妊娠期宫颈上皮内瘤变筛查57例临床分析

目的观察妊娠妇女宫颈细胞学异常的诊治及临床转归,探讨影响孕妇细胞学转阴的相关因素。方法选取2012年3月至2017年11月就诊于中国医科大学附属盛京医院行宫颈细胞学筛查并发现异常的孕妇90例,随访其临床病例特点、诊治方法及终止妊娠后12个月细胞学的转阴情况。结果成功随访57例,包括:DNA倍体异常和妊娠期未明确意义的非典型鳞状上皮细胞(atypical squamous cells of undetermined significance,ASCUS)35例,ASCUS不除外高度病变者(ASC-H)7例,低度鳞状上皮内病变(low grade squamous intraepithelial lesion,LSIL)8例,高度鳞状上皮内病变(high grade squamous intraepithelial lesion,HSIL)7例。其中病理活检12例,10例孕期同时行宫颈手术,47例孕妇选择保守观察,要求终止妊娠后复查。47例保守观察的孕产妇中:①早孕期发现宫颈细胞学异常32例,中晚孕期发现宫颈细胞学异常15例,随访至终止妊娠后12个月,宫颈细胞学的总体转阴率分别为71.9%和60.0%,两者比较差异无统计学意义(P>0.05)。②早孕期终止妊娠31例,中晚孕期终止妊娠16例,随访至终止妊娠后12个月,宫颈细胞学的总体转阴率分别为71.0%和62.5%,两者比较差异无统计学意义(P>0.05)。③异位妊娠25例,正常宫内妊娠22例,随访至终止妊娠后12个月,宫颈细胞学的总体转阴率分别为76.0%和59.1%,两者比较差异无统计学意义(P>0.05)。47例保守观察的孕妇中行高危型人乳头瘤病毒(human papilloma virus,HPV)检测40例,其中阳性25例,阴性15例,随访至终止妊娠后12个月宫颈细胞学的总体转阴率分别为52.0%和86.7%,有吸烟史14例,无吸烟史33例,随访至终止妊娠后12个月宫颈细胞学的总体转阴率分别为42.9%和78.8%,两者比较差异有统计学意义(P均<0.05)。随访成功的57例孕妇中3例孕期阴道流血伴宫颈细胞异常,但孕期拒绝阴道镜活检确诊,外院终止妊娠后我院复查时发现为宫颈癌。结论①妊娠本身并不影响孕期宫颈细胞学异常的转阴,但同时合并HPV感染或有吸烟习惯将不利于孕妇细胞学异常的消退。②妊娠期发现宫颈细胞学异常在排除恶性病变后可以选择保守观察,但产后需严密随访。③不可忽视孕期细胞学异常伴HPV感染,需重视妊娠期HPV阳性患者的HPV消退及细胞学复查情况。④要重视妊娠妇女的宫颈癌筛查,当细胞学检查异常或临床症状和体征不能除外子宫颈癌者应直接转诊阴道镜检查,所有宫颈癌筛查异常的孕妇终止妊娠后需严密随访。

Clinical analysis of 57 cases of cervical intraepithelial neoplasia screening during pregnancy

Objective To observe the diagnosis,treatment and clinical outcome of pregnant women with abnormal cervical cytology,and to explore the cytological conversion and relevant influencing factors of these pregnant women.Methods 90 pregnant women with abnormal cervical cytology were collected from Shengjing Hospital Affiliated to China Medical University during March 2012 to November 2017.We followed up the clinical characteristics,methods of diagnosis and treatment as well as the outcome of cervical cytology after termination of pregnancy.Results Successful followed up 57 cases,including 35 cases of DNA ploidy abnormalities and atypical squamous cells of undetermined significance(ASCUS),7 cases of ASC-H,8 cases of low grade squamous intraepithelial lesion(LSIL)and 7 cases of high grade squamous intraepithelial lesion(HSIL).While pathological biopsy was performed in 12 cases and cervical surgery was performed in 10 cases.47 cases selected conservative observation during pregnancy and required reexamination after termination of pregnancy.Among 47 pregnant women selected conservative observation,①32 cases of cervical cytology abnormality were found in the early pregnancy,and 15 cases of cervical cytology abnormalities were found in the middle and late pregnancy.The overall regression rate of cervical cytology was 71.9%and 60.0%after follow-up to 12 months after termination of pregnancy.There was no significant difference between the two groups(P>0.05).②31 cases terminated pregnancy in early pregnancy and 16 cases in mid to late gestation.They were followed up until 12 months after termination of pregnancy and the overall regression rate of cervical cytology was 71.0%and 62.5%,respectively.There was no significant difference between the two groups(P>0.05).③25 cases of ectopic pregnancy and 22 cases of normal intrauterine pregnancy were followed up until 12 months after termination of pregnancy.The overall regression rate of cervical cytology was 76.0%and 59.1%,respectively.There was no significant difference between the two groups(P>0.05).Among the 47 pregnant women taking conservative observation,40 were detected by high-risk human papilloma virus(HPV),including 25 positive cases and 15 negative cases.The overall regression rate of cervical cytology was52.0%and 86.7%followed-up to 12 months after termination of pregnancy.There were 14 cases of smoking history,33 cases of no smoking history,and the overall regression rate of cervical cytology was 42.9%and 78.8%,respectively 12 months after termination of pregnancy.The difference was statistically significant(P<0.05).Of the 57 pregnant women who were successfully followed up,3 had vaginal bleeding with cervical cell abnormality during pregnancy,but they refused to have a colposcopy biopsy during pregnancy.After the termination of pregnancy in the external hospital,we found cervical cancer.Conclusion①Pregnancy itself did not impact on the negative conversion of cervical cytology abnormalities during pregnancy,but the combination of HPV infection or smoking habits will not be conducive to the regression of cytological abnormalities in pregnant women.②Cervical cytology abnormalities found during pregnancy can be conservatively observed after exclusion of malignant lesions,but close follow-up is required after delivery.③The abnormality of cervical cytology with HPV infection during pregnancy should not be ignored.It is necessary to pay attention to the HPV regression and cytological review of HPV-positive patients during pregnancy.④It is necessary to pay attention to the screening of cervical cancer in pregnant women.When the cytological examination is abnormal or the clinical symptoms and signs cannot exclude cervical cancer,the colposcopy should be directly referred to.All pregnant women with abnormal cervical cancer screening should be closely followed after termination of pregnancy.