Cervical dysplasia and pregnancy

Cervical dysplasia and pregnancy is a problem that raises many questions about its importance and the complexity of the tactics of treatment and management of pregnancy. For a pregnant woman who has been diagnosed with this problem, it always seems dangerous, is not an exception for the doctor, since the risk of complications is always assessed individually and the tactics of doing such a pregnancy are different. After all, it is known that the very process of bearing a child and the pathology of the cervix are mutually burdening states, so it is necessary to understand some of the issues of etiology, the main characteristic and tactics of treatment for certain types of metaplasia of the cervix.

[1], [2]

Causes of the dysplasia of the cervix in pregnancy

Among the etiological factors of development of dysplasia, before infection, infectious agents - viruses or bacteria - are in the first place. Among the viral agents - it is most often the infection of a woman with human papillomavirus. This virus has a tropism for the female genital organs and causes the development of another disease - condyloma or cervical papilloma. But a prolonged infection can cause dysplasia of the cervix. Other possible agents are herpes viruses that have tropism to the epithelium of the cervix and a high oncogeneity, so they can be a trigger mechanism for the development of dysplastic processes in the cell.

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

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.

[3], [4]

Risk factors

Pregnancy is a condition where a woman's body is reconstructed in such a way that it becomes more vulnerable than in any other situation, since a state of physiological immunosuppression occurs. Therefore, a violation of the normal barrier function of the vaginal microflora and a decrease in local defense responses allows the development of various concomitant conditions, which in turn can contribute to the development of dysplasia.

Development of cervical dysplasia during pregnancy does not happen often, most often this condition develops before pregnancy. Allocate risk factors for cervical dysplasia and causative factors. Common risk factors include bad habits, smoking, drinking alcohol, eating disorders and carcinogenic products, environmental factors. All these changes are accompanied primarily by a decrease in the reactivity of the whole organism, and against this background, functional and then morphological changes in organs and systems develop. But this way of life is categorically contraindicated in pregnancy, so dysplasia of the cervix in pregnancy is not prone to aggravation of the condition, which allows women to bear a child even with metaplasia.

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

[5], [6], [7], [8]

Pathogenesis

With regard to the pathogenesis of development of dysplasia in pregnancy, it is necessary to know some normal anatomical features of the structure of the cervix 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 multilayer non-coring epithelium - located in the endocervix closer to the vaginal canal and is a continuation of it;
• intermediate zone - located further and is the border on the way to the cervix;
• Cylindrical epithelium - lining 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 cylindrical epithelium is located among cells of the flat epithelium. This occurs when a certain etiological factor disrupts the normal life cycle of the cell, the process of its normal division is disrupted, and abnormal cells appear in numerical numbers in the area where they should not normally exist. The genetic apparatus of the cell is disrupted in such a way that atypy of cells 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 can not provide a normal metabolism in the cytoplasm, which is the cause of dysplasia. Such changes pose a particular danger in terms of the fact that these cells already carry a potential threat due to a violation of their normal division and at any time may be their uncontrolled reproduction. In the case of dysplasia during child bearing, the process of such multiplication of cells is even more active, since the hormonal influence promotes the growth and reproduction of the fetal cells, and consequently of the entire female body, so dysplasia of the cervix during pregnancy is a more dangerous condition.

[9], [10], [11], [12], [13], [14]

Symptoms of the dysplasia of the cervix in pregnancy

Dysplasia of the cervix, which is diagnosed before pregnancy, as a rule, no manifestations have not already when bearing a child. It can be a purely defect that does not have clinical symptoms right up to the time of delivery, then the first signs can appear. This can be traumatic damage at the site of dysplasia, ruptures of the cervix, bleeding, the development of concomitant pathologies in the form of infection and the formation of genital warts and papillomas. Then in the postpartum period, when examined, women can see such changes. Sometimes there may be discharge from the vagina of a different consistency.

If dysplasia of the cervix is diagnosed for the first time already during pregnancy, it is most often an asymptomatic course of the disease, since there are no local painful sensations. The detection of pathology in this case is carried out with screening examinations of pregnant women. Sometimes one of the manifestations of dysplasia in pregnancy can be painful intercourse or spotting after it, which occurs when traumatizing the dysplastic areas of the cervix. This symptom can be aggravated due to the increase in the uterus, so it is necessary to differentiate these changes.

