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Pap Smear

1. CASE PRESENTATION
GENERAL DATA
•E.N.
•41 years old
•G5P5 (5-0-0-5)
•Married
•Filipino
•Roman Catholic
•Agusan Del Sur
•Consulted June 10, 2016
CHIEF COMPLAINT
Left Lower Quadrant Pain
HISTORY OF PRESENT ILLNESS

LMP: June 5-7, 2016


PMP: May 6-9, 2016
HISTORY OF PRESENT PREGNANCY
(+) intermittent occasional hypogastric pain, crampy, pain
score 3/10, non radiating, no precipitating or aggravating
2 Months PTC factors
(-) anorexia or weight loss
(-) abdominal enlargement or palpable abdominal mass
(-) vaginal bleeding or abnormal vaginal discharge
(-) changes in bowel or bladder habits
(-) no dysuria
Patient consulted a private MD, advised TVS but was unable
to comply and was lost to follow up
HISTORY OF PRESENT ILLNESS
6 Days PTC (+) recurrence of hypogastric pain, crampy,
5/10, radiating to the left lower quadrant.
Patient self-medicated with Paracetamol
500 mg tab which afforded temporary
relief. She prompted to have an ultrasound
done.
Ultrasound Findings June 6, 2016
Length Width AP Description Impression as of June
Cervix 3.0cm 3.1cm 3.2cm 6, 2016 (Day 2 of
Uterus 5.7cm 6.4cm 4.7cm The uterus in anteverted with Menses):
smooth contour and
homogenous echopattern • Normal size
Endometri 1.2cm The endometrium is anteverted uterus
um hyperechoic with intact
subendometrial halo • Thickened
Right Ovary 2.3cm 1.9cm 2.1cm endometrium
Left Ovary 12.6cm 11.8cm 12.9cm Left ovary is unilocular thin • Normal right ovary
walled cyst with low to medium
echoes, measuring 10.4 x 10.5 • Left ovarian new
x9.7 cm growth probably
Sassone score=5
Others There is no free fluid in the cul de sac
endometrial cyst
HISTORY OF PRESENT ILLNESS
4 days PTC – she consulted a private MD,
4 Days PTC advised surgery but opted to transfer to our
institution due to financial constraints.

Prompted consult at OPD


REVIEW OF SYSTEMS
GENERAL No fever, chills, weight loss, fatigue

HEENT No headache, blurring of vision, tinnitus

NECK No pain, stiffness, lump

RESPIRATORY No cough, hemoptysis, dyspnea

No chest pain, palpitations, edema, cyanosis, easy


CARDIOVASCULAR
fatiguability

GASTROINTESTINAL No change in bowel movement, melena


REVIEW OF SYSTEMS
No burning sensation, dysuria, hematuria, incontinence,
GENITOURINARY
urinary retention

PERIPHERAL
No leg cramps, varicose veins
VASCULAR

No muscle weakness, backache, muscle pain, limitation of


MUSCULOSKELETAL
motion, limping

NEUROLOGIC No paralysis, tremors, numbness, memory loss


PAST MEDICAL HISTORY
• Unrecalled childhood illnesses and vaccination
• No hypertension, diabetes mellitus, pulmonary
tuberculosis, bronchial asthma, and goiter
• No history of previous hospitalization or surgical
operation
• No known allergies to food or medication
FAMILY HISTORY
• (+) Hypertension, Maternal
• No diabetes mellitus
• No bronchial asthma
• (+) Pulmonary tuberculosis, Maternal
• No thyroid disease
• No cancer
PERSONAL & SOCIAL HISTORY
• College graduate
• Housewife
• Non smoker
• Non-alcoholic beverage drinker
• Denies use of illicit drugs
MENSTRUAL HISTORY
13 years old, lasted 3 days, used 2
MENARCHE
pads/day, no dysmenorrhea)

INTERVAL 29-34 days

DURATION 3-4 days

AMOUNT 2- 3 moderately-soaked pads per day

SYMPTOMS
None
ASSOCIATED
SEXUAL HISTORY
1ST SEXUAL
18 years old
CONTACT
# OF SEXUAL
2
PARTNERS
FORMS OF Natural (Withdrawal) and Barrier
CONTRACEPTION Method (Condom)

STD None

SYMPTOMS No dyspareunia
ASSOCIATED No post-coital bleeding
OBSTETRIC HISTORY
YEAR SEX OUTCOME MODE PLACE WEIGHT FMC

G1 1993 M FT NSD HOME Unrecalled (-)

