregnancy should have her cervix
visualised via a speculum to ensure that
unexpected malignancy is not the cause and
should have her Pap smear repeated.
Procedure
When providing a Pap smear for a woman who
is pregnant, as in the non-pregnant woman,
the whole cervix should be clearly visualised
so that the squamo-columnar junction can be
adequately inspected and sampled. Adequate
sampling of the transformation zone is
indicated by the presence of both squamous
and glandular cells in the smear. Reports of
absent endocervical component are more
common in pregnancy –
if the cervix has been well visualised and the
Pap smear provider feels an adequate smear
has been collected and no other abnormality
has been detected, then routine follow-up is
recommended.
The use of a nylon or plastic brush and spatula
in pregnant and non-pregnant women has
been shown in multiple studies, including a
Cochrane review, to be the method obtaining
the highest rate of adequate smears (i.e. with
endocervical cells reported.) 1-9 In addition,
studies involving around 1900 pregnant
women showed no increased risk of serious
outcomes for the woman or the pregnancy
4 - 6; 9; 11-12. There was a small increase in the
incidence of vaginal spotting following the
procedure - this was self-limiting. Pregnant
women offered Pap smears should be warned
that spotting may occur and reassured that it
poses no risk to the foetus.
The manufacturers of the Cytobrush
recommend that the device not be used after
ten weeks of pregnancy.² The Ayre spatula
plus a cotton swab is recommended in one
1993 paper as being as effective as other
devices.10 The plastic Cervex sampler used
under direct vision is also an appropriate tool
and likely to be the most familiar to clinicians.6
Liquid-based cytology is indicated if the smear
is contaminated with mucus – this is more
often the case when smears are collected
plastic spatula
cervex brush
endocervical brush
cytobrush
in pregnancy. There is no need to wipe the
mucus away from the cervix if collecting a
sample that is also sent for liquid-based
cytology. It is recommended that whatever
device is used it only be inserted under direct
vision into the cervical canal. If patulous
vaginal walls make visualising the cervix
difficult, a condom with the tip cut off may
be placed over the blades of the speculum
to help hold back the vaginal walls, or they
may be held aside with sponge forceps or a
wooden tongue depressor held by the person
performing the smear, or an assistant.
When a Pap smear is performed in the
postnatal period, low levels of oestrogen
associated with breastfeeding may cause
a degree of atrophic vaginitis making the
collection or interpretation of the smear
unsatisfactory. If this occurs the application of
local oestrogen as cream or pessaries for two
weeks prior to a repeat smear should solve the
problem, and will not interfere with lactation.
When a Pap smear is offered but declined
advise the pregnant woman to have a smear at
an early date post-natally.
Guideline for the Management
of Screen Detected
Abnormalities in Pregnancy
If the results of a Pap smear taken during a
pregnancy indicate a high grade abnormality,
the investigation of screening detected
abnormalities during pregnancy should follow
the same guidelines as for the non-pregnant
woman¹³.
Cytobrush ® is a registered trademark of CooperSurgical
Protocol
Cervical screening should be offered
to all pregnant women presenting for
antenatal care who have not had a
Pap smear performed in accordance
with national guidelines i.e. within the
previous two years for women with no
history of abnormal cytology, or within
the time specified for follow-up of
women with abnormal cytology and/or
a history of treatment of a cervical
abnormality.
Pregnant women having cervical
cytology should be advised that vaginal
spotting may occur after the procedure;
explain that this comes from the cervix
and poses no risk to the pregnancy and
is self-limiting.1,2
Although collecting a smear in
pregnancy has not been shown to pose
any risk to the foetus women with a
history of threatened miscarriage or
pre-term labour may be reluctant to
undergo a Pap smear during pregnancy;
in such cases the woman should
be advised to have the Pap smear
performed as soon as the pregnancy is
safely established.
The NHMRC Guidelines for the Management of
Asymptomatic Women with Screen Detected
Abnormalities (2005) states that high grade
lesions need early referral for colposcopic
assessment, preferably by a colposcopist
experienced in assessing the pregnant cervix¹³.
