孕期宫颈上皮瘤变的处理课件.pptVIP

孕期宫颈上皮内瘤变的处理 Mark Hunter, MD Am J Obstet Gynecol 2008, 199(3):3-9 筛查 所有妊娠妇女均应在产检时接受宫颈涂片检查 关于宫颈涂片 孕期涂片异常：5-8%（1.2%-CCa） 敏感性：70-80% 准确性 = 非孕期 假阳性：外翻、炎症、蜕膜细胞 随诊 涂片正常 ACSACOG指南 连续≥3次涂片（-） 无不典型增生、免疫抑制或宫内已烯雌酚暴露等病史 ≥30岁 → 3年后重复一次宫颈涂片 涂片正常+hr-HPV (+) 产后6周重复细胞学和HC2 随诊（续）- 涂片异常 所有涂片异常者均应接受阴道镜检查 操作困难！ 训练有素、经验丰富 阴道镜印象与病检相关性良好 95%：±1级 活检 没有确凿的证据表明孕期宫颈活检会引起大量出血或不良妊娠结局 时机：中孕期 毛刷vs钻取 宫颈内搔刮（ECC）→ ? 处理 – ASCUS – HPV检测 HC2 (+) 浸润癌：1% HPV检测 20岁→不推荐 20岁→建议 HC2 (-) 产后6周重复涂片+/-HC2 处理 – AGC/AIS A-S反应？ 处理同非妊娠状态，但是不建议进行ECC、冷刀锥切、内膜活检 处理 – 鳞状上皮内病变 LSIL 阴道镜 可以延迟到产后6周 HSIL 均应行阴道镜 75%持续至产后但无进展 62%逆转至CIN1 怀疑CIN2/3或浸润癌→活检 活检(-)→产后6周阴道镜和细胞学 组织学诊断的CIN CIN1 观察 CIN2/3 阴道镜和细胞学随诊 间隔不短于12周 如果外观恶化或细胞学提示癌 重复活检 产后6周重复阴道镜及活检 锥切 适应证 涂片、阴道镜或活检提示浸润癌 诊断性！ LLETZ 冷刀 流产/早产：20-25% 严重阴道出血： 5-15% 复发：50% 币样（coin）活检 癌 CIN3 CIN2 CIN1/正常 AGC-AIS HSIL ASC-H LSIL 阴道镜 ASCUS HC2 20岁 + 产后涂片+/-HC2 - 20岁 每3月重复阴道镜 活检 CIN/- 癌 ？ 无变化 产后阴道镜/活检 孕期经病检证实的CIN并不是终止妊娠的指征！ 分娩方式 仅仅取决于产科因素 阴道分娩过程中宫颈损伤继发的局部炎症反应可能会有利于宫颈病变的缓解率 HSIL：VD (67%) vs CS (13%) Breast cancer, Hodgkin’s disease, leukaemia and melanoma are among the most frequently encountered malignancies during pregnancy, cervical cancer is considered to be the most prevalent malignancy. The incidence of cervical cancer in pregnancy is estimated to be 1-10/10 000 pregnancies, depending on the inclusion of carcinoma in situ and postpartum patients. Approximately 30% of women diagnosed with cervical cancer are in their reproductive years1, and 3% of cervical cancers are diagnosed during pregnancy。Pregnancy provides an exceptional opportunity for early diagnosis of cervical cancer * * ACSACOG guidelines: Routine Pap test repeated at 3-year interval, if 3 or more consecutive normal Paps, no history of dysplasia, immunodeficiency or in utero diethylstilbestrol exposure, and over 30 years of age All abnormal smears have to be referred for colposcopic examination. Careful colposcopy excluding micro-invasive or invasive carcinoma allows the gynaecologist to defer definit