G2 1995 M FT NSD HOME Unrecalled (-)

G3 1998 F FT NSD HOME Unrecalled (-)

G4 1999 F FT NSD HOME Unrecalled (-)

G5 2008 F FT NSD HOME Unrecalled (-)


GYNECOLOGIC HISTORY
• No screening for STD done
• No human papilloma virus vaccine
• No Pap smear done before consult
PHYSICAL EXAMINATION

Conscious, coherent, ambulatory, not in


GENERAL SURVEY
cardiorespiratory distress

BP: 110/70 mmHg


HR: 77 bpm
RR: 20 cpm
VITAL SIGNS Temperature: 36.1oC
Height: 150 cm
Weight: 45
BMI: 20.00 (Overweight)
PHYSICAL EXAMINATION
Anicteric sclerae, PERTL at 3mm, no
HEENT nasoaural discharge, no tonsillopharyngeal
congestion

No masses or lesions, no cervical


NECK
lymphadenopathy

Symmetric breasts, no masses or dimpling,


BREAST no redness, no lesions, nontender, no nipple
inversion or retraction
PHYSICAL EXAMINATION

CHEST AND Symmetric chest expansion, no retractions,


LUNGS clear breath sounds on both lung fields

Adynamic precordium, normal rate, regular


HEART
rhythm, no murmurs
PHYSICAL EXAMINATION

Soft, flabby, normoactive bowel sounds, no


tenderness, (+) Pelvoabdominal mass
ABDOMEN
measuring 10x10cm, more to the left,cystic
movable, non-tender
PHYSICAL EXAMINATION
Inspection Grossly normal external genitalia, parous introitus

Clean looking, parous cervix, no erosions, no bleeding or


Speculum exam
discharge per os, clean looking vaginal walls, no lesions

Vagina admits two fingers with ease, cervix firm, closed,


uterus not enlarged, (+) left adnexal mass measuring
Bimanual 10x10cm, cystic movable, nontender, no right adnexal
Examination mass or tenderness

Rectovaginal Good sphincteric tone, intact rectal vault, no nodulations


examination in the cul de sac
PHYSICAL EXAMINATION

Grossly normal, with full and


EXTREMITIES equal pulses, no edema, no
cyanosis
ASSESSMENT

41 years old
Gravida 5 Para 5 (5-0-0-5),
Ovarian cyst, left probably
Endometriotic cyst
Rule out endometrial
pathology
PLAN
• Endometrial sampling done
• For cardiopulmonary clearance
• May go home
• DAT, increase OFI
• Diagnostics for :
• Pap Smear – done
• Complete blood count with platelet count, Urinalysis, Blood
Typing with Rh, Serum Na, K, Cl, BUN, Crea, Chest Xray, 12-L
ECG
• Definitive plan: for Elective total abdominal hysterectomy, left
salpingoophorectomy, right salpingectomy
Laboratory findings: June 13
CBC Value CBC Value

Hemoglobin 110 (120-180) Segmenters 0.65 (0.50-0.70)

Hematocrit 0.33 (0.37-0.47 Stab Cells

WBC 8.9 (5.0-10.0) Lymphocytes 0.33 (0.20-0.40)

Platelet count 382 (150-450) Eosinophils 0.02 (0.01-0.03)

Blood type O+ Monocytes


Laboratory findings: June 13
UA Result UA Result

Color Straw Pus Cells 0-1/hpf (0-2/hpf)


Transparency Clear Red Cells 0-2/hpf (1-2/hpf)
Reaction 7.0 Epithelial few
Spec. Grav. 1.010 Eosinophils 0.02 (0.01-0.03)
Protein negative A. Urates/phosphates Few
Sugar negative Bacteria Few
Mucus threads Few
Laboratory Findings June 14, 2016
Blood Chemistry Values
BUN 3.5 (1.66-8.3)
Crea 91.00 (53-110)
ALT 16.0 (0-36)
AST 17.0 (0-32)
LDH 222.0 (103-227)
Na 143.4 (135-148)
K 3.53 (3.5-5.3)
Cl 104.40 (97-108
Pap Smear Results (June 10, 2016)
• Specimen Adequacy:
Satisfactory for evaluation of epithelial cell
abnormalities
• Interpretation/Result:
Negative intraepithelial cell lesion or maliganancy
• Hormonal Evaluation:
Parabasal: 0% Intermediate: 30% Superficial: 70%
THE CERVIX
• Narrow, lowest portion
of the uterus
• Connects the main body
of the uterus to the
vagina
• Normally 2-3 cm in diameter
• Consistency:
• Non-pregnant: firm
• Pregnant: soft
• On colposcopy:
• Smooth, glistening mucosal
surface
• Minimal discharge
• Small, round external os
(nulliparous women, women who
gave birth via CS)
• About 2 cm long
• Parts:
• Endocervix – upper 2/3
• Squamocolumnar junction
• Endocervical canal
• Ectocervix – lower 1/3
Squamocolumnar Junction

