The main cause of death among gynaecologic malignancies is the cervical cancer which is the fourth most frequent disease in women worldwide.1 Since they were first developed more than 70 years ago, effective methods for detecting cervical cancer and treating cervical intraepithelial neoplasia (CIN), a condition that can lead to cancer, have significantly decreased both the incidence and mortality of this illness.2,3

Early detection and treatment of precancerous lesions can result in massive improvements of survival, and are especially important in developing countries where access to expensive cancer treatment is limited. Screening younger women will detect many lesions that are not likely to develop into cancer, will lead to considerable overtreatment, and is not cost- effective.4 The available methods for cervical cancer screening are the Papanicolaou (Pap) test (i.e., cytology), Human Papilloma Virus (HPV) testing, Visual Inspection using 5% acetic acid and Visual Inspection using Lugol’s Iodine.

The first visit to the hospital for majority of the women in India is during pregnancy, hence, pregnancy makes a good opportunity for the screening of premalignant and malignant cervical disease. Antenatal period is a time when women come voluntarily to seek health care for pregnancy. This opportunity should be utilized to down stage cancer cervix by detection of pre invasive lesions with cytology. Present study was aimed to study diagnosis of cervical cancer via pap smears and colonoscopy during pregnancy

Present study was single-center, prospective, comparative, parallel-group, observational study, conducted in department of Obstetrics & Gynecology, at Government Multispecialty Hospital, Sector 32, Chandigarh 160016, India. Study duration was of 6 months (Sept.2023 to March 2024). Study was approved by institutional ethical committee.

Inclusion criteria

• Ante Natal Women aged between 21 to 40 years, with 12-32 weeks of Gestational age Willing to participate in present study

Exclusion criteria

• Abnormal PAP smear in past 3 years
• Active bleeding
• Leaking or discharge present on speculum examination
• History of vaginal medication in past 48 hours
• History of threatened abortion in present pregnancy
• Placenta Praevia
• Active Genital Lesions
• Obvious growth over cervix
• Known or treated case of cancer cervix

Study was explained to participants in local language & written informed consent was taken. Convenient non-probability sampling technique was used to select study participants from the study population. Complete clinical information including documenting the date of last menstrual period or pregnancy, exogenous hormone use, and past history of abnormal bleeding or abnormal PAP test results, dysplasia or cancer was done. Patients should have abstained from vaginal intercourse, douching, and medicinal or contraceptive cream preparation for a minimum of 24 to 48 hours before a test. Treatment of cervicitis or vaginitis prior to PAP testing has been taken.

Screening was done by conventional PAP smear method. Sampling of complete transformation zone shall be ensured as it is paramount to the sensitivity of the PAP test Skilled cytotechnologists and pathologists meticulously examined the stained slides, searching for any abnormal cell changes indicative of dysplasia or malignancy. Findings were documented according to the 2014 Bethesda system guidelines, and patients with abnormal cytology underwent further evaluation, including colposcopic examination and directed biopsy as warranted.

During colposcopy, the patient was positioned on a specialized examination table with their feet placed in stirrups, akin to pelvic examinations. A lubricated speculum facilitated gentle insertion into the vagina to visualize the cervix. Subsequently, a solution of acetic acid (typically 3-5%) was applied to the cervix using a cotton swab or spray bottle, aiding in highlighting any abnormal areas through acetowhite changes. The cervix was closely examined using a Digital video colposcope (COLpro 777-Full HD) with magnifications of 1- 45x with inbuilt green filter, a specialized magnifying instrument positioned near the vaginal opening, providing a magnified view. After this Lugol‟s iodine was applied. Biopsies was taken from areas which stain white and where there was no uptake of Lugol’s iodine. These tissue samples were sent to a Department of Pathology for histopathological examination for analysis as per the Modified Swede Colposcopic Index (MSCI). Following the procedure, patients were advised on post-procedure care, which may involve mild cramping or spotting and avoidance of strenuous activities for a few days.

Means and proportions were calculated for continuous and categorical variables respectively. Difference in proportions was tested for statistical significance using Chi square test. Difference in means was tested using Independent sample student t test. A p value <0.05 will be considered statistically significant. Data entry was done using MS Excel 2016 and data analysis will be carried out using IBM SPSS version 22.0

Among 200 participants, majority fell within the 21-25 age group (52 %), followed by aged 26-30 (28 %). The mean age of the participants was 31.3 ±10.6 years. The majority of participants had a gestational age of 12 weeks (56%) followed by 13 to 20 weeks (24%). The majority of participants were married between the ages of 21 and 25 years (38 %), followed by married at or before the age of 20 (36.5%). Among the participants, 30% were categorized as primigravida, indicating their first pregnancy, while the remaining 70% were classified as multigravida, representing those with more than one pregnancy. 44% of participants fell within the normal BMI range (18.5–24.9), while 24% were classified as overweight (25–29.9). Moreover, 20% of participants were categorized as obese (BMI ≥30), and 12% were identified as underweight (BMI <18.5).