[15]

Cervical dysplasia and pregnancy planning

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

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

[16], [17]

Stages

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

• 1 degree - it is mild dysplasia, in which the changed dysplastic cells extend deep into not more than one third of the epithelial cover.
• 2 degrees - is a moderate dysplasia, in which the changed dysplastic cells extend deep into not more than two thirds.
• 3 degrees - this is a severe dysplasia, in which the changed dysplastic cells extend in depth by two-thirds or more, but without invasion of the basal membrane.

This classification of dysplasia 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 in pregnancy is not different, so it is important to have an accurate clinical diagnosis indicating the degree of dysplasia.

[18]

Complications and consequences

First of all, it should be noted that the consequence of dysplasia may be malignancy, so this disease must be amenable to mandatory treatment. Given the development of this pathology during pregnancy, it is possible complications in the form of miscarriage, the threat of abortion, premature birth, intrauterine infection of the fetus. All this requires careful monitoring to prevent such complications.

First of all, it is necessary to plan pregnancy with carrying out of all obligatory researches and treatment of pathology of female reproductive system in advance. If cervical dysplasia has been diagnosed already during pregnancy, then monitoring of the condition with colposcopy and cytological examination every three months is necessary. In the case of concomitant hormonal pathology or an infectious process, it is necessary to treat these conditions.

[19], [20], [21]

Diagnostics of the dysplasia of the cervix in pregnancy

Since the course of this pathology is often asymptomatic, an important element of timely diagnosis and prevention of complications are preventive examinations at the gynecologist, which the woman must undergo annually. In pregnancy, this pathology is detected more often, which is due to mandatory regular examinations and examinations of a woman not only during the gestation period, but also at the stage of pregnancy planning. With 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, a woman examines a histological examination of a cervical canal smear. It is very important that the smear be taken on the right technology. To do this, a dabble is taken with a special brush, bent at right angles from the three zones of the cervix - 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 performed to determine its type. There are six basic 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 dysplasia of the cervix (CIN-ІІ);
   3. severe cervical dysplasia (CIN-III);
4. suspected cancer;
5. cancer;
6. a non-informative smear (not all types of epithelium are represented).

This analysis allows you to accurately determine the diagnosis.

If there is a suspicion of dysplasia, that is, if a third type of smear is performed, then additional instrumental methods of investigation are carried out, but since the results of this examination can be in 3-4 weeks, during pregnancy, a screening method for determining such conditions is performed scheduled for all pregnant women in the first trimester. This is an instrumental method of research - 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. This increase allows you to see those areas of dysplasia, which are not determined by routine examination in the mirrors. Also, special methods are applied to color the areas of the examined epithelium of the cervix using trichloroacetic acid, iodine or Lugol solution, and look at the degree of coloration. The sites of metaplastic epithelium will be pale against a normally colored epithelium. In addition to simple colposcopy, colposcopy with a targeted aspiration biopsy is also performed. Such a diagnosis can confirm the presence of dysplasia in pregnancy, even if visually nothing can be found, and the result of histological examination will enable you to accurately establish the degree of dysplasia and determine the tactics of observation.

[22], [23], [24]

Differential diagnosis

Dysplasia of the cervix in pregnancy must be differentiated from other precancerous conditions and benign cervical structures: polyps or condylomas, erosion, leukoplakia without atypia, adenomatosis, since the tactics of managing these conditions in pregnant women are different.

Erosion of the cervix is a defect in the mucosa, which in colposcopy has a characteristic appearance and can be easily distinguished from dysplasia.

Leukoplakia is the appearance of the horny epithelium on the cylindrical epithelium of the cervical canal itself or on the flat epithelium of exocervix. These areas are easy to distinguish, because they look like whitish islets 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, as a concomitant condition with dysplasia and they have a characteristic appearance - neoplasms by the type of cauliflower on a wide or narrow stem.

In any case, the morphological examination of the epithelial smear allows for differential diagnosis with other precancerous diseases and a precise diagnosis of the disease.

