Management of High-Grade Squamous Intraepithelial Lesion (HSIL) in Pregnant Women

Initial Evaluation

The American College of Obstetricians and Gynecologists recommends colposcopy with biopsy of lesions suspicious for CIN 2,3 or cancer for pregnant women with HSIL, but defers all treatment unless invasive cancer is suspected 1, 2
Colposcopy is mandatory for all pregnant women with HSIL cytology, preferably performed by clinicians experienced in evaluating pregnancy-induced colposcopic changes 1, 3
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, 2

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 4

The American College of Obstetricians and Gynecologists advises against performing 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 4
Do not defer colposcopy in pregnant women with HSIL—unlike ASC-US or LSIL where deferral until postpartum is acceptable, HSIL carries a high risk of CIN 2+ and invasive cancer 2, 3
Do not use HPV testing for triage—intermediate triage using HPV testing or repeat cytology is inappropriate for HSIL due to high disease risk 2, 3
Colposcopy can miss significant CIN 2,3 lesions, so careful examination and appropriate follow-up are essential 1, 3

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

Excisional cervical procedures (e.g., LEEP) should not be performed during pregnancy for CIN 2‑3 unless invasive cancer is suspected or confirmed, making cancer the sole indication for such intervention in pregnant patients. 5

Performing excisional procedures during pregnancy is linked to significant maternal bleeding and an increased risk of preterm birth. 6
Among pregnant women who undergo LEEP, approximately 47 % have residual CIN identified postpartum, indicating a high rate of persistent disease and limited diagnostic value. 6
Overall, the complications and high recurrence rates of excisional procedures outweigh any potential benefit, given the low likelihood of cancer progression during pregnancy. 5

Endocervical curettage is absolutely contraindicated in pregnant women and should never be performed. 7
If invasive cancer is not suspected based on cytology, colposcopic findings, or biopsy, all treatment should be deferred until after delivery. 5

After delivery, both excisional (LEEP, cold‑knife conization) and ablative (cryotherapy, laser) methods are acceptable, with overall treatment failure rates ranging from 5 % to 15 % and no significant difference between modalities. 5
Excisional techniques are preferred because they provide tissue for pathological assessment, allowing detection of occult invasive cancer. 8