cervical biopsy


cervical biopsy

A biopsy of the uterine cervix usually performed days to wks after a pap smear reveals changes–especially epithelial cell abnormalities, warranting further evaluation Complications Discomfort, bleeding; the tissue obtained is placed in formalin and submitted to a pathologist for interpretation. See Cervical intraepithelial neoplasia, Colposcospy, Pap smear.

Colposcopy

Synonym/acronym: Cervical biopsy, endometrial biopsy.

Common use

To visualize and assess the cervix and vagina related to suspected cancer or other disease.

Area of application

Vagina and cervix.

Contrast

None.

Description

In this procedure, the vagina and cervix are viewed using a colposcope, a special binocular microscope and light system that magnifies the mucosal surfaces. Colposcopy is usually performed after suspicious Papanicolaou (Pap) test results or when suspected lesions cannot be visualized fully by the naked eye. The procedure is useful for identifying areas of cellular dysplasia and diagnosing cervical cancer because it provides the best view of the suspicious lesion, ensuring that the most representative area of the lesion is obtained for cytological analysis to confirm malignant changes. Colposcopy is also valuable for assessing women with a history of exposure to diethylstilbestrol (DES) in utero. The goal is to identify precursor changes in cervical tissue before the changes advance from benign or atypical cells to cervical cancer. Photographs (cervicography) can also be taken of the cervix.

This procedure is contraindicated for

  • high alertPatients with bleeding disorders or receiving anticoagulant therapy, especially if cervical biopsy specimens are to be obtained because the biopsy site may not stop bleeding
  • high alertWomen who are currently menstruating as bleeding may obscure abnormal findings

Indications

  • Evaluate the cervix after abnormal Pap smear
  • Evaluate vaginal lesions
  • Localize the area from which cervical biopsy samples should be obtained because such areas may not be visible to the naked eye
  • Monitor conservatively treated cervical intraepithelial neoplasia
  • Monitor women whose mothers took DES during pregnancy

Potential diagnosis

Normal findings

  • Normal appearance of the vagina and cervix
  • No abnormal cells or tissues

Abnormal findings related to

  • Atrophic changes
  • Cervical erosion
  • Cervical intraepithelial neoplasia
  • Infection
  • Inflammation
  • Invasive carcinoma
  • Leukoplakia
  • Papilloma, including condyloma

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Inadequate cleansing of the cervix of secretions and medications.
    • Scarring of the cervix.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
    • Severe bleeding or the presence of feces, blood, or blood clots, which can interfere with visualization.

  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the uterus and cervix for disease.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, or sedatives.
  • Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, and there may be moments of discomfort. Inform the patient that the procedure is performed by a health-care provider (HCP), with support staff, and takes approximately 30 to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications.
  • Explain to the patient that if a biopsy is performed, she may feel menstrual-like cramping during the procedure and experience a minimal amount of bleeding.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Complications of the procedure may include bleeding, infection, and cardiac arrhythmias.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Obtain and record baseline vital signs.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
  • Administer medications, as ordered, to reduce discomfort and to promote relaxation and sedation.
  • Place the patient in the lithotomy position on the examining table and drape her. Cleanse the external genitalia with an antiseptic solution.
  • If a Pap smear is performed, the vaginal speculum is inserted, using water as a lubricant.
  • The cervix is swabbed with 3% acetic acid to remove mucus or any cream medication and to improve the contrast between tissue types. The scope is positioned at the speculum and is focused on the cervix. The area is examined carefully, using light and magnification. Photographs can be taken for future reference.
  • Tissues that appear abnormal or atypical undergo biopsy using a forceps inserted through the speculum. Bleeding, which is common after cervical biopsy, may be controlled by cautery, suturing, or application of silver nitrate or ferric subsulfate (Monsel’s solution) to the site.
  • The vagina is rinsed with sterile saline or water to remove the acetic acid and prevent burning after the procedure. If bleeding persists, a tampon may be inserted after removal of the speculum.
  • Biopsy samples are placed in appropriately labeled containers with special preservative solution, and promptly transported to the laboratory.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Monitor the patient for signs of respiratory depression.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Observe the patient until the effects of the sedation, if ordered, have worn off.
  • Instruct the patient to remove the vaginal tampon, if inserted, within 8 to 24 hr; after that time, the patient should wear pads if there is bleeding or drainage.
  • If a biopsy was performed, inform the patient that a discharge may persist for a few days to a few weeks.
  • Advise the patient to avoid strenuous exercise 8 to 24 hr after the procedure and to avoid douching and intercourse for about 2 wk or as directed by the HCP.
  • Monitor for any bleeding.
  • Instruct the patient to expect slight bleeding for 2 days after removal of biopsy specimens, but emphasize that persistent vaginal bleeding or abnormal vaginal discharge, an increasing amount of bleeding, abdominal pain, and fever must be reported to the HCP immediately.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include biopsy cervical, CT abdomen, culture viral, MRI abdomen, Pap smear, and US pelvis.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.