产后阴道微生态变化及影响因素

Vaginal floral characteristics and the influence factors in postpartum women

目的了解产后6～8周的NSL期妇女阴道微生态的特点及其影响因素。方法回顾性分析2010年4月至5月在北京大学第一医院妇产科门诊进行产后6～8周复查的产妇223例（研究组）以及同期参加健康体检的正常非妊娠妇女200例（对照组）。取2组研究对象阴道上1／3分泌物，采用阴道微生态评价系统进行微生态评价，Nugent评分进行细菌性阴道病（bacterial vaginosis，BV）诊断。研究组填写调查问卷，主要包括自觉症状、是否已开始性生活、哺乳情况、分娩方式等。计数资料组间比较采用t检验，计量资料组间比较采用x^2检验。结果研究组平均年龄为（30．5±3．9）岁，对照组平均年龄为（30．9±2．4）岁，2组差异无统计学意义。研究组阴道优势菌以革兰阳性球菌（69／175，39．4％）和革兰阳性杆菌（54／175，30．9％）为主，对照组以革兰阳性杆菌（180／189，95．2％）为主，2组差异有统计学意义（X^2167．478，P〈0．001）。研究组出现菌群密集度0级及I级的比例较对照组增多，2组差异有统计学意义[密集度0级为47例（22．2％）比2例（1．0％），密集度I级为34例（16．0％）比1例（0．5％），X^2=96．302，P〈0．001]。菌群多样性方面，研究组0～Ⅳ级分别为47例（22．4％）、108例（51．4％）、34例（16．2％）、19例（9．0％）及2例（1．0％）；对照组0～Ⅳ级分别为2例（1．0％）、92例（48．2％）、87例（45．5％）、10例（5．3％）及0例（o％）；2组总体构成差异有统计学意义（X^2=69．871，P〈0．001）。研究组阴道pH为5．0±0．5，高于对照组的参考值（〈4．5）。研究组阴道清洁度情况较好，I度及Ⅱ度分别为129例（64．2％）及53例（26．3％）。研究组阴道菌群的功能异常比例较高，过氧化氢水平降低者占84．3％（177／210），唾液酸酶阳性者占6．7％（14／210），白细胞酯酶阳性者占91．0％（191／210），对照组均为阴性。产后Nugent评分异常率较高，共有71．8％（140／195）可以诊断为BV或BV中间型，其中有症状的患者仅为23．5％（33／140）。性生活对于产后菌群无明显影响。研究组中，母乳喂养者发生阴道优势菌异常的比例显著高于人工喂养者[正常优势菌比例分别为25．9％（30／116）及42．9％（21／49）]，差异有统计学意义（X^2=4．631，P=0．031）。分娩方式也对产后菌群有较大影响，研究组中剖宫产者产后更易发生阴道优势菌异常[经阴道分娩者及剖宫产者正常优势菌分别为34例（42．5％）及20例（22．5％），X^2=7．726，P=0．005]。结论产后6～8周复查时，产妇阴道微生态较非妊娠期妇女有明显异常，无症状菌群异常发生率高。母乳喂养、分娩方式是产妇阴道菌群异常的主要影响因素。

Objective To investigate the vaginal flora characteristics, clinical symptoms and signs of lactating women 6-8 weeks after delivery and the influence factors. Methods Two hundred and twenty-three puerpera 6-8 weeks after delivery who went to outpatient department of Peking University First Hospital for postpartum review （study group） and 200 normal non-pregnant women （control group） from April to May, 2010 were enrolled into this study. All in study group were evaluated by a questionnaire regarding their symptoms, sexual behavior, breast-feeding situation and delivery mode. Vaginal secretions from upper 1/3 of vagina were collected and evaluated by vaginal microbial evaluation system. Bacterial vaginosis （BV） was diagnosed if Nugent score ≥7. Enumeration data between groups was compared by t test, and quantitative data by Chi-square test. Results The density of vaginal flora in study group was different from that of control group （X^2 = 96. 302, P〈0. 001）; so did the flora diversity of two groups （X^2 =69. 871, P〈0. 001）. There was no difference between mean age of study group [（30.5 ± 3.9） years] and control group [（30.9±2.4） years], P〉0.05. The cesarean section rate was 52.7% （89/169）, 13 women （7.7G） had began their sexual behavior before interview, 116 women （70.3 %） took breast feeding. Dominant bacteria in the vagina of lactating women were Gram-positive cocci （69/175, 39.4%） and Gram positive bacillus （54/175, 30.9%）, which was different from control group （Gram-positive bacillus, 180/189, 95.20% ）, P〈0. 001. The vaginal p H of study group was 5.0±0.5, which was higher than that （%4.5） of control group. In study group, incidence of lower hydrogen peroxide level of vagina was 84.3%/00 （177/210） ; positive rate of sialidase was 6.7% （14/210） ; positive rate of leukocyte esterase was 91.0% （191/210）. A large number of postpartum women had an abnormal Nugent score, most of them showed a state of intermediate BV （132/195, 67.7%） or BV （8/195, 4. 1%）, while a few patients had symptoms of BV （23.5G, 33/140）. Sexual behavior had no significant effect on postpartum vaginal flora. The proportion of abnormal vaginal flora in breastfeeding mothers （74. 1%, 86/116） was significantly higher than that （57. 1G, 28/49） in artificial feeding mothers, P= 0. 034. Delivery mode also affected postpartum vaginal flora. Women underwent cesarean section were more susceptible to abnormal vaginal flora （77.5 %, 69/89） than those underwent vaginal delivery （57. 5%, 46/80）, ）%,X^2= 7. 726, P=0. 005. Conclusions Vaginal flora of postpartum women 6-8 weeks after delivery had significant difference from that of non- pregnant women. The incidence of asymptomatic abnormal vaginal flora was high. Breastfeeding and delivery mode are influence factors of abnormal vaginal flora.