Colposcopy is safe during pregnancy. The main
aim of colposcopy in the pregnant woman is to
exclude the presence of invasive cancer and to
reassure the woman that her pregnancy will not
be affected by the presence of an abnormal Pap
smear ¹³.
The colposcopic evaluation of the cervix may be
more difficult due to vaginal laxity preventing
the complete visualisation of the transformation
zone. The increased vascularity due to pregnancy
may also be difficult to interpret. Biopsy of the
cervix is usually unnecessary in pregnancy,
unless invasion is suspected colposcopically ¹³.
Experienced colposcopists will not usually
perform a biopsy if they are confident that they
have excluded an invasive cancer. If no lesion
is identified at colposcopy, it is advisable to
request a review of all the cytological slides¹³.
If the diagnosis of a high-grade abnormality
is confirmed, a second opinion from another
colposcopist with wide experience in the
colposcopic evaluation of pregnant women
is recommended. In this situation it will be
prudent to review the woman at approximately
20–24 weeks with cytology and colposcopy to
determine as far as possible that she does not
have an invasive lesion¹³.
References
1
Martin-Hirsch P, Jarvis G, Kitchener H, Lilford R. Collection devices
for obtaining cervical cytology samples Cochrane Database
Systematic Reviews 2005 Issue 1.
2. Holt J, Stiltner L, Jamieson B. Should a nylon brush be used for Pap
smears from pregnant women? J Fam Pract 2005; 54: 463-4.
3. National Guidelines Clearinghouse. Veterans Health Administration,
Department of Defense. Clinical practice guideline for the
management of uncomplicated pregnancy. Washington, DC:
Department of Veterans Affairs, 2002.
4
Stillson T, Knight AL, Elswick RK. The effectiveness and safety of
two cervical cytologic techniques during pregnancy. J Fam Pract
1997; 45: 159-164.
5
Smith-Levitin M, Hernandez E, Anderson L, Heller P. Safety, efficacy
and cost of three cervical cytology sampling devices in a prenatal
clinic. J Reproductive Med, 1996; 41 (10): 749-53.
6
Paraiso MF, Brady K, Helmchen R, Roat T. Evaluation of the
endocervical cytobrush and cervix-brush in pregnant women.
Obstet Gynecol 1994; 84: 539-543.
7
Bauman BJ. Use of a cervical brush for Papanicolaou smears
collection. J Nurse Midwifery 1993; 38: 267-275.
8
McCord ML, Stovall TG, Meric JL, Summitt RL, Coleman SA. Cervical
cytology: A randomized comparison of four sampling methods. Am
J Obstet Gynecol 1992; 166:1772-1779.
9
Orr JW, Barrett JM, Orr PF, Holloway RW, Holimon JL. The efficacy
and safety of the cytobrush. Gynecol Oncol 1992; 44: 260-262.
10 Rivlin ME, Woodliff JM, Bowlin RB et al. Comparison of cytobrush
and cotton swab for Papanicolaou smears in pregnancy. J Reprod
Med 1993; 38: 147-150.
11. GrossmanJH,RivlinME,MorrisonJC.Cytobrush versus swab
endocervical sampling for the detection of obstetric chlamydial
infection.Am J Perinatol1993;10:7678.
12. FosterJC,SmithHL.Use of the Cytobrush for Papanicolaou smear
screens in pregnant women.J Nurse Midwifery1996;41:211217.
13. NHMRC. Screening to Prevent Cervical Cancer: Guidelines for
the management of asymptomatic women with screen detected
abnormalities. Canberra, NHMRC; 2005.
Date protocol endorsed: 08/11/10 Date for review: 08/11/12
Contact Details
Queensland Cervical Screening Program
PO Box 2368 , FORTITUDE VALLEY BC QLD 4006
Telephone: 07 3328 9467 Fax: 07 3328 9487