Table 1: General characteristics

The examination revealed that 90% of participants had a healthy cervix, while 10% exhibited cervical erosion. Notably, no participants displayed signs of cervical growth during the examination.

Table 2: Per speculum examination among study participants

A notable portion (5%) of participants exhibited unsatisfactory PAP smear results, potentially hindering accurate interpretation. Additionally, 11% of participants tested positive for Candida, indicating fungal infection, while 2.5% showed evidence of bacterial vaginosis. Trichomonas vaginalis, a parasitic infection, was observed in 1% of participants. The majority (79%) demonstrated negative findings for intraepithelial lesion or malignancy (NILM), suggesting a healthy cervical status. Among epithelial cell abnormalities, 1.5% of participants exhibited Atypical Squamous Cells of Undetermined Significance (ASCUS), necessitating further monitoring.

Table 3: PAP smear findings among study findings

Based on Modified Swede Colposcopic Index (MSCI) among study participants who had ASCUS in their PAP smear results. Among these participants, the majority (66.7%) exhibited normal colposcopy findings, indicating the absence of significant abnormalities. Additionally, a minority (33.3%) showed colposcopy findings consistent with low-grade lesions, suggestive of mild cervical dysplasia or precancerous changes. Notably, no participants in this subgroup presented with high-grade lesions during colposcopy.

Table 4: Colposcopy findings based on Modified Sweden Colposcopic Index (MSCI)

No statistically significant differences were observed in age, gestational age, or married life duration between the two groups, significant associations were found with BMI, gravida status, and findings from per speculum and per vaginum examinations. Participants with abnormal PAP smears displayed a higher mean BMI (p=0.014) and were exclusively multi-gravidas (p=0.017), suggesting potential risk factors. Moreover, abnormal findings during per speculum (p=0.038) examinations were more prevalent among individuals with abnormal PAP smears

Table 5: Determinants of abnormal pap smear among study participants

Chi-square

Bold-Independent t test

*p≤0.05 is statistically significant

The prevalence of abnormal PAP smear results during pregnancy can vary significantly depending on the population undergoing screening, with reported rates as high as 5-8%.[41] However, our study found a lower prevalence of 0.9% among screened pregnant women. Given that cervical cancer is preventable and readily detectable through screening, leveraging prenatal care for cervical screening can significantly contribute to early detection and prevention efforts.5

Colposcopy is a diagnostic procedure in which a colposcope (a dissecting microscope with various magnification lenses) is used to provide an illuminated, magnified view of the cervix. Combining two screening tests (e.g., HPV followed by VIA or cytology) in resource-limited settings for patients with HIV, but not for the general population.6 Two-test strategies can be either: additive, with screen-positive defined as an abnormal result on either test; or sequential, in which only patients with an abnormal result on the first test undergo a second test and only those who are also positive on the second test would receive treatment.7 Use of a two-test approach decreases the number of patients receiving unnecessary treatment.8

If colposcopy is performed, lesions suspicious for cervical intraepithelial neoplasia (CIN) 2,3 or cancer should be biopsied.4 If biopsy reveals CIN 1, additional cytologic and colposcopic evaluation should be performed postpartum, but no sooner than four weeks after delivery. If biopsy reveals CIN 2,3, and invasive disease is not suspected, repeat colposcopic evaluation can be performed every 12 to 24 weeks during pregnancy, or deferred until after four weeks postpartum. Colposcopic evaluation of the cervix in pregnancy can be challenging; it should be done by a colposcopist experienced in recognizing both pregnancy-related and cancer- related cervical changes.4

In the current study, 52% of the pregnant women were aged between 21 and 25 years, with a mean age of 31.3 ± 10.6 years and a range from 21 to 40 years. This demographic distribution mirrors similar findings reported in previous studies. Prabhu RBT et al.,9 observed a comparable percentage with a mean age of 25.7 years, while Mukhtar NF et al.,10 reported a mean age of 31.3 years, with participants ranging from 20 to 39 years. In study by Rudra S et al.,11 58% within age group of 20-25 years, Shamsunder S et al., 12 found that participants had a mean age of 24.7 ± 3.5 years, with 43% falling within the 20-25 age group, while Gill P et al., 13 noted that 43% of participants belonged to the 20-25 age range. Similarly, Siddiqui S et al.,14 reported that 52.7% of participants were aged between 21 and 25 years.

The demographic distribution observed in the study reflects prevalent societal trends in India, characterized by a higher incidence of pregnancies among younger age groups. This trend can be attributed to various factors, including early marriage norms and societal expectations surrounding family planning. Across many regions in India, cultural traditions emphasize the significance of early marriage and childbirth, thereby increasing the likelihood of pregnancies among women in their early twenties.

