Management of pregnancy - VA/DoD Clinical Practice Guidelines ...

VA/DoD Clinical Practice Guideline
For Pregnancy Management
The American Cancer Society (ACS) (Saslow, 2002) recommends routine cervical screening for sexually active
women between the ages of 21 and 70. Furthermore, ACS recommends cervical screening be performed annually
with conventional cervical cytology smears or every two years using liquid-based cytology. Women over age 30
who have had three consecutive, technically satisfactory normal/negative cytology results may be screened every
two to three years (unless they have a history of in utero diethylstilbestrol (DES) exposure, are HIV positive, or are
immunocompromised by organ transplantation, chemotherapy, or chronic corticosteroid treatment) (Saslow et al.,
2002).
The United States Preventative Services Task Force (USPSTF) strongly recommends screening for cervical cancer
in women who have been sexually active and have a cervix. Indirect evidence suggests most of the benefit can be
obtained by beginning screening within three years of onset of sexual activity or age 21 (whichever comes first) and
screening at least every three years (USPSTF, 2003). All pregnant women are included in this population, and
recommendations for screening apply during this time in their lives. There is no evidence of an increased incidence
of cervical dysplasia during pregnancy that would necessitate more frequent testing (Lurain & Gallop, 1979). This
fact, combined with increased rates of false positive cervical cytology in pregnancy, challenges the common practice
of uniformly performing cervical smears at the first antenatal visit.
The goal in evaluating abnormal cervical cytology is to rule out the presence of invasive cervical cancer (LaPolla et
al., 1988). Colposcopy is safe during pregnancy, but should be performed only by colposcopists experienced in
pregnancy exams (Wright et al., 2007).
The use of cytobrush and spatula may cause minimal spotting in pregnancy, but is not associated with any adverse
outcomes (Hoffman et al., 1991; Koonings et al., 1992). The endocervical swab is less sensitive than a brush for
endocervical sampling and should therefore not be used (Martin-Hirsch et al., 1999).
EVIDENCE TABLE
Recommendations Sources of Evidence LE QE SR
1 Screening cervical smear in pregnancy Lurain & Galop, 1979 II-2 Good B
2 Method of cervical smears Hoffman et al., 1991
Koonings et al., 1992
I Good A
3 Management of abnormal cervical Wright et al., 2007 III Fair C
smears
LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A)
I­ 32. Screening for HSV: Weeks 10­12 or onset of symptoms
BACKGROUND
Herpes Simplex Virus (HSV) is one of the most common sexually transmitted infections but it is not a reportable
disease so the true incidence is not known. It is estimated that approximately 45 million adolescent and adult
Americans are infected with HSV-2 (Fleming et al., 1997). However, HSV-1 can also cause genital disease.
Approximately 10 percent of women who are HSV-2 seronegative have partners who are seropositive and are at risk
of transmission during pregnancy (Gardella et al., 2005). Most new infections in pregnancy are asymptomatic
(Brown et al., 1997). Approximately 80 percent of infected infants are born to mothers with no reported history of
HSV infection (Whitley et al., 1988).
RECOMMENDATIONS
1. Routine HSV screening of pregnant patients is not recommended. [I]
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