Cervical dysplasia and pregnancy

Cervical dysplasia and pregnancy is a problem that raises many questions due to its importance and complexity of treatment tactics and pregnancy management. For a pregnant woman who has been diagnosed with this problem, it always seems dangerous, and for a doctor too, since the degree of risk of complications is always assessed individually and the tactics of managing such a pregnancy are different. After all, it is known that the process of bearing a child and cervical pathology are mutually aggravating conditions, so it is necessary to understand some issues of etiology, the main characteristics and tactics of treatment for certain types of cervical metaplasia.

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Causes cervical dysplasia in pregnancy

Among the etiological factors of dysplasia development even before pregnancy, infectious agents - viruses or bacteria - are in the first place. Among viral agents, this is most often a woman's infection with the human papilloma virus. This virus has a tropism for female genital organs and causes the development of another disease - condylomas or papillomas of the cervix. But a long-term infection can cause the development of cervical dysplasia. Other possible agents are herpes viruses, which have a tropism for the epithelium of the cervix and high oncogenicity, so they can be a trigger for the development of dysplastic processes in the cell.

Among possible bacterial infections, the etiological factor of dysplasia development can only be intracellular microorganisms - these are ureaplasma, toxoplasma, chlamydia, gonococci. These microorganisms penetrate into the cell and remain there for a very long time, while protecting themselves from immune cells and maintaining a chronic inflammation focus. This is not the true cause of dysplasia, but against its background, similar changes can develop that will further lead to dysplasia.

If all these processes occur against the background of physiological immunosuppression, then the probability of developing cervical dysplasia during pregnancy is very high, and this is very dangerous, because then it is very difficult to predict and treat such a condition.

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Risk factors

Pregnancy is a condition when a woman's body is rebuilt in such a way that it becomes more vulnerable than in any other situation, since a state of physiological immunosuppression occurs. Therefore, the disruption of the normal barrier function of the vaginal microflora and the reduction of local protective reactions allows various concomitant conditions to develop, which in turn can contribute to the development of dysplasia.

The development of cervical dysplasia during pregnancy does not happen often, most often this condition develops before pregnancy. There are risk factors for the development of cervical dysplasia and causal factors. General risk factors include bad habits, smoking, alcohol consumption, poor diet and consumption of carcinogenic products, and the influence of environmental factors. All these changes are accompanied primarily by a decrease in the reactivity of the entire body, and against this background, functional and then morphological changes in organs and systems develop. But such a lifestyle is strictly contraindicated during pregnancy, so cervical dysplasia during pregnancy is not prone to worsening the condition, which allows women to bear a child even with metaplasia.

If we take into account the fact that dysplasia in a woman was diagnosed before pregnancy, then risk factors for this could also be frequent changes of sexual partners, early onset of sexual activity, infectious and inflammatory diseases of the female genital organs, frequent surgical interventions with trauma to the birth canal, and hormonal imbalances.

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Pathogenesis

As for the pathogenesis of dysplasia development during pregnancy, it is necessary to know some normal anatomical features of the structure of the cervix in order to know when to talk about dysplasia. The histological structure of the cervix in a healthy pregnant woman is an alternation of epithelial cells:

• flat multilayered non-keratinizing epithelium - located in the endocervix closer to the vaginal canal and is a continuation of it;
• the intermediate zone is located further and is the border on the way to the cervix;
• Columnar epithelium – lines the cavity of the cervix and the cervical canal.

Normally, there is a clear boundary between these layers. Dysplasia is a violation of the normal anatomical structure and alternation of these zones, in which the epithelium of one zone can move to another, for example, the columnar epithelium is located among the cells of the squamous epithelium. This occurs when some etiological factor disrupts the normal life cycle of the cell, the process of its normal division is disrupted and abnormal cells appear in numerical quantities in the area where they should not normally be. The genetic apparatus of the cell is disrupted in such a way that cell atypia is formed, that is, the process of cell division can stop at a certain phase of mitosis, and then the development of numerical cells with an incorrect set of chromosomes can be initiated. Such cells cannot ensure normal metabolism in the cytoplasm, which is the cause of dysplasia. Such changes are especially dangerous in terms of the fact that these cells already pose a potential threat due to the disruption of their normal division and at any moment their uncontrolled reproduction can occur. In the case of dysplasia during pregnancy, the process of such cell proliferation is even more active, since hormonal influence promotes the growth and proliferation of fetal cells, and accordingly the entire female body, therefore, cervical dysplasia during pregnancy is a more dangerous condition.

