Cervical Cytology Results Among Pregnant and Non-Pregnant Women in Brazil

Published:January 23, 2023DOI:



      To compare the prevalence of abnormal cervical smear results among pregnant and non-pregnant women with and without representation of the transformation zone (TZ) in a mid-sized city in Brazil.
      Study design
      This observational analytical and retrospective study analyzed cervical smear results from pregnant and non-pregnant women in a mid-sized city in Brazil. Private data were collected at private clinics over seven years and from public services over 16 years. All results were reported according to Bethesda System. Pregnant women were separated from non-pregnant women, and women were stratified into two age groups (25–29 years and 30–34 years) in general analyses. For TZ representation and cytologic-histologic correlation, there was no age stratification.


      Among public services cervical smears, the frequency of atypical squamous cells of undetermined significance (ASC-US) was higher for pregnant women in the entire group (odds ratio [OR] 1.91; confidence interval [CI] 1.07-3.39) and among women from 30 to 40 years old (OR 2.79; CI 1.38–5.66). The same occurred for low-grade squamous intraepithelial lesion (LSIL) in the total group (OR 3.50; CI 1.44–8.53) and among women 30 to 40 years old (OR 4.57; CI 1.45–14.42).
      The frequency of ASC-US was higher in pregnant women with TZ representation exams than those without (OR 4.62; CI 2.17-9.84). The same occurred for those with atypical squamous cells, which cannot exclude high-grade squamous intraepithelial lesion (OR 9.81; CI 1.63–59.15) and LSIL (OR 10.47; CI 3.39–32.36).
      Among pregnant women with abnormal cervical smear results, 85.74% were followed up through cytology, and an average of 26.12% of patients underwent biopsy, of which almost all were positive for dysplasia.


      Pregnant and non-pregnant women did not differ in cervical smears with actual precursor lesions. Nevertheless, considering the opportunistic nature of Brazilian cervical cancer screening, prenatal visits present an opportunity to perform cervical smears in pregnant women. TZ representation correlated with higher rates of abnormal cervical smears, reinforcing the clinical importance of endocervical/metaplastic cell representation, including among pregnant women.


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      1. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FA, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS Jr, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER; American Cancer Society; American Society for Colposcopy and Cervical Pathology; American Society for Clinical Pathology. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol. 2012 Apr;137(4):516-42. 10.1309/AJCPTGD94EVRSJCG. PMID: 22431528.

        • Stonehocker J.
        Cervical cancer screening in pregnancy.
        Obstet Gynecol Clin North Am. 2013 Jun; 40 (PMID: 23732031): 269-282
        • Sung H.
        • Ferlay J.
        • Siegel R.L.
        • et al.
        Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.
        CA: A Cancer J Clin. 2021; 71: 209-249
        • Who
        Comprehensive Cervical Cancer Control: A Guide to Essential Practice.
        WHO, Geneva, Switzerland2014
      2. Lee JM, Lee KB, Kim YT, Ryu HS, Kim YT, Cho CH, Namkoong SE, Lee KH, Choi HS, Kim KT. Cervical cancer associated with pregnancy: results of a multicenter retrospective Korean study (KGOG-1006). Am J Obstet Gynecol. 2008 Jan;198(1):92.e1-6. 10.1016/j.ajog.2007.06.077. Epub 2007 Oct 1. PMID: 17905175.

      3. Instituto Nacional de Câncer José Alencar Gomes da Silva. Brazilian Cervical Cancer Screening Guidelines. – 2. ed. rev. atual. – Rio de Janeiro: INCA; 2016.

      4. Ribeiro L, Bastos RR, Vieira MT, Ribeiro LC, Teixeira MTB, Leite ICG. Opportunistic screening versus missed opportunities: non-adherence to Pap smear testing in women attending prenatal care. Cad Saude Publica. 2016;32(6):S0102-311X2016000605003.

      5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Atenção ao pré-natal de baixo risco / Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. – Brasília : Editora do Ministério da Saúde, 2012.

        • Nayar R.
        • Wilbur D.C.
        The Bethesda System for Reporting Cervical Cytology: Definitions, Criteria, and Explanatory Notes.
        3rd ed. Springer, Switzerland2015
        • Hunter M.I.
        • Monk B.J.
        • Tewari K.S.
        Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease.
        Am J Obstet Gynecol. 2008 Jul; 199 (PMID: 18585520): 3-9
      6. Xavier-Júnior JC, Dufloth RM, do Vale DB, Tavares TA, Zeferino LC. High-grade squamous intraepithelial lesions in pregnant and non-pregnant women. Eur J Obstet Gynecol Reprod Biol. 2014 Apr;175:103-6. 10.1016/j.ejogrb.2014.01.018. Epub 2014 Jan 20. PMID: 24522115.

