I. Pregnancy combined with uterine fibroids 1. Incidence: pregnancy combined with uterine fibroids is more common, with an incidence of 0.3-2.6%. 2.The effect of pregnancy on uterine fibroids. (1) Change in the position of fibroids: as the uterus increases with pregnancy, the position of fibroids changes and can move up and down and left and right. (2) Myoma enlarges and becomes softer. Due to the effect of high E and P, fibroid cells become hypertrophic and edematous, fibroids grow faster and become softer. Sometimes it is difficult to identify the fibroids because of the obvious softening of the fibroids and the surrounding muscle layer. If the fibroid is not diagnosed before pregnancy, it is difficult to diagnose after pregnancy, especially in the posterior wall where it is possible to miss the diagnosis. (3) Myoma degenerative necrosis: due to increased hormone level, mechanical compression and poor blood circulation of enlarged myoma, it can cause myoma vitreous degeneration, mucous degeneration, fatty degeneration, red degeneration, the latter is more common. (4) Myoma twist: It can be seen in subplasmic myoma with the tip, which can be complicated by uterine torsion and local pressure pain or acute abdomen. 3, the impact of fibroids on pregnancy (1) miscarriage, premature birth: the rate of spontaneous abortion is 20-30%, 2-3 times higher than that of those without fibroids. Except for the compression by huge fibroids, the rate of preterm delivery is not significantly different from that of general pregnancy. (2) Abnormal fetal position, fetal deformation and IUGR: Due to mechanical obstruction by myoma, fetal movement is restricted, which may cause abnormal fetal position, and fetal deformation and IUGR may also occur as a result. (3) Abnormal placenta: Myoma may cause the adjacent part of the meconium to develop poorly, which may affect the implantation of the pregnant egg or cause early abruption of the placenta and adhesion of the placenta during delivery, so that it cannot be expelled by itself. (4) Prolonged labor: myoma can cause abnormal contraction of the uterus, primary or secondary contraction weakness, resulting in prolonged labor. (5) Postpartum hemorrhage: myoma hinders uterine contraction, resulting in postpartum hemorrhage, especially in submucosal fibroids. (6) Uterine torsion: When there is a fibroid on one side of the uterine body, with the softening of the cervix in pregnancy, there is a possibility of uterine torsion and sudden and severe abdominal pain, resulting in shock. (7) puerperal infection: poor uterine regeneration, poor drainage of malignant fluid or prolapsed submucosal fibroids, etc. are likely to induce puerperal infection. 4. Diagnosis: (1) History of uterine fibroids or infertility and menstrual changes before pregnancy. (2) Early pregnancy reaction with menopause and positive HCG. (3) Gynecologic examination reveals a larger uterus than in the same pregnancy, with an enlarged uterus that is hard and uneven, or with nodular protrusions. (4) With the gradual increase of the gestational months, the uterus rises to the abdominal cavity and nodal protrusions are obvious. (5) There are obvious pressure symptoms, such as frequent urination, urgent urination and constipation. (6) Ultrasonography 5. Differential diagnosis (1) Double uterine pregnancy, stump uterine pregnancy (2) Ovarian tumor (3) Adnexal inflammatory mass 6. Treatment (1) Treatment of uterine fibroids before pregnancy: whether fibroids affect conception depends on the site, size and number of fibroid growth. The infertility rate of myoma patients is 22-32%, with the highest rate of infertility in submucosal myoma. In patients under 40 years of age with a history of multiple spontaneous abortions or long-term infertility, myomectomy or hysteroscopic surgery for submucosal fibroids is feasible and is expected to improve reproductive function and prevent complications of fibroids after pregnancy. The literature reports that the pregnancy rate after myoma debulking is 56.3%, including 77.6% for full-term pregnancy and 75.9% for pregnancy within 3 years after surgery. (2) Choice of delivery method: a. Vaginal delivery: If the tumor is smaller than 6 cm and located in the abdominal cavity without obstructing the birth canal, trial of delivery is possible. b. Cesarean section: if the tumor is located in the pelvic cavity and obstructs the birth canal, elective cesarean section will be performed. Regardless of vaginal delivery or