妊娠合并宫颈上皮内瘤变18例分析

Clinical analysis of pregnancy complicated with cervical epithelial neoplasia--18 cases

目的探讨妊娠合并宫颈上皮内瘤变（CIN）的诊断方法、处理原则、追踪方法和病情变化，初步了解此类患者人乳头瘤病毒（HPV）的感染情况。方法回顾性分析2004年1月至2008年3月在北京大学第一医院妇产科分娩的妊娠合并CIN的18例患者的临床资料。结果18例患者均完整进行“三阶梯”诊断。妊娠合并CIN检出率为0．16％。18例均行保守观察处理，孕期每3个月复查1次宫颈细胞学及阴道镜检查，孕期无疾病进展。妊娠期病理诊断CIN14例、CIN24例、CIN310例。10例CIN3患者中4例产后复查仍示CIN3，1例产后复查为CIN2，此5例患者均于产后6～8周确诊后行宫颈电刀切除手术，且术后6～11个月细胞学检查恢复正常，另1例产后细胞学为高度鳞状上皮病变（HSIL），后失访，其余患者病理活检降级或细胞学正常；8例CIN1及CIN2产后病理活检诊断均降级或细胞学正常。18例患者中14例于孕期检测HPV，其中12例（85．7％）阳性，此12例中7例产后复查HPV，6例仍阳性。18例中剖宫产14例（77．8％），胎膜早破4例（22．2％），新生儿低出生体重1例，无新生儿窒息或新生儿呼吸窘迫综合征发生。结论宫颈“三阶梯”诊断方式对于诊断妊娠合并CIN是安全的。妊娠期未见CIN病情进展。妊娠期CIN保守观察处理未见妊娠不良结局。

Objective To discuss the diagnosis, treatment and following-up of cervical intraepithelial neoplasia （CIN） during pregnancy. Methods Eighteen pregnant women with CIN, presented to the hospital from Jan. 2004 to May. 2008, were retrospectively reviewed. Pap smear, HPV, copolscopy and cervical biopsy were performed for diagnosis and all were followed up by Pap smear and copolscopy during pregnancy every 12 weeks, while 15 were followed up until 6 8 weeks postpartum. Results The incidence of CIN during pregnancy was 0. 16%. All of the 18 women had abnormal Pap smear, followed by colopscopy and biopsy. Conservative management during the pregnancies every 3 months showed no progress in CIN. Among the 18 cases, 17 delivered at term and only 1 preterm （36^＋4 weeks）. Two out of the 18 women had normal delivery （11.1%）, 2 by forceps （11.1%） and 14 by cesarean sections （77.8%）. No neonatal apnea or neonatal respiratory distress syndrome had been observed. Pathological diagnosis was confirmed in all cases prenatally, including 4 CIN1, 4 CIN2 and 10 CIN3. Four out of the 10 CIN3 remained after delivery, while 1 changed to CIN2. These 5 cases underwent leep electrical excision procedure and Pap smear results turned to normal at 6 to 11 months after delivery. One HSIL case were lost. The rest 4 CIN3 and all of the 8 CIN1 and CIN2 cases turned to normal or lesser degree. Fourteen of the 18 women received HPV test during pregnancy, and 12 （85.7%） were positive, among which 7 women were followed up at postpartum and 6 of them were HPV positive. Conclusions The three steps method for diagnosis of CIN during pregnancy is safe and effective. Conservative management of CIN during pregnancy is recommended.