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Symptoms cervical dysplasia in pregnancy

Cervical dysplasia, which is diagnosed before pregnancy, usually has no manifestations during pregnancy. It may be a pure defect that has no clinical symptoms until the moment of birth, then the first signs may appear. These may be traumatic injuries at the site of dysplasia, cervical ruptures, bleeding, the development of concomitant pathology in the form of infection and the formation of condylomas and papillomas. Then, in the postpartum period, during examination, women may see similar changes. Sometimes there may be vaginal discharge of varying consistency.

If cervical dysplasia is first diagnosed during pregnancy, it is most often an asymptomatic course of the disease, since there are no local painful sensations. In this case, the pathology is detected during screening examinations of pregnant women. Sometimes, one of the manifestations of dysplasia during pregnancy can be painful intercourse or bloody discharge after it, which occurs when the dysplastic areas of the cervix are injured. This symptom can worsen due to an increase in the uterus, so it is necessary to differentiate these changes.

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Cervical Dysplasia and Pregnancy Planning

Of course, pregnancy should be planned to avoid various complications during pregnancy and childbirth and to give birth to a healthy baby. If cervical dysplasia is diagnosed during pregnancy, then this is a completely different tactic, but there are some peculiarities in the case of diagnosis before conception. If this diagnosis was diagnosed in the process of pregnancy planning, then naturally it is necessary to conduct a comprehensive examination of the female body. Cytological examination allows you to determine the degree of dysplasia, which is very important for determining the treatment tactics. At any degree of dysplasia in the process of pregnancy planning, it is recommended to first carry out comprehensive treatment of this pathology, then wait a year, during which it is necessary to monitor the condition after treatment and conduct general strengthening therapy, and only after at least a year after that, it is recommended to become pregnant. But there are nuances, because sometimes circumstances develop in such a way that there is no time for complete treatment and rehabilitation, then with dysplasia of I and II degrees you can become pregnant, because pregnancy cannot radically affect metaplasia and increase its degree. With grade III cervical dysplasia, pregnancy is not recommended, since this disease should be under strict oncological control, and due to the high risk, urgent treatment of such pathology is necessary. Therefore, with grade III, first of all, it is necessary to be cured. But this pathology cannot affect the fetus even with grade III dysplasia, but the general condition of the woman after childbirth may worsen, since the stimulating effect of hormones with increased proliferative processes can increase in the cervix during pregnancy. Therefore, it is better to consider the issue of planning a pregnancy with a concomitant diagnosis of cervical dysplasia. It is also very important for cervical dysplasia and pregnancy planning to conduct a comprehensive examination to determine the hormonal background and the group of TORCH infections. This study is necessary to exclude the infectious nature of dysplasia. It is also recommended to conduct PCR for the presence of human papillomavirus DNA in the woman's body, which today is one of the etiological factors in the possible development of cancerous pathology of the cervix. If this viral agent is detected in a woman, her husband must also be examined, since he may be a carrier of the virus, so this is an important element in planning a pregnancy with concomitant dysplasia.

All these studies will help determine the exact diagnosis and further tactics for pregnancy planning.

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Stages

According to the histological classification, there are 3 degrees of cervical dysplasia during pregnancy, which corresponds to cervical dysplasia in women in general:

• Grade 1 is mild dysplasia, in which altered dysplastic cells spread deep into no more than one third of the epithelial layer.
• Grade 2 is moderate dysplasia, in which the altered dysplastic cells extend in depth by no more than two-thirds.
• Grade 3 is severe dysplasia, in which altered dysplastic cells extend into the tissue by two-thirds or more, but without invasion of the basement membrane.

Such classification of dysplasias is necessary in order to accurately determine the tactics of treatment, observation and prevent possible complications during pregnancy. The clinical picture of these different types of dysplasia during pregnancy does not differ, so it is important to have an accurate clinical diagnosis indicating the degree of dysplasia.

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Complications and consequences

First of all, it should be noted that dysplasia may result in malignancy, so this disease must be treated. Given the development of this pathology during pregnancy, complications such as miscarriage, threatened termination of pregnancy, premature birth, intrauterine infection of the fetus are possible. All this requires careful monitoring to prevent such complications.

First of all, it is necessary to plan pregnancy with all mandatory examinations and treatment of pathology of the female reproductive system in advance. If cervical dysplasia was diagnosed during pregnancy, then it is necessary to monitor the condition with colposcopy and cytological examination every three months. In case of concomitant hormonal pathology or infectious process, it is necessary to treat these conditions.