cesarean delivery, pregnancy combined with fibroids can cause the uterine muscles not to contract due to the presence or location of fibroids, resulting in uterine contraction weakness bleeding and placental adhesions. If postpartum bleeding cannot be controlled, hysterectomy is required. (3) Myomectomy in pregnancy. Myomectomy in pregnancy can be considered in the following cases: a. Myoma is growing rapidly and its presence has become an obstacle to continue pregnancy. b. Myoma is the cause of multiple previous miscarriages. c. Myoma tip torsion, myoma entrapment or uterine torsion resulting in acute abdominal pain. d. Surgery should be considered if the fibroid is red and conservative treatment is not effective. However, surgery may lead to miscarriage, preterm delivery and hysterectomy, so it should be fully considered and analyzed first, and the doctor-patient communication must be detailed and in-depth to fully understand the medical risks. (4) Cesarean section with myoma removal: Due to the increase in the rate of cesarean section in recent years, the number of myoma found intraoperatively is increasing, the uterine wall is rich in blood flow during pregnancy, the myoma is found to be bleeding actively intraoperatively, even difficult to control, and there is a possibility of increased postpartum bleeding or infection. After delivery of the fetus, the uterus contracts and deforms. The position of the fibroid changes, and the boundary between the fibroid and the surrounding area is unclear, which increases the difficulty of surgery. During surgery, it is advisable to use electric knife. When suturing the uterine muscles, the sutures are too tight and easy to cut the muscles, and the sutures are too loose and not easy to stop bleeding, so the knotting should be moderately tight. If the fibroid is single, 90% of patients do not recur after surgery, and more than half of multiple fibroids do not recur after surgery. Therefore, it is very valuable to remove the fibroids intraoperatively. In Beijing Union Medical College Hospital, myomectomy only increases bleeding by 100-200 ml. In our department, myomectomy is performed at the same time of cesarean section for fibroids over 1 cm, and bleeding is not much. (5) Red degeneration of uterine fibroids combined with pregnancy or puerperium, manifested as acute severe abdominal pain, fever, enlarged fibroids with pressure pain, accompanied by elevated blood cells, etc. After diagnosis, conservative treatment should be given: bed rest, fluid support, sedation and pain relief, cold compress for lower abdomen, contraction suppression and infection prevention. Pregnancy combined with ovarian tumor 1. Incidence: 1:450 reported in Shanghai, 1:300-1:8000 reported in various countries, malignant tumor 2-5%, while malignant in unpregnant women 15-20%. When pregnancy and ovarian tumor coexist, malignancy is very rare. 2. The mutual influence of pregnancy and ovarian tumor; When pregnancy and ovarian tumor coexist, usually the ovarian tumor is present first, and the conception rate of ovarian tumor patients is low clinically, about 40%. Once the tumor is exfoliated or removed, conception is often possible within a short period of time. The tumor itself has no direct effect on the growth and development of the fetus after conception, unless the tumor is so large that it occupies most of the pelvic cavity, thus hindering and limiting the enlargement of the uterus, which may lead to late miscarriage or preterm delivery. If the ovarian tumor is embedded in the pelvic cavity, it may obstruct the descent of the fetal dewlap during delivery and obstructive obstructed labor may occur. The pelvic circulation is rich in pregnancy, but so far, no evidence has been found that pregnancy accelerates the growth and spread of tumors. The incidence of ovarian tumor torsion in unpregnant women is about 2%, and up to 11-16% during pregnancy, because the enlarged uterus changes the position of ovarian tumor and induces torsion. Postpartum uterine contraction increases the range of movement of the tumor in the abdominal cavity, which is also prone to torsion. Occasionally, there are cases of rupture and bleeding due to compression of ovarian tumor by the pregnant uterus. 