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임신에 관한 질세포학적 연구

임신에 관한 질세포학적 연구
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(The) value of vaginal cytology in pregnancy
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연세대학교 대학원
[영문] Vaginal cytologic is very helpful during pregnancy although it has not been widely used in obstetrics. In this paper the etiologic factors of cytologic change, especially those seen during the last month of pregnancy, the cytologic prediction of delivery, the cytologic evaluation of prolonged pregnancy, of the pregnancy with unknown duration, of postmaturity and of abortion will be discussed. The data to be presented are based on 497 pregnant patients seen Ewha Woman's University Hospital, Seoul, Korea(374 at the end of pregnancy, 35 having spontaneous abortion, 17 suspected of having abortion and 71 in the first half of a normal pregnancy). Ⅰ. Cytology during last month of pregnancy A. Method Vaginal smears were taken every 5 days beginning to the 36th week of gestation. (a) The vaginal smear must be made before the manual examination, using a dry speculum and wooden tongue blades. The smear is taken from the mid portion of the lateral wall of the vagina and is not contaminated with secretions and cells from cervix or lower portion of the vagina. (b) A Papanicolaou stain was done on the lateral vaginal wall cells. (c) There must be no labor pains or rupture of membranes. (d) Vaginitis(especially Trichomonas) must be treated with antibiotic suppositories for 3-4 days before the study. B. Results Study of smears from 374 patients has shown 3 types of smears. (a) Pre-term type: Consist of numerous intermediate cell type clusters. (b) Term type: The diminution or disappearance of the cell clusters is the main characteristic of this type. No parabasal cells were seen. The term type begins to appear in last 15 days and especially during the 8th to 5th day before delivery. (c) Postmaturity or Postpartum type(Pregnancy regressive type): is composed of an increased karyopyknotic index(12%) and eosinophilic index(23%) and numerous parabasal cells. The cell clusters have almost disappeared. 1. Cytologic prediction of delivery: Of the 247 cases of pre-term type, 34 or 13.77% had spontaneous delivery within the next 5 days. Of the 127 cases of the term, 109 or 85.83% deliveried spontaneously within the next 5 days. 2. Are the modifications mechanical or hormonal? In the study of 336 cases, the modification of the term type were not the consequence of any mechanical alteration of cervical effacement, dilation or engagement, and were not altered by parity, the presenting part, or the presence of twins. 3. Prolonged pregnancy: In 84 patients who were more than 1 to 7 weeks beyond their expected day of delivery, 41 patients showing the pre-term type, and all deliveried within 15 days alteration to the term type of smear. One primigravida, who was 55 days after expected date of confinement, revealed no evidence of postmaturity, 26 patients in excess of 3 or more weeks beyond their expectd date were able to avoid the risks of artificial induction and showed no sign of postmaturity. All 43 patients of term type had normal spontaneous deliveries except 2 with contracted pelves and one ruptured utrus treated surgically. Pitocin inductions on the term type were all patients very sucessful. 4. Unknown duration of pregnancy: In this group, 15 patients of pre-term type, did not deliver for at least 4 days. Almost all 7 cases of the term type deliveried spontaneously within 5 days. Delivery time was highly predicable(87-100%) by the use of the cytologic test. 5. Postmaturity: Of 22 patients who having pregnancy of unknown duration, one showed postmaturity with evidence of a typical placental insufficiency. The remaining functional area was only 5cm in diameter, baby weighed 3.1kg, was 50cm in length, deeply stained with meconeum, and unfortunately died during the induction of delivery. Ⅱ. Cytology during first half of pregnancy A. Method: With the foregoing technic a vginal smear was made monthly in each of the normal pregnancy group, and every other day in the abortion group. B. Results: 1. Normal pregnancy group: 71 cases at 6 to 23 weeks gestation showed karyopyknotic index under 13% and the eosinophilic index was less than 7%. The most significant indices are believed to be cell clusters ranging from 28 to 31 in 10 fields of low power and cell clusters/karyopknotic or eosinophilic insex ratio which is larger than 1 in 94 % of normal early pregnant women. 2. Spontaneous abortion: All of this group with or without hormone treatment, during 3-19 weeks of gestation spontaneously aborted. In the study of 34 pre-abortive cases, there was noted an increas in the karyopyknotic index up to 38%, the eosinophilic index up to 25%, and a decrease in the cell clusters to only 3-4 per 10 low power fields. 3 of the 4 cases of missed abortion showed a significant rise in karyopyknotic index up to 52%(occasionally 90%), and rise in the eosinophilic index up to 40%(occasionally 91%) and decrease in the cell clusters down to 10. One case was almost normal except cell clusters had decreased to 10-14. Of special interest is the fact among 35 abortion cases, although abnormal smears were found in only 71%(25 cases) on the basis of an increasing karyopyknotic index or eosinophilic index. However when the quantitative diminution of cell clusters down to 3-4 per 10 low power fields was added the incidence of abnormal smear was 97% accurate(only one exception). When the finding of inverted cell clusters/karyopyknotic index or eosinophilic index ratio, C/K or E<1 was considered accuracy was 80-100%. Pseudohormonal effect: The smear taken after progesterone had been given to the abortive cases showed a decreasing karyopyknotilic index and eosinophilic index to approximately 50% of the non-treated group, which gives an impression of temporary improvement. However, the numbers of cell clusters were not significantly changed or improved. 