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https://doi.org/10.22502/jlmc.v10i2.489 Original Research Article

Prevalence of Abnormal PAP Smear in Pregnancy: A
Hospital-Based Study in Western Nepal

Aruna Pokharela,d, Arati Shresthaa,d, Deepak Shresthab,d, Shreyashi Aryalb,d,
Archana Tiwaric,d

Abstract:
Introduction: Cervical carcinoma is the third most common malignancy worldwide. The World
Health Organization in 2014 reported the crude incidence rate of cervical cancer in Nepal as 24.2
per 100,000 women per year. This study was carried out with the aim of finding out the
prevalence of cervical smear abnormality in pregnancy. Methods: An observational study was
conducted in the department of Obstetrics and Gynecology of a tertiary center for a period of one
year from May 2021 to April 2022. All pregnant women up to 28 weeks of gestation who had
National Health Insurance coming for antenatal check-up underwent PAP smear test. The
cytological results were reported based on the Bethesda classification system 2001. Results: Of
200 pregnant women enrolled in the study, the Pap smear report revealed that 32% of the study
subjects had inflammatory smear showing candidiasis and bacterial vaginosis with reactive
inflammatory changes. However, 66.5% of the subjects showed negative for intraepithelial lesion
or malignancy and only 0.5% of subjects had signs related to carcinoma cervix in which the
subject had a low-grade squamous intraepithelial lesion. No satisfactory sample was reported in
1% of the subjects. Conclusion: Pap smear during pregnancy not only gives the opportunity to
screen but also helps to create awareness.

Keywords: Carcinoma cervix, Pap smear, Pregnancy.

Submitted: 24 June, 2022
Accepted:29  November, 2022
Published: 20 January, 2023

a- Lecturer, Department of Obstetrics and
Gynaecology.
b- Associate Professor, Department of Obstetrics
and Gynaecology.
c- Associate Professor, Department of Pathology.
d- Lumbini Medical College and Teaching
Hospital, Palpa, Nepal.

Corresponding author:
Aruna Pokharel
Department of Obstetrics and Gynaecology,
Lumbini Medical College, Palpa, Nepal
e-mail: aruna.pokharel549@gmail.com
ORCID: https://orcid.org/0000-0002-7592-5222

INTRODUCTION:
Cervical carcinoma is the third most common
gynecological malignancy.[1] There has also
been an increased frequency of Cervical
Intraepithelial Neoplasia (CIN) in
pregnancy.[2] Early detection and treatment
of precancerous lesions can decrease the
incidence and risk of cervical carcinoma. In
addition to the prevalence of risk factors like
low socio-economy, high parity, early

How to cite this article: Pokharel A, Shrestha A,
Shrestha D, Aryal S, Tiwari A. Prevalence of
Abnormal PAP Smear in Pregnancy: A
Hospital-Based Study in Western Nepal. J
Lumbini Med Coll. 2022;10(2): 8 pages.
DOI: https://doi.org/10.22502/jlmc.v10i2.
Epub: 20 January, 2023

J. Lumbini Med. Coll. Vol 10, No 2, Jul-Dec 2022

https://doi.org/10.22502/jlmc.v10i2.489
mailto:aruna.pokharel549@gmail.com
https://orcid.org/0000-0002-7592-5222
https://doi.org/10.22502/jlmc.v10i2


Pokharel A, et al. Prevalence of Abnormal PAP Smear in Pregnancy

marriage in low and middle-income countries
(LMICs), lack of awareness about cervical
cancer and poor screening also contribute to
the high incidence and mortality due to
cervical cancer.[3] According to a report by
WHO in 2014, the crude incidence rate of
cervical cancer in Nepal was 24.2 per 100,000
women per year.[4]

The American College of Obstetrics and
Gynecologists (ACOG) recommends cervical
cancer screening be done every three years
from the age of 21 years till 65 years.[3]
Given the large number of follow up and even
the first hospital visits during pregnancy, most
pregnant women can be evaluated, identified
and treated early in case of abnormal
Papanicolaou (PAP) results. The accuracy of
PAP smear in pregnancy is almost similar to
that of non-pregnant state.[2] In addition to
carcinoma, inflammatory conditions during
pregnancy can also be identified and treated
accordingly for the ongoing pregnancy to be
uneventful.[3] While in high-income
countries, PAP testing has become a routine in
pregnant women, in LMICs like ours,
screening is still not that common due to lack
of awareness, fear, misconception and even
shyness. To this researcher’s best knowledge,
there has been no published study done in
pregnant Nepalese women till date. Hence,
this study was undertaken to determine the
prevalence of abnormal cervical smear and
genital infections among antenatal women.

METHODS:
This was a hospital-based observational study
conducted in the out-patient department
(OPD) of Obstetrics and Gynecology in
Lumbini Medical College and Teaching
Hospital (LMCTH) over a period of one year
from May 2021 to April 2022. The study was
started after obtaining the approval from the
Institutional Review Committee (IRC-LMC
03-B/021).
All the pregnant women presenting to
Gynecology OPD till 28 completed weeks of

gestation having National Health Insurance
were enrolled into the study. Those with
history of per vaginal bleeding or actively
bleeding, known case of CIN or cervical
carcinoma and women who had a normal PAP
smear report within one year were excluded
from the study.