3. Diagnosis (1) Routine examination in early pregnancy: it may be found in 3 months of pregnancy, but it is difficult to find ovarian tumor with diameter around 8cm through pelvic or abdominal examination in more than 4 months of pregnancy. (2)Ultrasound examination of pelvis. (3) Tumor marker examination: CA125, CEA, AFP, LDH 4. Differential diagnosis: the appearance of masses next to the uterus during pregnancy is not always ovarian tumor. (1)Ovarian corpus luteum cyst: the maximum diameter can be up to 6cm, usually gradually shrinks to disappear in the third trimester of pregnancy. (2) Simple cysts of the ovary, which are single-compartment thin-walled cysts, smooth, mobile, with the walls being compounded with flattened epithelial or fibrous tissue. The origin of the tissue cannot usually be determined and may come from follicular cysts. (3) Multiple xanthin cysts: caused by high HCG stimulation, gradually disappearing and receding in mid pregnancy. (4) Gestational xanthogranuloma: a xanthinized solid tumor formed by ovarian tissue overreacting to HCG and sex hormones, sometimes bilaterally, and can cause masculinization manifestations in pregnant women. However, it is not an ovarian tumor and does not require treatment. It resolves on its own at the end of pregnancy, but can recur in the next pregnancy. (5) Uterine malformation: double uterus or stump-angle uterus (6) Subplasma myoma (7) Posterior flexed uterus: early pregnancy, enlarged uterus, softening of the isthmus, if the examination is not careful there is a risk of mistaking the cervix for the uterus and the uterine body for ovarian tumor. 5. Treatment: When ovarian masses are found during pregnancy, the treatment depends on the early or late stage of pregnancy, the size and nature of the masses and whether the patient has symptoms. Physiologic cysts are observed and followed up, and usually disappear naturally after mid-pregnancy. If the cyst continues until mid-pregnancy and neither increases nor decreases in size, it should be treated in the third month after delivery or during cesarean delivery. If the cyst is larger than 6 cm and malignancy is highly suspected, the cesarean section should be performed immediately without considering the month of pregnancy, and if the pregnancy can continue after surgery, progesterone and other contraction inhibitors should be applied. In cases of tumor torsion and acute abdominal pain, immediate surgery is also indicated. In most cases, ovarian tumor debulking is performed to preserve the normal ovarian tissue. If the ovarian tumor is found to be malignant, the principles of surgical treatment are the same as those for non-pregnant patients. The abdominal fluid is taken to find cancer cells, and the ovary is removed for rapid frozen section to determine the nature, tissue type and cellular classification of the tumor, and the stage of ovarian cancer is determined by abdominal exploration. The prognosis of ovarian malignant tumors in pregnancy is better than that of non-pregnant patients. a: most of the tumors occur in young women with low birth rate or no history of pregnancy; b: most of the tumors are early stage; c: the cells are well differentiated and most of them are low grade malignant; d: the prognosis is better than that of non-pregnant patients. The pregnancy should be continued until the end of pregnancy without chemotherapy. In late pregnancy with unilateral malignant germ cell tumor, even if the lesion is beyond the ovary, but the contralateral ovary is not affected, only unilateral adnexal resection and tumor cell reduction can be performed, and postoperative chemotherapy with PVB or BEP regimen can be given. Chemotherapeutic drugs can cause fetal malformations, IUGR and induce the risk of carcinogenesis in the offspring. However, the teratogenic effect is related to the gestational week, and the greatest effect is usually seen during the fetal organogenesis period from 5 to 8 weeks of gestation. Chemotherapeutic drugs can enter breast milk, so if the mother needs to continue chemotherapy after delivery, breast-feeding is prohibited. Cervical cancer combined with pregnancy refers to cervical cancer found during pregnancy or within six months after delivery, with an incidence rate of 0.08 per 1,000. However, some scholars advocate that cervical cancer found within one year or two years after delivery belongs to the category of this disease. Since it involves the prognosis of both the mother and the fetus, it is a tricky problem for clinicians to grasp how to ensure the safe arrival of the newborn without affecting the treatment effect of the patient, therefore, the combined pregnancy of cervical cancer is very difficult to handle compared with non-pregnancy