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Diagnostics cervical dysplasia in pregnancy

Since the course of this pathology is often asymptomatic, an important element of timely diagnosis and prevention of complications is preventive examinations by a gynecologist, which a woman should undergo annually. During pregnancy, this pathology is detected more often, which is associated with mandatory regular examinations and examinations of a woman not only during the period of bearing a child, but also at the stage of pregnancy planning. During a simple examination of a woman in mirrors, this pathology is not visualized, because these changes are not visible to the naked eye. But, like any examination, during the examination of a woman, a histological examination of a smear of the cervical canal is carried out. It is very important that the smear is taken using the correct technology. To do this, a smear is taken with a special brush bent at a right angle from three zones of the cervix - the endocervix, the intermediate zone and the cervical canal, that is, all three types of epithelium must be present. After this, a histological examination of the smear is carried out to determine its type. There are six main types of smears:

1. histological picture of a healthy woman;
2. inflammatory and benign changes in the smear;
3. cervical intraepithelial neoplasia
   1. mild cervical dysplasia (CIN-I);
   2. moderate cervical dysplasia (CIN-II);
   3. severe cervical dysplasia (CIN-III);
4. suspected cancer;
5. Cancer;
6. uninformative smear (not all types of epithelium are represented).

This analysis allows for an accurate diagnosis.

If dysplasia is suspected, that is, if the smear is of the third type, then additional instrumental research methods are carried out, but since the results of this examination can be in 3-4 weeks, then during pregnancy, the screening method for determining such conditions is carried out routinely for all pregnant women in the first trimester. This is an instrumental research method - colposcopy. This method allows you to examine the cervix with a special device that has a magnifying power of 7 to 28 times, depending on the power. Such magnification allows you to see those areas of dysplasia that are not determined during a normal examination in mirrors. Special methods of staining the areas of the examined epithelium of the cervix are also carried out using trichloroacetic acid, iodine solution or Lugol, and they look at the degree of staining. Areas of metaplastic epithelium will be pale against the background of normally stained epithelium. In addition to simple colposcopy, colposcopy with targeted aspiration biopsy is also performed. Such diagnostics allow us to confirm the presence of dysplasia during pregnancy, even if nothing can be detected visually, and the results of histological examination will make it possible to accurately determine the degree of dysplasia and determine the monitoring tactics.

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Differential diagnosis

Cervical dysplasia during pregnancy must be differentiated from other precancerous conditions and benign formations of the cervix: polyps or condylomas, erosions, leukoplakia without atypia, adenomatosis, since the tactics of managing these conditions in pregnant women are different.

Cervical erosion is a defect of the mucous membrane that has a characteristic appearance during colposcopy and is easily distinguished from dysplasia.

Leukoplakia is the appearance of keratinized epithelium on the columnar epithelium of the cervical canal itself or on the squamous epithelium of the exocervix. These areas are easy to distinguish because they appear as whitish islands among the epithelial cover, in contrast to the intact mucosa in dysplasia, which is not visible to the naked eye.

Polyps and condylomas can be a concomitant condition with dysplasia and they have a characteristic appearance - neoplasms like cauliflower on a wide or narrow stalk.

In any case, morphological examination of the epithelial smear allows for differential diagnosis with other precancerous diseases and an accurate clinical diagnosis.

Treatment cervical dysplasia in pregnancy

Treatment of cervical dysplasia during pregnancy has its own distinctive features, since it is necessary to exclude the harm of a certain treatment method for the fetus along with the high efficiency of this method for the mother's body. The main task of treatment is to maintain pregnancy against the background of dysplasia and active treatment of this pathology after childbirth. The question of maintaining pregnancy is decided by the woman herself, but the main tactics are determined by several points. With dysplasia of 1 and 2 degrees, pregnancy is recommended to be maintained with appropriate drug treatment, with dysplasia of 3 degrees, a repeated biopsy with morphological examination is recommended. If the diagnosis is confirmed, early termination of pregnancy can be recommended under certain conditions, but this is not a direct indication and the woman herself decides this individually.

Drug treatment of cervical dysplasia during pregnancy is used in two cases - dysplasia against the background of infection and against the background of hormonal disorders. In the case of dysplasia against the background of infection with viruses, mainly the human papilloma virus, active antiviral therapy is not carried out during pregnancy, as this can harm the fetus. In case of infection with bacterial agents, active antimicrobial therapy is carried out with local anti-inflammatory drugs, the choice of drug is individual and depends on the type of pathogen. Preference is given to local agents.

Cervical dysplasia during pregnancy, which develops against the background of hormonal imbalance, can have consequences in the form of a threat of termination of pregnancy, therefore it requires treatment with hormonal replacement drugs. Such treatment is carried out in the first trimester, and in the second and third trimesters, tocolytic therapy is carried out in case of a threat of termination of pregnancy. One of the hormonal drugs that can be used for luteal phase insufficiency of the ovary is a progesterone drug.