Treatment of the dysplasia of the cervix in pregnancy

Treatment of dysplasia of the cervix during pregnancy has its own distinctive features, since it is necessary to exclude the harm of a particular method of treatment for the fetus, along with the high efficiency of this method for the maternal organism. The main task of treatment is the preservation of pregnancy against the background of dysplasia and active treatment of this pathology after childbirth. The issue of retention of pregnancy is decided by the woman herself, but the main tactic is due to several points. At a dysplasia of 1 and 2 degrees pregnancy it is recommended to save with corresponding medicamental treatment, at a dysplasia of 3 degrees the repeated biopsy with morphological research is recommended. In case of confirmation of the diagnosis, it is possible to recommend termination of pregnancy at an early stage under certain conditions, but this is not a direct indication and the woman herself decides individually.

Drug treatment of cervical dysplasia in pregnancy is used in two cases - dysplasia on the background of infection and against the background of hormonal disorders. In the case of development of dysplasia against the background of infection with viruses, mainly human papillomavirus, active antiviral therapy during pregnancy is not performed, as this can harm the fetus. When infected with bacterial agents, active antimicrobial therapy is performed by local anti-inflammatory drugs, the choice of preparation is individual and depends on the type of pathogen. Preference is given to the means of local influence.

Dysplasia of the cervix in pregnancy, which develops against a background of hormonal imbalance, can have consequences in the form of a threat of termination of pregnancy, therefore, requires treatment with hormonal replacement drugs. Such treatment is carried out in the first trimester, and in the second and third trimester, tocolytic therapy is performed with the threat of abortion. One of the hormonal drugs that can be used in cases of insufficiency of the luteal phase of the ovary is the preparation of progesterone.

Duphaston is an oral hormone drug, which is a synthetic analogue of natural progesterone. The mechanism of action of this drug consists in replacement therapy in the absence of the second ovarian phase, which leads to the development of cervical pathology and the lack of progesterone for normal gestation. The drug is available in the form of tablets of 10 mg, is used according to an individual scheme with total dosages in the form of a 10 mg dose twice a day from the 5th day of the cycle or from the 11th day of the cycle. The features of the procedure depend on the type of disorder and can be adjusted individually with admission 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, violation of libido.

Operative treatment of cervical dysplasia during pregnancy has its limited use, since any invasive intervention can contribute to the threat of termination of pregnancy. According to the protocols for the treatment of dysplasia in 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 a comprehensive diagnosis and clarification of the diagnosis.

Alternative methods of treatment have their priorities because of the limited possibilities of exactly operational and drug methods. This causes women to seek more simple and harmless methods of treatment, but remember that they can also be dangerous for the child under certain conditions, so before using any methods it is necessary to consult a doctor.

The main recipes for alternative treatment are the use of herbs and tinctures from them, as well as natural healing remedies.

1. Honey, as a natural source of nutrients and trace elements, which increase local immunity and stimulate regeneration, is widely used to treat the pathology of 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 flaxseed oil and three tablespoons of water, insist day and night, moistened with a tampon in this solution, put into the vagina, which should be repeated for 10 days. Such a drug has no 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-edema, regenerating, immunomodulating effect. Aloe leaves are squeezed into a glass with two teaspoons of honey and, wetting a tampon, is inserted into the vagina, repeating the procedure once a day for a whole month.
3. Widely used infusions of herbs. Prepare a herb collection of leaves of mint, raspberries and currants - take them in equal quantities, pour hot water and boil for another 5 minutes, after which they cool and drink half the glass in a warm day every other day for a month.
4. Infusion of chamomile and blueberry is prepared from three tablespoons of chamomile leaves, to which are added three tablespoons of fruit or blueberry leaves, and then it is brewed in a liter of boiled water. Before taking a spoon of honey and take half a cup 3 times a day.

Homeopathic preparations, which are used in the treatment of cervical dysplasia in pregnancy, stimulate the regeneration of the epithelium and reduce inflammatory manifestations. The use of homeopathic remedies during pregnancy is somewhat limited and requires individual consultation with the doctor. Possible use of such drugs:

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

Forecast

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

Dysplasia of the cervix and pregnancy - a frequent and actual pathology precisely because of the frequent detection of it and a threat to the mother herself. Given that this disease has an asymptomatic course, it is necessary to diagnose and start treatment right after delivery, since the risk of malignancy is very high, and treatment during labor is limited. To prevent this pathology even before pregnancy, it is necessary to follow very simple rules - to undergo preventive examinations in a gynecologist on time.

[25], [26], [27], [28], [29]