cervical cancer. Screening for abnormal cervical lesions during pregnancy and maternal health care awareness should be enhanced to obtain the earliest disease diagnosis and the best treatment outcome. The main clinical manifestations of cervical cancer combined with pregnancy are vaginal bleeding, leukorrhea in large amount or mixed with blood or with fishy odor. Cervical intrauterine neoplasia (CIN) is usually asymptomatic. Vaginal bleeding during pregnancy is often attributed to pregnancy complications (e.g., miscarriage), and abnormal leukorrhea is simply considered as vaginitis and delays the diagnosis of this disease. Therefore, all pregnant women should undergo a careful pelvic examination and cervical smear at the first pregnancy check-up, or colposcopy or colposcopic biopsy if liquid-based cytology shows positive malignant cells. The diagnostic agreement between colposcopy and colposcopic biopsy is 95%, and the latter is 95% with the final pathologic diagnosis. When there is sufficient cytologic evidence of invasive cervical cancer in pregnancy and colposcopy is inadequate, diagnostic conization can be considered, but in the first trimester, the incidence of miscarriage due to cervical conization is 33% , while conization under colposcopy can reduce its risk. Management 1. Management of carcinoma in situ Many publications prove that it is safe to postpone definitive treatment until fetal lung maturity in patients with stage IA cervical cancer. If the interstitial infiltration is less than 3 mm and there is no lymphovascular infiltration, cathartic hysterectomy is performed at 6 weeks postpartum; if the interstitial infiltration is 3-5 mm with lymphovascular infiltration, the patient can also be followed up until full term, and the delivery method is cesarean section with radical hysterectomy. 2.Management of early invasive carcinoma When the interstitial infiltration is >5mm, it should be regarded as true invasive cervical cancer. The treatment method depends on the gestational age and the patient’s wish. With the continuous improvement of medical technology level, modern neonatal medical and care technology can provide 75% survival rate for newborns delivered at 28 weeks of gestation and up to 90% for those delivered at 32 weeks of gestation. Fetal lung maturity can be detected by amniocentesis and should be treated immediately when the fetal lung is mature. 27 cases of invasive cervical cancer were diagnosed or treated during pregnancy in a retrospective analysis by Duggan et al. Most patients had stage I lesions and the predominant histologic type was squamous carcinoma, followed by squamous adenocarcinoma and adenocarcinoma. 8 patients with stage IA or IB delayed treatment until optimal fetal outcome with a mean diagnosis-to-treatment interval of 144 days (53-212 days) and 19 who opted for immediate treatment had a mean diagnosis-to-treatment interval of 17 days (2- 42 days), yielding a consistent fetal outcome. Nine cases of intrauterine fetal death and two neonatal deaths were observed in the immediate treatment group. eight patients with deferred treatment survived disease-free at a mean follow-up of 23 months. The authors concluded that stage I cervical cancer combined with pregnancy and cautious deferral of treatment to obtain fetal maturation is a reasonable option. Sivanesaratnam et al. suggested that stage IB and IIA patients should be treated surgically because the pregnant women are young patients and surgical treatment can preserve ovarian function and avoid vaginal stenosis and difficulty in sexual intercourse caused by radiotherapy. For stage IB lesions >2 cm and stage IIA lesions significantly infiltrating the vaginal vault, surgical treatment after low-dose radiotherapy is chosen, with preoperative half-volume irradiation given, feasible intracavitary radium therapy twice with intrauterine dose of 1500 mgh and vault volume of 2000 mgh; or rear-mounted radiotherapy 2-3 times with point A dose of 35 Gy; external irradiation can be used for huge tumors with doses of 30 -35Gy. Radical hysterectomy + pelvic lymph node dissection will be performed 2-4 weeks after the end of radiotherapy. 