Sample size: The sample size was calculated
using the following formula:
N = Z2 p (1-p)/e2
Where, N = minimum sample size,
p = proportion of cervical smear abnormality,
taken as 90% from the study of Himabindu P
et al.[5]
Z = 1.96 at 95% confidence interval level.
e=margin of error=5%
The minimum sample size calculated was
139.

A total of 200 antenatal women were included
in the study. All women coming for antenatal
check-up up to 28 weeks were explained
about the study and informed consent taken.
Data was collected using a preformed
proforma which included information on the
participants’ demographic characteristics,
obstetric history, and past history of cervical
cytology screening, if any. Before the test all
the participants were asked if they were aware
about PAP test.

During examination, the participants were
placed in dorsal position. After exposing the
cervix using Cusco’s self-retaining speculum,
per speculum findings were noted. The
ectocervix was sampled using an Ayre’s
spatula and smeared on a glass slide. It was
immediately fixed with 95% ethyl alcohol,
and sent to lab. It was evaluated and reported
by the department of Pathology according to
modified Bethesda Classification, 2001 as
Negative for Intraepithelial Lesion or
Malignancy (NILM), inflammatory, Atypical
Squamous Cells of Undetermined
Significance (ASCUS), Low grade Squamous
Intraepithelial Lesion (LSIL), High grade

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Pokharel A, et al. Prevalence of Abnormal PAP Smear in Pregnancy

Squamous Intraepithelial Lesion (HSIL),
ASC-H (Atypical Squamous Cells- cannot
rule out High Grade Lesion) and Atypical
Glandular Cell (AGC).[6]

Majority of the reports were collected by the
participants themselves or their family
members. Some defaulter cases’ reports were
collected by the researcher from the
department of Pathology.

A healthy cervix was defined on the basis of
naked eye observation of cervix on speculum
examination. The cervix that looked pink,
round, smooth with a central external os was
said to be healthy.

The Microsoft Excel program 2016 version
was used for data entry and management.
Statistical Package for Social Sciences (SPSS)
18.0 software (SPSS Inc., Chicago, IL, USA)
was used for statistical analysis. Descriptive
statistics was used for demographic data and
expressed in frequency and percentage.

RESULTS:
The most common finding in per speculum
examination was a healthy cervix observed in
155 (77.5 %) of the study participants and two
(1%) had growth in cervix (Fig. 1).

Fig. 1: Distribution of study participants based on the per speculum examination (N=200)

The PAP smear report revealed that 64 (32%)
participants had inflammatory smear showing
candidiasis and bacterial vaginosis with
reactive inflammatory changes. One (0.5%)
participant had LSIL. No satisfactory sample

was obtained in two (1%) of the participants
(Table 1).

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Pokharel A, et al. Prevalence of Abnormal PAP Smear in Pregnancy

Table 1: Distribution of the study participants
based on the PAP smear report (N=198)*

Pap smear report Frequency (%)

NILM 133 (66.5)

Inflammatory smear 64 (32)

LSIL 1 (0.5)
*no satisfactory result was obtained in two
samples.

In the age wise distribution of the study
participants, it was seen that the majority of
study participants, 69 (34.5%) were in the age
group between 21 and 25 years with the
minimum age of 17 years and maximum, of
40 years. The mean age was 25.3±5.2 years.
In the parity wise distribution, it was seen that
the majority of study participants, 139
(69.5%) were multigravida.

Majority of the study participants (n=68,
34%) at the time of presentation were
between 21 and 25 weeks of gestation with
the mean gestational age of 19.4±6.7 weeks.
The minimum period of gestation at
presentation was five weeks (Table 2).

Table 2: Distribution of the study participants
based on their gestational age (N=200)

Gestational age (in
weeks)

Frequency (%)

5-10 29 (14.5)

11-15 35 (17.5)

16-20 26 (13)

21-25 68 (34)

26-28 42 (21)

In this study, it was observed that the majority
of the study participants (n=156, 78%) were
not aware about PAP smear and only 44
(22%) knew about the procedure.

It was observed that the lower the age of
marriage, the higher the chance of
inflammatory change of cervix. Thirty
(49.2%) participants had inflammatory smear
who were married before 20 years. It was
noticed that the incidence was gradually
decreasing with women married later (Table
3).

Table 3: Distribution of the study participants based on their age at marriage and the PAP smear
report (N=198)

PAP smear
report

Age at marriage (years)

≤20 (n=61) 21-25 (n=41) 26-30 (n=47) 31-35 (n=48)* >35 (n=3)*

NILM 30 (49.2%) 21 (51.2%) 35 (74.5%) 45 (93.7%) 2 (66.7%)

Inflammatory
smear

30 (49.2%) 20 (48.8%) 12 (25.5%) 2 (4.2%) 0

LSIL 1 (1.6%) 0 0 0 0

*One participant each had an unsatisfactory PAP smear report.