• Aka transformation zone


• Area where columnar cells from the
endocervix joins the squamous cells of
ectocervix
• Undergoes metaplasia, affected by:
• Age
• Parity
• Hormonal changes
• Where precancerous changes occur and
most cervical cancers start
Cervical Epithelium
• Basal Layer
• Single row of cells resting on a thin
basement membrane
• Active mitosis occurs in this layer
• Parabasal Layer
• Several layers of cuboidal cells
• Intermediate Layer
• Thickness related to progesterone
predominance
• Superficial Layer
• Most mature layer
• Varies in thickness, depending on
the degree of estrogen stimulation
BASAL PARABASAL INTERMEDIATE SUPERFICIAL
High N:C ratio; Moderate amount of Polygonal cytoplasm; Polygonal, transparent,
Little amount of cytoplasm Larger nuclei flat, and thin; Pyknotic
cytoplasm compared to round nucleus
superficial cells
Obtained when Predominant in the Related to Related to estrogen
uppermost layers are absence of hormones progesterone effect
absent predominance (luteal
phase)
Post-partum Atrophic states, Pregnancy (luteal Proliferative phase
menopause, post- phase), secretory
partum phase
Main cell type in
women of
reproductive age
What is pap smear?
• It is smear technique used as screening method for cervical neoplasm
using vaginal and cervical cytology.
• Usually used as a primary method of assessing the risk of gynecologic
pathology present in the patient.
• Cervical screening method used to detect potentially pre-cancerous
(called cervical intraepithelial neoplasia (CIN) or cervical dysplasia)
and cancerous processes in the transformation zone of the cervix
Reading Pap smear
• Pap smear analysis and reports are
all based on a medical terminology
system called The Bethesda System.
• Standardization reduces the
possibility that different laboratories
might report different results for the
same smear.
Normal Cytology
SUPERFICIAL CELLS
• large polygonal cells possessing a flat, delicate, transparent pink cytoplasm
and small, dark nuclei,
INTERMEDIATE-TYPE CELLS
• Same size as the superficial cells or somewhat smaller.
• Their cytoplasm is usually basophilic (cyanophilic) the nuclei of the intermediate
cells measure about 8 µm in average diameter, are spherical or oval, with a clearly
defined nuclear membrane surrounding a well-preserved homogeneous, faintly
granular nucleoplasm (vesicular nuclei)
PARABASAL CELLS
• These small cells are spherical in shape, have a basophilic cytoplasm and
spherical nuclei.
• The angulated appearance of these cells suggests origin from the
transformation zone. Such cells are usually classified as metaplastic
Normal Cytology
Reading Pap Smear
The major categories for abnormal Pap smears reported in the Bethesda Systems
are as follows
• ASC-US: This abbreviation stands for atypical squamous cells of undetermined
significance.
• LSIL: This abbreviation stands for low-grade squamous intraepithelial lesion. Under
the old system of classification, this category was called CIN grade I.
• HSIL: This abbreviation stands for high-grade squamous intraepithelial lesion. Under
the old system of classification, this category was called CIN grade II, CIN grade
III, or CIS.
• ASC-H: This means atypical cells are present and HSIL cannot be excluded.
Management Summary of the
Abnormal Pap Smear (ASCCP)
Management
ASC-US A. Repeat Pap Smear in 6 mos or
B. Immediate Colposcopy or
C. HPV-DNA test
ASC-H Colposcopy (+/- Biopsy and ECC)
LSIL Colposcopy +/- Biopsy and ECC
HSIL Colposcopy +/- Biopsy and ECC or
LEEP
Glandular Colposcopy +/- Biopsy and ECC +/- Endom
Lesions Biopsy
2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Cancer Screening Tests Thomas C. Wright, Jr MD, Stewart Masad MD,
Charles Dunton MD, Mark Spitzer MD, Edward Wilkinson MD, Diane Solomon MD for the 2006 ASCCP Consensus Conference American Journal of Obstetrics and
Gynecology October 2007 Vol 197(4): 346-355
Reading Pap Smear
Maturity Index
• Concise and objective method • Shift of MI to the left denotes
for gaining insight regarding the Less mature cells exfoliated
patient’s endocrine milieu • Ex: 100/0/0 parabasal
• Expresses the level of cellular • Shift to the right indicates more
maturation attained at the time of mature cells are exfoliated
exfoliation • Ex: 0/0/100 squamous / superficial
• Expressed as % of parabasal, • Note: For total hysterectomized px –
intermediate, and superficial cells still examine the vaginal wall –
(PIS) (some vaginal tissues are still
• Least mature cells seen on the left present)
Indications of Pap smear
As a screening tool, there are indications to know who should be
undergoing pap smear. Using age demarcation, Pap smear screening is
divided to maximize the efficiency of one’s result to the changes that
may occur in a yearly basis.
• Begins at age 21 (regardless when the sexual activity began
• 21-29 (at least every 3 years)
• 30-65 (every 3 years if 3 consecutive pap smears are negative)
• >65 (not recommended to have if with adequate negative results
prior)
Indications of Pap smear
• Co testing – HPV and Cervical cytology administered together extends
the screening interval to every 5 years for women aged 30 and above.
*preferred method by the ACOG as per the 2012 guidelines
Recommendation for Pap Smear
Factors that may affect the results
• False negative – 5-10%
• Due to poor collection, dry specimen, stacking of cells
• False positive:
• Herpes virus
• Severe cervical infection
• Trichomonas vaginalis
• Chemotherapy
Conventional Cytology
• Spatula and conical cervical brush