3.Treatment of advanced invasive carcinoma Stage IIB-IV patients, if diagnosed in the first 3 months of pregnancy, should be firstly treated with external irradiation in anticipation of spontaneous abortion before the irradiation dose reaches 40Gy, and then perform intracavitary irradiation after uterine regeneration, and perform hysterectomy if not aborted. In the middle or end of pregnancy, in principle, regardless of the viability of the fetus, classical cesarean section should be performed to terminate the pregnancy, and external irradiation should be performed within 10 days after delivery, followed by intracavitary radiotherapy after complete uterine regeneration, and if necessary, irradiation of the abdominal aortic area and tissue interposition therapy. Tenari et al. reported two cases of locally advanced cervical cancer combined with mid-stage pregnancy who strongly requested to continue the pregnancy with neoadjuvant chemotherapy until fetal maturity. One case recurred 5 months after surgery, and the other case has survived disease free for 2 years. Prognosis In conclusion, the available data suggest that the management of pregnancy in combination with cervical cancer should be considered in the light of its clinical stage, the time of diagnosis of the disease and the patient’s wishes. CIN lesions, including carcinoma in situ, can be observed until full term at any stage of pregnancy, and more conservative treatment (freezing, laser or cervical electrocyclopexy) or hysterectomy can be given after delivery; stage IA cases can also be followed up until full term, and the mode of delivery and management of cervical cancer should depend on the depth of interstitial infiltration and the presence or absence of lymphovascular infiltration. For early stage invasive cervical cancer before IIA, cautiously postponing treatment to obtain fetal maturity is a reasonable choice. Treatment is mainly surgical, and in stage IIA cases with large lesions and obvious stage IB infiltration, neoadjuvant chemotherapy or low-dose intravaginal irradiation and external pelvic irradiation can be given before radical hysterectomy; in advanced cases, in principle, regardless of gestational age and fetal maturity, pregnancy should be terminated immediately after diagnosis. In advanced cases, in principle, regardless of gestational age and fetal maturity, pregnancy should be terminated immediately after diagnosis and radiotherapy should be given. Most scholars advocate that cesarean section is preferable for cervical cancer combined with pregnancy, but the survival rate has not shown its superiority compared with vaginal delivery. IV. Pregnancy combined with cervical epithelial sarcomatoid lesions 1. Effect of pregnancy on cervical lesions The effect of pregnancy and delivery on atypical cervical lesions is not well understood. Previous studies have shown that the physiological changes of pregnancy lead to activation of cervical human papillomavirus (HPV). However, the results of a recent cohort study by Nobbenhuis et al. showed similar rates of high-risk HPV positivity in pregnant and non-pregnant women and higher rates of postpartum HPV clearance in pregnant women compared to non-pregnant women. The lower rate of postpartum HPV positivity may be associated with a decrease in the number of sexual partners during pregnancy and fewer cases of new HPV infections in pregnant women compared to non-pregnant women. In addition, tissue repair of cervical trauma due to childbirth enhances the local immune response after delivery, which also contributes to the lower rate of postpartum HPV positivity. Recent studies have shown that 65% to 74.1% of cervical intraepithelial neoplasia (CIN) II and 20% to 70% of CIN III patients had spontaneous remission of lesions after delivery. 2002, Minako et al. reported that eight patients with cervical squamous carcinoma diagnosed at stage IAI during pregnancy regressed to CIN I to CIN III after delivery. four pregnant women with cervical cancer at stage IA2 to IB2 had stable lesions after delivery. Only a minority (7%) of pregnant women with CNI II progressed to CIN III after delivery, and 6.6% of pregnant women with atypical cervical lesions progressed to carcinoma in situ after delivery. Anil et al. reported that three patients with CIN Ⅲ biopsied during pregnancy showed two cases of IB1 cervical cancer and one case of IA1 cervical cancer after postpartum conization. 