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Pokharel A, et al. Prevalence of Abnormal PAP Smear in Pregnancy

DISCUSSION:
Cancer cervix falls in the category of
preventable and easily diagnosable cancers.
The available gold standard screening test to
detect pre-invasive cervical lesions which are
treatable is PAP smear. Such lesions if not
diagnosed and treated in time may progress to
carcinoma. Though a wide range of cancer
cervix occurs in peri-menopausal age group,
pre-malignant changes begin much earlier.
That is why, current guidelines recommend
PAP smear is to begin from the age of 21
years in all sexually active women and to be
done every three years and HPV DNA
co-testing every five years as screening
method.[5] As pregnant women also fall
under the same age group, PAP smear testing
in pregnancy helps not only in identifying
pre-malignant lesions of cervix but also in
diagnosing asymptomatic genital infections
which if left untreated might even hamper
pregnancy outcome.[6] This study contained
women from age group 16 to 39 years.
Majority (34.5%) belonged to 21 to 25 years
of age. Similar result was seen in the study
conducted by Ethirajan S et.al in India.[3]
Majority of the women in this study were
multigravida (69.5%) while majority were
primigravida in other studies.[3,5]

Regarding awareness about PAP smear, only
22% of women knew what it means and what
it is used for, which is slightly better than the
result of the study done in India.[3] However,
this is in contrast to the study done by
Manikkam B.[8] in Coimbatore where 80% of
women and study done in Istanbul showed
that 83.9% women were aware about PAP
smear.[9] Better literacy rate and developed
health care facilities might be the reasons for
this.

Many females complain of pain in the lower
abdomen on and off which is even severe at
times. So, performing PAP smear at first
antenatal visit to know the presence or
absence of squamous intraepithelial lesion,

candidiasis, bacterial vaginosis and all of
which infections may be of risk to mother and
fetus. This initial smear can be used as a
baseline diagnostic tool to treat infections if
present.[10,11] In this study, maximum (34%)
women presented for their first antenatal visit
at 21 to 25 weeks of gestation. Though
pregnancy does not hamper the false negative
results rate, normal physiological changes
occurring during pregnancy may result in
difficult interpretation of PAP smear. For
example, commonly seen mucus plug during
pregnancy due to hyperplasia of cervical
glands due to increased estrogen and
progesterone associated with overall increase
in vaginal secretions may obliterate the
visualization of cervix.[12] In this study, there
was no difficulty in visualizing the cervix of
the involved women, and, maximum (77.5%)
had healthy cervix similar to the study done
by Priya S S et al.[2] Only 1% study
participants showed growth which seemed
benign. They were counseled for regular
follow up and further evaluation later.

In the studies done in past, prevalence of
abnormal cervical cytology varied from study
to study.[2] Ueda Y et al. reported 3.68% in
2010 to 4.35% in 2013 in Japan, 4.8% was
reported in 2018 in Thailand by Phaliwong P
et al., 4.9% in 2019 in Italy by Martinelli M et
al. and 16% in Africa in 2020 by Obeid DA et
al.[13,14,15,16] The prevalence of abnormal
PAP smear in pregnancy could be as high as
6-7% depending upon the population
undergoing screening.[17] In present study,
0.5% of study population had LSIL which is
almost similar to the study done by
Manikkam B.[8] where 1% of women had
pre- malignant lesion in PAP smear with 0.5%
being ASCUS and Njaojaruwong et al.[15]
with prevalence of abnormal cytology 0.4%.
In contrast to the PAP report of present study,
study done by Rasheed FA et al. in Nigeria,
out of 161 pregnant women, six had ASCUS,
11 had LSIL and three had HSIL.[18] But
liquid based cytology was used in that while

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Pokharel A, et al. Prevalence of Abnormal PAP Smear in Pregnancy

conventional PAP with Ayre’s spatula was
done in this study which might have led to
this difference. In the present study, out of
30% of inflammatory smear, 4% were of
bacterial vaginosis, 10% of candida infection
while remaining were nonspecific
inflammatory smears.

In LMICs like ours, where the awareness
regarding PAP smear and its importance has
just begun to rise, where still most of the
population rely on insurance to do necessary
investigations, screening during pregnancy
has a huge role in identifying at risk cases.
Identifying and treating at risk cases and
infected cases, not only improves pregnancy
outcome but also decreases the morbidity and
mortality due to cancer cervix. It also serves
as an excellent tool to educate and aware the
female and her members encouraging them
for regular PAP screening for themselves and
community.

The study has a few limitations. As this study
has small sample size and also only women
up to 28 weeks of gestation are included,
many cases might have been missed. Rather
than conventional Pap smear, Liquid Based
Cytology and HPV DNA are more sensitive
but are not available here.

CONCLUSION:
Incidence of cancer cervix has been
increasing every year and timely
identification of pre malignant lesions could
reduce this. In countries like ours, where
many women do not undergo routine cervical
screening, antenatal period during which
women visit hospital, provides excellent
opportunity to screen. As PAP smear is not
only of diagnostic but therapeutic importance,
community should be made aware about this
and encouraged to test.

Conflict of Interest: The authors declare no
competing interests exist.

Source of Funding: None declared.

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