In the present study, 56% of participants who underwent screening for Opportunistic Cervical Cancer had a gestational age of 12 weeks. Prabhu TRB et al., 9 observed that 56% were <12 weeks of gestational age. Similarly, Gill P et al., 13 observed that 54% of participants were within the gestational age range of 14 to 28 weeks. Additionally, Priya SS, Shankar R15 found that 25% of participants had a gestational age of 15 weeks or less, while Khaskheli et al., 16 reported that 17.6% of participants were under 12 weeks gestation.

In the current study, a high proportion of participants, specifically 70%, were multigravida, consistent with similar findings reported in previous studies. Mukhtar NF et al.,10 reported a comparable proportion of 69.1%. Prabhu TRB et al.,9 (76%), Sudhakaran S et al.,17 (79.2%) observed a slightly higher percentage. In contrast, Gill P et al.,13 (58%), Shamsunder S et al.,12 (34.1%). found a lower percentage of multigravida participants. The higher proportion of screening in multigravida may be attributed to the fact that multigravida individuals may be more familiar with prenatal care routines and may be more likely to adhere to recommended screening practices compared to primigravida individuals who are experiencing pregnancy for the first time and may prioritize other aspects of prenatal care.

In the current study, 5% of the PAP smears yielded unsatisfactory results, potentially attributed to factors such as inadequate sample collection, technical errors, or dryness of the smear. This percentage is greater than that reported by Manikkam et al. 18 and Prabhu TRB et al.,9 which observed rates of 3%, but lower than findings from Priya SS and Shankar R, 15 who reported a 6% rate of unsatisfactory smears.

In the current study, the prevalence of abnormal PAP smears was 21% with 1.5%, with three cases of ASCUS, which aligns with findings from Sudhakaran S et al., 17 Manikkam B18 and Vural et al.19 This prevalence is lower compared to Gill P et al.,13 study, which reported a total prevalence of 3.4% for abnormal cervical cytology, including 2.2% for ASCUS, 0.4% for ASC-H, 0.4% for HSIL, and 0.4% for AGC. Conversely, Shamsunder S et al.,12 reported a higher prevalence of abnormal PAP smears at 5.9%, including 3.5% ASCUS, 1.1% LSIL, and 1.62% AGC. Siddiqui S et al.,14 found a lower prevalence, with ASCUS observed in 0.47% of cases and LSIL in 0.23% of cases, resulting in a total prevalence of 0.7%.[46] Additionally, Priya SS and Shankar R15 reported a 1% prevalence of abnormal PAP smear among screened pregnant women.

In this study, the prevalence of abnormal smears containing candida, bacterial vaginosis, and Trichomonas vaginalis was 11%, 2.5%, and 1%, respectively. This aligns with findings from previous studies. For instance, Niyaf NA et al.,20 reported rates of 9% for bacterial vaginosis, 7% for monilial infection, and 3% for trichomonas vaginalis. Similarly, Ngaojaruwong N et al.,21 observed a prevalence of candida infections at 23.4%, bacterial vaginosis at 14%, and trichomonas infection at 0.2%. Additionally, Khaengkhor et al.,22 reported rates of candida infections at 11%, bacterial vaginosis at 21%, and trichomonas infection at 0.6%. In contrast, Ghuge et al.,23 found a significantly higher prevalence of bacterial vaginosis at 65.6%, compared to present study's 2.5%.

In this study, BMI, multigravida status, and abnormal per speculum, examinations emerged as risk factors associated with abnormal PAP smear findings. Notably, abnormal smears were observed in multigravida only with none in primigravida, indicating its significance as a risk factor. Consistent with current study findings, prior studies by Manikkam et al.,17 Prabhu TRB et al.,9 Himabindu et al.,24 and Bijeta et al.,25 also noted a higher prevalence of abnormal smears among multipara individuals. These results emphasize the importance of cervical screening irrespective of gravidity status and suggest that the first pregnancy serves as an opportune moment for initial PAP smear screening in areas lacking comprehensive screening programs.

To address these limitations, future research could employ longitudinal or randomized controlled trial designs and adopt more rigorous sampling methods to ensure representative participant selection. Additionally, efforts should be made to enhance awareness and access to cervical cancer screening programs, particularly among pregnant women, to facilitate early detection and intervention. Overall, this study underscores the importance of tailored screening strategies and the potential benefits of utilizing MSCI in optimizing cervical cancer management.

Present study underscores the importance of targeted cervical cancer screening programs among pregnant women in North India, revealing a notable prevalence of abnormal cervical cytology. The identification of risk factors such as multigravida status, abnormal per speculum and per vaginum examinations, and higher BMI underscores the need for tailored interventions to address these factors and improve maternal health outcomes.

Leveraging the Modified Sweden Colposcopy Index (MSCI) proved advantageous, thus optimizing healthcare resources and enhancing patient care. Looking ahead, collaborative efforts among healthcare providers, policymakers, and community stakeholders are essential to strengthen cervical cancer screening programs, enhance healthcare provider training, and promote patient education. By doing so, we can effectively mitigate the burden of cervical cancer and advance maternal health outcomes among pregnant women in North India and beyond.

Conflict of Interest: None to declare

Source of funding: Nil

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