• Place the spatula firmly against the ectocervix with the long
projection extending into the endocervical canal
• Spatula is then rotated several times 360 degrees around the portion
and removed
Conventional Cytology
• Transfer is best performed by using the spatula to thinly spread
the cells onto the glass slide
• Endocervical canal is then sampled, using a conical cervical brush,
which is placed in endocervical brush, which is placed in the
endocervical canal so that the last few bristles remain visible and
then gently rotated 90-180 degrees once
Liquid based cytology
• The sample of (epithelial) cells is taken from the Transitional Zone; the squamo-
columnar junction of the cervix, between the ecto and endocervix.
• Liquid-based cytology uses an arrow-shaped brush, rather than the conventional
spatula. The cells taken are suspended in a bottle of preservative for transport to
the laboratory, where using Pap stains it is analysed.
Liquid-base Cytology
• A sample is obtained using a plastic spatula with either an
endocervical brush or a cervical broom in the manner of conventional
screening
• The sample is rinsed into a vial containing preservative solution
• The sample vial is capped, labelled and sent to the laboratory where
it is placed into a processor that gently mixes the sample to disperse
cells and break up any blood, mucus or non-diagnostic debris
• The sample is either centrifuged to produce a cell pellet or drawn
through a filter under negative pressure to collect cells
• It is fixed onto a glass slide and stained by the Papanicolaou staining
method for examination under a microscope.
Preparation
• Ideally, cervical screening should be scheduled when the patient is
not menstruating
• Proceed with screening even if the patient has bleeding or cervicitis
• Avoid vaginal intercourse, douching, use of tampons, use of vaginal
cream for 24-48 hours prior to cervical screening
Doing Pap smear (Conventional)

Positioning
• Privacy
• Buttocks just off table
• Good Lighting
• Drape
Padded Stirrups
• Soft, padded stirrups
• Oven mitts
• Socks
• Battle dressings
Inspection
• Spread labia
• Discharge
• Ulcers
• Growths
Vaginal Speculum
Warm Speculum
• Warm water
• Not too hot
• Lubricates speculum
• Don’t use K-Y, Surgilube
or Vaseline to lubricate
speculum
Insert Speculum
• Spread labia
• Keep labia apart
• Blades remain closed
until fully inserted
Squamo-Columnar Junction
• Junction of pink cervical skin
and red endocervical canal
• Inherently unstable
• Key portion of the cervix to
sample
• Most likely site of dysplasia
Sample Cervix
• Use concave end
• Rotate 360 degrees
• Don’t use too much force
(bleeding, pain)
• Don’t use too little force
(inadequate sample)
Cytobrush
• Insert ~ 2 cm (until brush
is fully inside canal)
• Rotate only 180 degrees
(otherwise will cause
bleeding)
Make Pap Smear
• As thin as possible
• Properly labeled
Spray with Fixative
• Within 10-15 seconds
• Allow to fully dry
before packaging
• Cytologic Fixative
(hairspray works
acceptably also)