妊娠相关宫颈细胞形态学特点及其临床处理

Pregnancy related cervical cytological changes and clinical management

目的探讨妊娠相关宫颈细胞形态学特点及其处理方法。方法回顾性分析2006年8月至2010年1月间，在中日友好医院行产前检查并分娩的妊娠期（含早、中、晚期妊娠）及产后42d妇女5152例的宫颈液基细胞学（LCT）涂片，采用Bethesda分类系统（TBS）进行诊断，对诊断为上皮细胞异常者均随访至产后3个月，观察其变化。对诊断为高度鳞状上皮内病变（HSIL）和鳞状细胞癌（SCC）者孕期进行阴道镜下活检，对不典型腺细胞（AGC）者产后6周进行宫颈管活检；并与活检组织病理学结果进行对比分析。结果（1）妊娠相关细胞学改变：5152例中检出舟状细胞3215例（62．40％），蜕膜细胞783例（15．20％），反应性腺细胞369例（7．16％），滋养叶细胞55例（1．07％）。（2）LCT结果：5152例中未见异常者4125例（80．07％）；感染性病变542例（10．52％）；上皮细胞异常485例（9．41％），其中不典型鳞状细胞（ASC）291例（5．65％），低度鳞状上皮内病变（LSIL）153例（2．97％），HSIL33例（0．64％），SCC1例（0．02％），AGC7例（0．14％）。（3）组织病理学结果：对HSIL和SCC妇女行阴道镜检查及活检，病理结果为宫颈上皮内瘤变（CIN）Ⅱ～Ⅲ28例，腺鳞癌1例。对AGC妇女行宫颈管活检，病理结果均为阴性。细胞学与组织病理学结果的总符合率为71％（29／41）。（4）随访：485例上皮细胞异常者均随诊至产后3个月。HSIL、SCC、AGC临床处理后LCT随访均无异常；ASC和LSIL未活检，LCT随访病变消退者占72．3％（321／444）。结论妊娠期和产后妇女宫颈细胞学特点是以舟状细胞为主，部分改变极易与恶性病变相混淆，应仔细甄别，避免过度诊断或误诊。应密切随诊异常涂片，适当放宽阴道镜活检的指征。

Objective To investigate characteristics of cervical cytology and management in pregnant women. Methods From Aug. 2006 to Jan. 2010, 5152 pregnant women who received antenatal and postpartum examination underwent cervical cytological screening by liquid-based cytological test （LCT） in China-Japan Friendship Hospital. The cytological diagnosis was in accordance with the Bethesda system （TBS） 2001 diagnosis and classification system. The abnormal LCT results were followed up at 3 months after postpartum. The diagnosis of high-grade squamous intraepithelial lesions （HSIL） and squamous cell carcinoma （SCC） were based on colposcopic examination and biopsy during pregnant. The diagnosis of atypical glandular cells （AGC） was based on curettage and biopsy at postpartum 6 weeks. The histopathology of biopsy were compared and analyzed. Results （ 1 ） Cervical cytological changes related with pregnancy： among 5152 cases, it was found navicular cells in 3215 eases （62. 40% ） , decidual cells in 783 eases （ 15.20% ）, reactive glandular cells in 369 eases （7. 16% ）, and trophoblastic cells in 55 eases （1.07%）. （2） LCT results： among 5152 eases, the normal samples were 4125 eases （80. 07% ）, the inflammatory samples were 542 cases （ 10. 52% ）, and the samples of abnormal epithelial cells were 485 eases （9.41%）. Among those abnormal cases, 291 cases （5.65%） were in atypical squamous cells （ASC）, 153 eases （2.97%） were in low-grade squamous intraepithelial lesions （LSIL）, 33 eases （0.64%） were in HSIL, 1 case （0.02%） were in SCC and 7 cases （0. 14%） were in AGC. （3） Histological pathology results： all women with HSIL and SCC underwent colposcopic examination and biopsy, it was found 28 cases in cervical intraepithelial neoplasia （CIN） Ⅱ - Ⅲ, 1 cases in adenosquamuus carcinoma. 7 women underwent curettage and biopsy at postpartum 6 weeks which were diagnosed by AGC, the histopathological diagnosis was all negative. The concordance rate of cytopathologic and histopathologic diagnosis was 71% （29/41）. （4） Follow-up： 485 women with abnormal LCT results were all followed up to 3 months at postpartum. Women with HSIL, SCC and AGC undergoing biopsy showed normal LCT results during follow-up. Those women with ASC and LSIL did not undergo colposcopic examination and biopsy. The regression rate was 72. 3% （321/444） at postpartum 3 months. Conclusions The navicular cells were primarily morphological characteristics of cytology during pregnant and postpartum women. Some changes were easily confused with malignant lesions. It should be careful discrimination, and avoid excessively diagnosis and misdiagnosis. It suggested that we should follow up those women closely and expand the indication of colposcopic biopsy.