Management of High-Grade Squamous Intraepithelial Lesion (HSIL) in a 10-Week Pregnant Woman
For a pregnant woman at 10 weeks gestation with HSIL, perform colposcopy with biopsy of lesions suspicious for CIN 2,3 or cancer, but defer all treatment (including excisional procedures) unless invasive cancer is suspected. 1
Initial Evaluation
Colposcopy is mandatory for all pregnant women with HSIL cytology, preferably performed by clinicians experienced in evaluating pregnancy-induced colposcopic changes. 1, 2
Biopsy of lesions suspicious for CIN 2,3 or cancer is the preferred approach, while biopsy of other lesions is acceptable but not required. 1
Endocervical curettage is absolutely contraindicated in pregnancy and should never be performed. 1, 3
The primary goal is to exclude invasive cancer, not to treat preinvasive disease during pregnancy. 3
When Excisional Biopsy Is Acceptable
Diagnostic excision is only acceptable if invasive cancer is suspected based on referral cytology, colposcopic appearance, or cervical biopsy results. 1
This represents the sole indication for excisional procedures during pregnancy, as treatment during pregnancy carries high complication rates and recurrence risk. 1
One older study suggested laser conization before 16 weeks gestation for high-grade CIN, but this contradicts current consensus guidelines and should not be followed. 4
Surveillance During Pregnancy
If CIN 2,3 is not diagnosed on initial colposcopy/biopsy, perform surveillance with cytology and colposcopy every 12-24 weeks from diagnosis until postpartum evaluation. 3
Repeat biopsy is indicated only if colposcopic findings worsen or suggest progression to invasive disease. 3
CIN diagnosed during pregnancy tends to be stable with frequent postpartum regression, though this is not universal. 3
Postpartum Management
Re-evaluation with cytology and colposcopy is recommended no sooner than 6 weeks postpartum for pregnant women with HSIL in whom CIN 2,3 was not diagnosed during pregnancy. 1
At postpartum evaluation, full colposcopic assessment or expedited excisional procedure may be indicated based on findings. 3
Studies show 76-78.6% of women with HSIL during pregnancy still have HSIL on postpartum biopsy, regardless of delivery route. 5
Critical Pitfalls to Avoid
Do not perform treatment (LEEP, conization, ablation) during pregnancy unless invasive cancer is confirmed—the only indication for therapy of cervical neoplasia in pregnant women is invasive cancer. 1
Do not defer colposcopy in pregnant women with HSIL—unlike ASC-US or LSIL where deferral until postpartum is acceptable, HSIL carries 53-66% risk of CIN 2+ and 2% risk of invasive cancer. 1, 2
Do not use HPV testing for triage—intermediate triage using HPV testing or repeat cytology is inappropriate for HSIL due to high disease risk. 1, 2
Colposcopy can miss significant CIN 2,3 lesions, so careful examination and appropriate follow-up are essential. 1, 2