2. Diagnosis of cervical lesions in pregnancy As in non-pregnancy, cervical cytology and colposcopy and biopsy are the most important diagnostic methods. The Centers for Disease Control and Prevention (CDC) in the United States proposed on 2 occasions in 1998 and 2002 that pregnant women who have not undergone cervical cytology within 1 year should have a cervical cancer smear at their first prenatal visit. The incidence of cervical cytologic abnormalities in pregnant women ranges from 0.93% to 5%, similar to that of nonpregnant women. Further colposcopy and, if necessary, colposcopically guided biopsy should be performed in these pregnant women. This test does not significantly increase the incidence of vaginal bleeding, miscarriage, or preterm delivery during pregnancy. Therefore, it is a safe, reliable, and reproducible diagnostic method for cervical lesions in pregnancy, and colposcopy-guided biopsy can be performed at any gestational week, although scratch biopsy of the cervical canal is prohibited. 3. principles of management of cervical lesions in pregnancy Since most cervical precancerous lesions do not progress significantly during pregnancy, most scholars at home and abroad now believe that these diseases can be managed conservatively. after the diagnosis of CIN Ⅰ and CIN Ⅱ is confirmed by biopsy histology, pregnant women who can be followed up by cytological examination and colposcopy system during pregnancy and postpartum do not need repeated tissue biopsy. Repeat biopsies will be performed every 10 weeks during pregnancy or at 28 weeks and postpartum. In pregnant women with CIN III and cervical carcinoma in situ, treatment should be individualized and chosen according to the length of gestation and the location and extent of the lesion; Melsheimer et al. suggested that cervical conization during pregnancy should be used only in mid-gestation, when the lesion is extensive and deep, and located in the cervical canal; in all other cases, it should be observed conservatively, with regular follow-up colposcopy and biopsy if necessary. In Carlo’s opinion, in pregnant women less than 16 weeks of gestation with biopsy-confirmed CIN, electrosurgical conization is feasible to completely exclude invasive cancer; in women more than 16 weeks of gestation, conservative treatment is advisable because of the tendency to bleeding. Colposcopic monitoring is performed every 8 weeks during pregnancy and 2 months after delivery, and biopsy is performed if necessary. For those with persistent lesions, conization is performed after delivery. 4. Mode of delivery The stable status of cervical precancer and carcinoma in situ is not related to the mode of delivery, and the choice of delivery mode depends on obstetric indications. In 1999, a study conducted by Nicole et al. showed that there was no statistical difference between the vaginal delivery group, the cesarean delivery group during labor and the elective cesarean delivery group for the remission rate of lesions before and after delivery. 1998, a study conducted by Ahdoot et al. showed that the rate of cellular remission after delivery was zero in cesarean delivery patients, but there were some literature shows that vaginal delivery favors lesion remission. The effect of vaginal delivery on the prognosis of cervical lesions is unknown since most women with cervical invasive cancer pregnancies undergo hysterectomy or cesarean section to end the delivery. 2000, Anil et al. analyzed the prognosis of 56 patients with prenatal diagnosis of cervical invasive cancer and 27 patients with cervical cancer diagnosed within 6 months after delivery and showed that cervical cancer diagnosed after delivery had a worse prognosis and a higher recurrence rate and that vaginal delivery was an important influencing factor that can increase the possibility of cancer cell spread. Therefore, cesarean delivery should be chosen for pregnant women with cervical cancer in pregnancy. In conclusion, the tendency of postpartum deterioration of cervical lesions in pregnancy is rare. During pregnancy, conservative observation, regular cytologic examination and colposcopic review, colposcopic biopsy if necessary, and review 2 months after delivery should be performed and treated according to the principles of gynecological treatment of cervical lesions according to pathologic findings. The choice of the mode of termination of pregnancy has yet to be determined in further studies with large samples. In the future, cancer screening should be conducted in pregnant women who have not undergone cervical smear within 1 year and included in the routine prenatal screening to increase the detection rate of cervical lesions in pregnancy. At the same time, standardized cancer screening should be conducted in non-pregnant women to reduce the incidence of pregnancy-associated cervical lesions.