Management of suspicious cervix in pregnancy, Gynaecology (1091)

Before the examination consider the following which can be determined by history taking.

• Is infection suspected?
• Has the patient had any previous treatment to her cervix?
• Is there a history of abnormal smears?
• Has she been sexually active recently?
• Does she have a cervical suture or vaginal pessary in place?
• Is she using vaginal pessaries which may change her vaginal discharge e.g. vaginal progesterone?
• Is there a history consistent with early labour including rupture of membranes?

If cervical screening history is uncertain and the patient is ≥25 years of age, the national Scottish Cervical Call Recall System database (SCCRS) may contain relevant information.

Opportunistic cervical smears should not be taken during pregnancy within the Obstetric Department.

If concerns regarding cervical appearance, it is important to describe and document the size, number, consistency and origin of any cervical lesions, along with any contact bleeding.

If any concern over appearance of cervix at examination, confirmation should be made by the on call Consultant or senior trainee (ST6/7) in the first instance.

If a vaginal infection is suspected, high vaginal swabs should be taken and consideration of STI screen.  These may include Chlamydia/Gonorrhoea nucleic acid amplification tests (NAAT) vulvovaginal swab or lesion swab for PCR medium e.g. for herpes.

Patients presenting with vaginal bleeding should be managed in line with current guidelines for Antepartum Haemorrhage or Vaginal bleeding in <24 weeks. (see relevant guidelines for gestation)

The appearance of the cervix can change in normal pregnancy. Features can include an increase in cervical size, a bluish appearance due to increase vascularity.  These physiological changes may appear suspicious to an inexperienced clinician (2).

Most cervical abnormalities are benign and patients can be reassured and managed conservatively.  Some changes are described below.

• Cervical ectopy – most common benign abnormality and may be associated with increased physiological discharge, no further investigation required.
• Nabothian Follicles/Cysts – normal finding in women of childbearing age
• Cervicitis/inflammation of the cervix – this can be acute or chronic and are most likely associated with Sexually Transmitted Infections (HSV, chlamydia, gonnorrhoea, trichomonas). Screening with appropriate swabs should be undertaken.
• Condyloma (genital warts) - may be present in remainder of genital tract including vagina and vulva.

Cervical Polyp –They can be found in up to 4% of women, and are commonly asymptomatic.  However, in pregnancy they may present with vaginal bleeding or antepartum haemorrhage. They can be ectocervical, endocervical or endometrial in origin.

Risk of malignancy is low estimated at <0.1% in the pre-menopausal woman (3).  If there is clinical concern that the polyp may be atypical and/or previous unresolved abnormal cervical cytology, then referral for review at colposcopy via USOC (Urgent Suspicion of Cancer) pathway should be submitted.  This should be an urgently dictated letter, which is sent to colposcopy via Scottish Care Information gateway (SCI-gateway) referral pathway by the transcribing secretary.

All patients with cervical polyps, irrespective of antenatal management should be reviewed in postnatally (obstetrics or general gynaecology) at 6-12 weeks. This should be highlighted via Alert tab in Badger, and referral made using a dictated letter, which is sent to colposcopy via SCI-gateway referral pathway by the transcribing secretary.

Suspicious cervical mass - cervical carcinoma is rare in pregnancy with estimated prevalence 1-10/10 000 pregnancies (2). 

If malignancy is suspected on clinical examination in a stable patient, then referral for review at colposcopy via USOC (Urgent Suspicion of Cancer) pathway should be submitted.  This should be an urgently dictated letter, which is sent to colposcopy via SCI-gateway referral pathway by the transcribing secretary.

Referral to colposcopy should be made by senior trainee (ST6/7)/consultant by written referral including summary of pregnancy.  This should be an urgently dictated letter, which is sent to colposcopy via SCI-gateway referral pathway by the transcribing secretary.  It is useful to copy in the patient’s named Obstetrician and their own GP.

Referral should contain:

• Patient’s named Obstetrician and contact details (may be useful to include their secretary as a contact point)
• Presenting symptoms
• Clinical findings indicating referral
• Investigations undertaken e.g. swabs
• Placental site
• Any issues with pregnancy

Clinical assessment of the cervix will be undertaken and outcome of this examination will be shared with patient’s named consultant Obstetrician and referring clinician.

Unless the suspicion of malignancy is high at colposcopy, it is most likely that a conservative approach will be adopted.  Any further follow-up will be arranged by the colposcopist postnatally.

If a biopsy during pregnancy if felt to be warranted, this will generally be undertaken by an experienced colposcopist in a theatre setting after planning with the obstetric team. This is due to the associated increase in haemorrhage and complications.