病例报告

妊娠合并宫颈癌1例诊治体会并文献复习

王彩华

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【摘要】  妊娠合并宫颈癌的发病率呈上升趋势,其临床表现与妊娠期其他疾病易混淆,且妇科检查会因妊娠而受到限制,从而导致误诊、漏诊。妊娠合并宫颈癌的诊治尚无成熟统一的方案,需要根据病理结果、临床分期、妊娠周数、胎儿发育情况及患者继续妊娠的意愿等制定个体化治疗方案。本文结合1例初诊为先兆流产的妊娠合并宫颈癌患者的诊治,从筛查、诊断、治疗以及终止妊娠的时机和方式等总结诊治体会,并进行相关文献复习,以期为妊娠合并宫颈癌的诊治提供参考。

【关键字】  妊娠合并宫颈癌,诊治体会,筛查,诊断

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[Abstract] The incidence rate of pregnancy with cervical cancer is on the rise. Its clinical manifestations are easily confused with other diseases during pregnancy, and gynecological examination will be limited due to pregnancy, resulting in misdiagnosis and missed diagnosis. There is no mature and unified plan for the diagnosis and treatment of pregnancy complicated with cervical cancer. It is necessary to formulate individualized treatment plan according to pathological results, clinical stages, weeks of pregnancy, fetal development and the patient's willingness to continue pregnancy. Based on the diagnosis and treatment of a pregnant woman with cervical cancer who was initially diagnosed as threatened abortion, the paper summarized the diagnosis and treatment experience from the aspects of screening, diagnosis, treatment, and the timing and manner of termination of pregnancy, and reviewed the relevant literature in order to provide reference for the diagnosis and treatment of pregnancy with cervical cancer.

妊娠合并宫颈癌是一种发病率不高(为0.01%~0.05%)的宫颈癌,好发于妊娠期、产褥期或产后6个月[1]。随着国家生育政策的逐渐放开、生育年龄的普遍提高,妊娠高峰年龄段与宫颈癌发病高峰年龄段的重合率增加,妊娠合并宫颈癌的病例也有所增加。妊娠合并宫颈癌较为罕见,其临床表现通常无特异性,易造成误诊、漏诊[2]。在诊治时,需同时考虑疾病的诊断和治疗、孕妇和胎儿的耐受性以及医学伦理等[3]。现有的专家共识、诊治指南均是以“小样本”为基础,存在缺乏可靠循证医学证据的问题,且在诊治方面的说法存在一定的差异[4]。显然,统一方案的缺乏,导致妊娠合并宫颈癌的诊治比较困难,尤其是对怀孕欲望强烈的患者。如何选择合理有效的诊治方案,优化处理患者、胎儿及肿瘤之间的问题,依然面临着巨大的挑战。如果选择继续妊娠,应尽量实现与非妊娠宫颈癌患者相同的治疗结果,避免加速妊娠期宫颈癌的进展或治疗本身对胎儿造成严重的不良影响。本文拟结合诊治的1例妊娠合并宫颈癌,从筛查、诊断、治疗及终止妊娠等方面梳理诊治体会,并复习相关文献,以期为妊娠合并宫颈癌的诊治提供参考。 1 病例资料 患者,女,30岁,妊娠20+6周时,出现无诱因阴道少量流血,考虑先兆流产进行保胎治疗。在住院期间,查液基薄层细胞学检查(thinprep cytologic test,TCT)-DNA示ASCUS,见DNA倍体异常细胞(≥3个),HPVE6E7mRNA阳性。建议患者行阴道镜检查,被拒绝,病情好转后出院。在患者出院后,反复出现阴道少量咖啡色分泌物,自行口服保胎药,而未就诊。妊娠27+1周来院产检,宫高26 cm,腹围100 cm,胎心正常,胎膜未破,宫口未开;妇检见宫颈柱状上皮外移,4点处可见1个大小2.0 cm×3.0 cm菜花状赘生物,质脆,触之易出血;三合诊示双侧宫旁组织,弹性尚可。行阴道镜检查,取样活检,病理示中-低分化鳞状细胞癌。MRI示宫颈左侧壁见不规则团块4.5 cm×2.5 cm,累及左侧宫旁,向下累及阴道穹窿,后缘与直肠前壁关系密切,未达骨盆壁,盆腔未见明显肿大淋巴结,考虑宫颈癌ⅡB期。患者及家属对胎儿较期待,拒绝行新辅助化疗。经多学科会诊讨论后,告知患者相关风险,建议妊娠34周行剖宫产。在妊娠期,积极保胎治疗,严密监测肿瘤标志物。妊娠34周,予地塞米松促胎肺成熟后剖宫产娩一活婴,外观无异常,体质量2 250 g,Apgar评分9~10分。术后抗炎治疗,患者恢复良好,平安出院,密切随访,择日返院放化疗。患者在知情同意书上签字,调查对象的临床资料递交伦理委员会审核并获得批准。
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