3. Suspected abortion: In 17 cases of suspectd abortion with spotting averaging 6.5 days perfectly normal smears were found. The prognosis even without treatment was excellent in 100%. Ⅲ. Comment According to Zandet(1959) the placenta starts to progesterone from the first month of pregnancy, 25 to 50mg, per day during first half and 280mg, per day during the last half. Brown cited by von Haam, found that estrogen produced by the placenta increased from 1mg, per day in the 10th week of pregnancy to 50-100mg, per day at the end of pregnancy. We know that navicular cells can not be considered as specifically diagnostic of pregnancy. However, Papanicolaou stressed that larger nuclei and more a compact grouping is a characteristic of pregnancy. According to Pundel(1959,1964) the alteration of the vaginal smear at term is a dynamic change reflecting the results of the estrogen-progesterone balance and the different degree of vaginal sensitivity. This seems a more logical explanation althouth there has been some other opinions(Luz 1959, Kamnitzer 1959). As many authors; Lichtfus and Pundel(1959), Gaudefroy(1959), von Haam(1959), Kamnitzer(1959) have emphasized, the most important factor in the hormonal evaluation is the correct technic in preparing the smeats as well as experience in reading them. the smear film must be uniform, preferably made in one direction. The changed cytologic finding in postmaturity is a new sign of intrauterine fetal distress. Luz(1959) found that estrogenic can be demonstrated in prolonged pregnancy, even earlier before term and is usually associated with decreasing levels of estrogenic secretion to less than 50% normal. Huruga(1936) states that in prolonged pregnancy artificial induction caused no reduction of fetal mortality in comparision with that of a non-inducted group. Eastman(1961) also had same opinion. We belive that induction without scientific indications is not only unnecessary, but also harmful. However if the term type of smear repeatedly appears in prolonged pregnancy, it seems wise to induce labor because factors other than hormonal may be present. Most authors agree that the karyopyknotic index and eosinophilic index rise in pre-abortive stage, but no attention has been paid to the quantitative changes of cell clusters. Birth(1961) found that the defficiency type(abnormal type) was present in 38.3% of all the aborting women, and the incidence of abortion, when the smear indicated a normal pregnancy pattern, was 4.7%. Wood et al states that of 33 cases of abnormal smears 16 cases aborted; Of 12 patients who showed normal type smears only one patient aborted. In our experience the quantitative decrease of cell clusters, or invertion of the cell cluster/Karyopyknotic or eosinophilic index ratio, gives a greater accuracy of actual incidence of abnormal cytologic changes in all aborting patients, 97% of patients the former type will abort, to the latter form 80-100% will abort. Ⅳ. Conclusion 1. So called the "term type" of smear begins to appear 15 days before the time of spontaneous delivery, and rapidly increased in the 8th to 5th day before delivery. 2. The pregnancy "pre-term" type showed an accuracy of 86% in predicting that spontaneous delivery would not occur within the next 5 days. 3. The pregnancy "Term type" predicted that spontaneous delivery would occur within the next 5 days with 85% accuracy. 4. The cytological change seen near term appeared not to be influenced by the mechanical factors as cervical dilation, effacement or parity. It is suggested that the changes are the result of hormone withdrawal. 5. Prolonged pregnancy is not always associated with postmaturity, but postmaturity can occur at any time if placental insufficiency is present. On the basis of cytological and clinical findings, 84 cases of pregnancy prolonged in excess of 1-7 weeks beyond the expected date all delivered healthy babies. Under the cytological control induction of labor was avoided without risk in 26 patients 3-7 weeks beyond their expected date of confinement. 6. Among 17 cases of pregnancy of unknown duration there was one showing typical postmaturity cytologically. Frequent cytological examination especially on pregnancics of unknown duration and of duration prolonged, can be very important in preventing postmaturity as well as prematurity due to limited obstetrical judgement. We strongly urge that for a correct evaluation of postmaturity the proper antibiotic vaginal suppositories be routinely instituted(especially for Trichomonas infrction) during repeated examinations in pregnancy prolonged 10 days or more. This avoide possible errors from infection. Otherwise it may be too late for satisfactory smear studies. 7. The following is a very interesting side light to this investigation. A quantitative diminution or disappearance of cell clusters in spontaneous abortions is a most sensitive diagnostic and prognostic with accuracy over 90% as comparated with a 71% accuracy based alone on the increasing karyopyknotic and eosinophilic index. Also inversion of the cell clusters and karyopyknotic or eosinophilic index ratio would be another significant sign of poor prognosics with an accuracy of 80-100% in threatened abortion. In general, the karyopyknotic index increased over 38%, eosinophilic index over 25% and is even more increased in midded abortion. 8. Hormonal treatment in a threatened abortion should be given immediately when the smear shows an abnormal picture, the aborted group had twise the non-abortive group duration of vaginal spotting. 9. If there is no cytological improvement in repeated smears over a short period of time, the incidence of abortion is high whether or not treatment is given. 10. Early detection and good management of abortion can be done by a routine vaginal smear performed especially from 5th week to 3rd month of pregnancy, considered as most commonest spotting period. We know that the excessive long term administration of progesterone in early pregnancy may produce an genital deformities in the female fetus as well as increasing embryonic mortality. 11. If the vaginal smear is normal, hormone treatment is not needed. 17 cases of clinically suspected abortion who showed normal smear had a 100% good prognosis even without treatment. Cytologic examination during prenancy is very important if technically accurate and by experienced personal. Also, it can be a valuable guide to the proper hormonal control of modern pregnancy.
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2. 학위논문 > 1. College of Medicine (의과대학) > 박사
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