        • Xavier-Júnior J.C.
        • Vale D.B.
        • Vieira L.F.
        • Lima M.T.
        • Zeferino L.C.
        • Dufloth R.M.
        Results of screening for cervical cancer among pregnant and non-pregnant women in Brazil.
        Int J Gynaecol Obstet. 2015 Jul; 130 (Epub 2015 Apr 1 PMID: 26044115): 36-39
        • Lertcharernrit J.
        • Sananpanichkul P.
        • Suknikhom W.
        • Bhamarapravatana K.
        • Suwannarurk K.
        • Leaungsomnapa Y.
        Prevalence and Risk Assessment of Cervical Cancer Screening by Papanicolaou Smear and Visual Inspection with Acetic Acid for Pregnant Women at a Thai Provincial Hospital.
        Asian Pac J Cancer Prev. 2016; 17 (PMID: 27644678): 4163-4167
        • Barut M.U.
        • Kale A.
        • Kuyumcuoğlu U.
        • Bozkurt M.
        • Ağaçayak E.
        • Özekinci S.
        • et al.
        Analysis of Sensitivity, Specificity, and Positive and Negative Predictive Values of Smear and Colposcopy in Diagnosis of Premalignant and Malignant Cervical Lesions.
        Med Sci Monit. 2015 Dec; 10 (PMID: 26655816; PMCID: PMC4678924): 3860-3867
      7. Nkwabong E, Laure Bessi Badjan I, Sando Z. Pap smear accuracy for the diagnosis of cervical precancerous lesions. Trop Doct. 2019 Jan;49(1):34-39. 10.1177/0049475518798532. Epub 2018 Sep 15. PMID: 30222058.

        • Cobucci R.
        • Maisonnette M.
        • Macêdo E.
        • Santos Filho F.C.
        • Rodovalho P.
        • Nóbrega M.M.
        • et al.
        Pap test accuracy and severity of squamous intraepithelial lesion.
        Indian J Cancer. 2016 Jan-Mar;53(1):74–6.; (PMID: 27146747)
        • Hong D.K.
        • Kim S.A.
        • Lim K.T.
        • Lee K.H.
        • Kim T.J.
        • So K.A.
        Clinical outcome of high-grade cervical intraepithelial neoplasia during pregnancy: A 10-year experience.
        Eur J Obstet Gynecol Reprod Biol. 2019 May; 236 (Epub 2019 Mar 25 PMID: 30933887): 173-176
      8. Terlan RJ, Cesar JA. Non-performance of Pap smears among pregnant women in the Extreme South of Brazil: prevalence and associated factors. Cien Saude Colet. 2018 Nov;23(11):3557-3566. Portuguese, English. 10.1590/1413-812320182311.35162016. PMID: 30427429.

        • Beharee N.
        • Shi Z.
        • Wu D.
        • Wang J.
        Diagnosis and treatment of cervical cancer in pregnant women.
        Cancer Med. 2019 Sep; 8 (Epub 2019 Aug 6. PMID: 31385452; PMCID: PMC6745864): 5425-5430
        • Coleman C.A.
        Evaluation and management of abnormal cervical cytology during pregnancy.
        Clin Obstet Gynecol. 2013 Mar; 56 (PMID: 23318571): 51-54
        • Zhang J.
        • Lu C.X.
        Spontaneous Regression of Cervical Intraepithelial Neoplasia 2: A Meta-analysis.
        Gynecol Obstet Invest. 2019; 84 (Epub 2019 May 3 PMID: 31055567): 562-567
      9. Holt J, Stiltner L, Jamieson B, Fashner J. Clinical inquiries. Should a nylon brush be used for Pap smears from pregnant women? J Fam Pract. 2005 May;54(5):463-4. PMID: 15865907

        • Orr Jr, J.W.
        • Barrett J.M.
        • Orr P.F.
        • Holloway R.W.
        • Holimon J.L.
        The efficacy and safety of the cytobrush during pregnancy.
        Gynecol Oncol. 1992 Mar; 44 (PMID: 1541438): 260-262
      10. Martin-Hirsch P, Jarvis G, Kitchener H, Lilford R. Collection devices for obtaining cervical cytology samples. Cochrane Database Syst Rev. 2000;(2):CD001036. 10.1002/14651858.CD001036. Update in: Cochrane Database Syst Rev. 2000;(3):CD001036. PMID: 10796736.

        • Suzuki S.
        • Hayata E.
        • Hoshi S.I.
        • Sekizawa A.
        • Sagara Y.
        • Tanaka M.
        • et al.
        Current status of cervical cytology during pregnancy in Japan.
        PLoS One. 2021 Jan 7; 16: e0245282
        • Sørbye S.W.
        • Suhrke P.
        • Revå B.W.
        • Berland J.
        • Maurseth R.J.
        • Al-Shibli K.
        Accuracy of cervical cytology: comparison of diagnoses of 100 Pap smears read by four pathologists at three hospitals in Norway.
        BMC Clin Pathol. 2017 Aug; 29: 18 PMID: 28860942; PMCID: PMC5576325
      11. Eversole GM, Moriarty AT, Schwartz MR, Clayton AC, Souers R, Fatheree LA, Chmara BA, Tench WD, Henry MR, Wilbur DC. Practices of participants in the college of american pathologists interlaboratory comparison program in cervicovaginal cytology, 2006. Arch Pathol Lab Med. 2010 Mar;134(3):331-5. 10.5858/134.3.331. PMID: 20196659

      12. Instituto Nacional de Câncer José Alencar Gomes da Silva. Manual of Quality Management for Cytopathology Laboratories. 2. ed. rev. ampl. INCA; 2016.

      13. Costa RF, Longatto-Filho A, Pinheiro C, Zeferino LC, Fregnani JH. Historical Analysis of the Brazilian Cervical Cancer Screening Program from 2006 to 2013: A Time for Reflection. PLoS One. 2015 Sep 24;10(9):e0138945. 10.1371/journal.pone.0138945. PMID: 26402737; PMCID: PMC4581862

      14. Bispo Pereira EH, Camilo-Júnior DJ, D'ávilla SCGP, Mattar NJ, Xavier-Júnior JCC. Comparison of cervical cancer screening results among public and private services in Brazil. Int J Gynaecol Obstet. 2022 Aug;158(2):289-294. 10.1002/ijgo.13985. Epub 2021 Nov 6. PMID: 34655231