Duphaston is an oral hormonal drug that is a synthetic analogue of natural progesterone. The mechanism of action of this drug is replacement therapy for insufficiency of the second ovarian phase, which leads to the development of cervical pathology and progesterone insufficiency for normal pregnancy. The drug is available in the form of 10 mg tablets, used according to an individual scheme with general dosages in the form of taking 10 mg twice a day from the 5th day of the cycle or from the 11th day of the cycle. The features of the intake depend on the type of disorder and can be adjusted individually with intake throughout the first three months of pregnancy.

Contraindications to the use of the drug are acute liver damage, acute heart failure and lactation. Side effects are allergic manifestations, dyspeptic manifestations in the form of nausea, vomiting, discomfort in the mammary glands, and libido disorders.

Surgical treatment of cervical dysplasia during pregnancy has its limited application, since any invasive intervention can contribute to the threat of termination of pregnancy. According to the protocols for the treatment of dysplasia during pregnancy, the use of laser vaporization, cone excision, scraping of the cervical canal, electrocoagulation is not recommended. These methods can be used only in the postpartum period after comprehensive diagnostics and clarification of the diagnosis.

Traditional methods of treatment have their own priorities due to the limited possibilities of surgical and medicinal methods. This forces women to look for simpler and more harmless methods of treatment, but it should be remembered that they can also be dangerous for the child in certain conditions, so before using any methods, it is necessary to consult a doctor.

The main recipes of folk treatment are the use of herbs and infusions from them, as well as natural healing agents.

1. Honey, as a natural source of nutrients and microelements that increase local immunity and stimulate regeneration, is widely used to treat pathologies of the female genital organs, including dysplasia. To create a medicine from honey, you need to make a solution of three tablespoons of honey, five drops of linseed oil and three tablespoons of water, leave it for a day and overnight, soak a tampon in this solution, insert it into the vagina, and repeat for 10 days. This remedy does not have a negative effect on the fetus, but has a pronounced reparative effect.
2. Honey can be combined with another natural source of vitamins – aloe. This plant has a pronounced bactericidal, anti-edematous, regenerating, immunomodulatory effect. Aloe leaves are squeezed into a glass with two teaspoons of honey and, having moistened a tampon, inserted into the vagina, repeating the procedure once a day for a whole month.
3. Herbal infusions are widely used. Prepare a herbal infusion from mint, raspberry and currant leaves - take them in equal quantities, pour hot water and boil for another 5 minutes, then cool and drink warm, half a glass every other day for a month.
4. Chamomile and blueberry infusion is prepared from three tablespoons of chamomile leaves, to which three tablespoons of blueberry fruits or leaves are added, and then this is brewed in a liter of boiled water. Before taking, add a spoonful of honey and take half a glass 3 times a day.

Homeopathic preparations used in the treatment of cervical dysplasia during pregnancy stimulate epithelial regeneration and reduce inflammatory manifestations. The use of homeopathic remedies during pregnancy is somewhat limited and requires individual consultation with a doctor. The following preparations may be used:

• Dysmenorm is a complex homeopathic preparation that affects hormonal imbalance in cervical dysplasia in pregnant women against the background of hormonal disorders with progesterone deficiency. The drug is available in tablet form and is taken 1 tablet 3 times a day half an hour before meals. Side effects are rare, but there may be nausea and temporary deterioration of the condition. Not recommended for patients with celiac disease.
• Ginekohel is a combined homeopathic preparation, which is produced in the form of drops and is used 10 drops three times a day, before which it must be dissolved in warm water. The principle of action is the regulation of hormonal disorders. Side effects are rarely noted in the form of skin allergic manifestations.

Forecast

The prognosis for the birth of a healthy child with dysplasia during pregnancy is positive, since the pathology does not have a significant impact on the fetus itself. There may be a negative prognosis for the mother with the wrong tactics of correcting this pathology in the postpartum period, therefore, treatment of dysplasia after childbirth is mandatory, with preference given to surgical methods.

Cervical dysplasia and pregnancy is a common and relevant pathology precisely because of its frequent detection and the threat to the mother herself. Considering that this disease is asymptomatic, it is necessary to diagnose it in time and begin treatment immediately after childbirth, since the risk of malignancy is very high, and treatment during childbirth is limited. To prevent this pathology even before pregnancy, it is necessary to follow very simple rules - undergo preventive examinations by a gynecologist in a timely manner.

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