Diagnostic tests to assess the course of pregnancy.

In our medical laboratory, a vaginal smear is examined for the karyopyknotic index, which allows us to assess the concentration of estrogen in female body, (the release of a mature egg, ready for fertilization). The test is used for diagnosis pathological processes in the female reproductive system.

What is the karyopyknotic index?

The process of maturation of the nucleus of epithelial cells is called karyopyknosis (shrinkage of the cell nucleus), this phenomenon precedes karyorrhexis (disintegration of the cell nucleus into parts).

Karyopyknotic index(KPI) is the percentage of epithelial cells that have pyknotic nuclei (up to 6 μm) to cells that have not undergone karyopyknosis (with vesicular nuclei - from 8 to 10 μm). The karyopyknotic index number depends on the strength hormonal effects on the female body.

When is this test prescribed?

Study of the cellular composition of the vagina experienced specialists prescribed for menstrual disorders, pathological gynecological bleeding, complicated menopause For:

assessing ovarian function;
identifying the causes of infertility and termination of pregnancy;
determining the day of ovulation;
diagnosing hormonal changes;
assessing the effectiveness of the use of hormonal drugs.

Research methodology

The biomaterial for research - a vaginal smear - is selected by a qualified gynecologist. Special training The procedure is not required, but the patient must abstain from sexual intercourse for two days.

during menstruation;
in the presence of an inflammatory process (colpitis, cervicitis);
after execution medical procedures(douching, manipulation in the cervical canal).

With the help of a special sterile device - a urogenital probe (Volkmann spoon), they are collected from the vaginal walls. epithelial cells, applied to a glass slide and dried in open air. IN laboratory conditions the smear is fixed in Nikiforov’s solution and stained using a monochrome or polychrome method.

A qualified laboratory doctor conducts microscopy of a colored smear in different fields of view and counts the formed elements.

Decoding analysis data

Main part cellular elements The vaginal contents consist of rejected cells of various epithelial layers of the mucous membrane - superficial, intermediate, para-basal, atrophic cells. When calculating the research results, the period is taken into account monthly cycle.

Indicators of the norm of the karyopyknotic index:

from 8 to 11 days (initial phase) - from 25 to 30%;
on day 14 (ovulation process) - from 60 to 85;
from 25 to 28 days (final phase) - 35.

An increase in the CPI is characteristic of an increase in estrogen saturation; a decrease indicates a low level of estrogen in a woman’s body.

Duration of analysis: Cost of analysis: rub.Add to calculator

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Determination of basal temperature in the first 12 weeks of pregnancy. At favorable course pregnancy basal temperature increased to 37.2-37.4°C. Temperatures below 37°C with fluctuations indicate an unfavorable course of pregnancy. The capabilities of this test are very limited, since in case of non-developing pregnancy, with anembryonia, the temperature remains elevated as long as the trophoblast lives.

Cytological examination of vaginal discharge is currently rarely taken into account, since among women with miscarriage there are many infected with symptoms of cervicitis, vaginosis, in which the study is not informative; in the absence of infection, this test can be used. Until 12 weeks of pregnancy, the cytological picture of a smear of vaginal contents corresponds to the luteal phase of the cycle and the karyopyknostic index (KPI) does not exceed 10%, at 13-16 weeks - 3-9%. Until 39 weeks, the CPI level remains within 5%. When signs of a threat of interruption appear, along with an increase in the CPI, red blood cells appear in smears, which indicates an increase in the level of estrogen, an imbalance in the progesterone-estrogen relationship and the appearance of microdetachments of the chorion or placenta.

Big prognostic value to assess the course of pregnancy in the first trimester, it has a dynamic determination of the level human chorionic gonadotropin. It is detected in urine or blood in the 3rd week of pregnancy. Its content in the urine increases from 2500-5000 units at 5 weeks to 80,000 units at 7-9 weeks, at 12-13 weeks it decreases to 10,000-20,000 units and remains at this level until 34-35 weeks, then increases slightly , but the significance of this rise is not clear.

Since human chorionic gonadotropin is produced by trophoblast, disruption of its function, detachments, dystrophic, generative changes lead to a decrease in the level of excretion of human chorionic gonadotropin. To assess the course of pregnancy, not only the value of human chorionic gonadotropin is important, but also the ratio of the magnitude of the peak of human chorionic gonadotropin to the duration of pregnancy. Too much early appearance human chorionic gonadotropin peaks at 5-6 weeks, as well as late appearance at 10-12 weeks and to an even greater extent, the absence of a peak of chorionic gonadotropin indicates a dysfunction of the trophoblast, and therefore the corpus luteum of pregnancy, the function of which is supported and stimulated by chorionic gonadotropin.

It should be noted that the early appearance of human chorionic gonadotropin and its high level may be associated with multiple pregnancy. When pregnancy does not develop, human chorionic gonadotropin sometimes remains for high level, despite the death of the embryo. This is due to the fact that the remaining part of the trophoblast produces human chorionic gonadotropin, despite the death of the embryo. Termination of pregnancy in the first trimester in most cases is the result of failure of the trophoblast as an endocrine gland.

To assess the course of pregnancy, a test for assessing trophoblast function, such as determining placental lactogen in blood plasma, can be used. True, he is more often represented in scientific research to confirm or deny the formation of placental insufficiency than in clinical practice. Placental lactogen is determined from 5 weeks of pregnancy, and its level constantly increases until the end of pregnancy. When dynamically monitoring the level of placental lactogen, the absence of an increase or decrease in its production is an unfavorable sign.

In the first trimester of pregnancy, determining the levels of estradiol and estriol has great prognostic and diagnostic value.

A decrease in the level of estradiol in the first trimester and estriol in the second and third trimesters indicates the development of placental insufficiency. The truth in last years This test is given less importance and is mainly used to assess placental insufficiency using ultrasound and Doppler measurements of fetal-placental and utero-placental blood flow, since it is believed that a decrease in estriol may be due to a decrease in aromatization processes in the placenta, and not to fetal suffering.

There is a decrease in estriol production when taking glucocorticoids.

In women with hyperandrogenism, to monitor the course of pregnancy and assess the effectiveness of glucocorticoid therapy, determining the content of 17KC in daily urine plays an important role. Each laboratory has its own 17KS level standards with which the data obtained should be compared. It is necessary to remind patients about the rules for collecting daily urine, the need for a diet without red-orange colored foods for 3 days before urine collection. In uncomplicated pregnancy, there are no significant fluctuations in 17CS excretion depending on the duration of pregnancy. Normally, fluctuations are observed from 20.0 to 42.0 nmol/l (6-12 mg/day). Simultaneously with the study of 17KS, it is advisable to determine the content of dehydroepiandrosterone. Normally, the level of DHEA is 10% of 17KC excretion. During pregnancy, significant fluctuations in the level of 17KC and DHEA do not occur. An increase in the content of 17KS and DHEA in the urine or 17OP and DHEA-S in the blood indicates hyperandrogenism and the need for treatment with glucocorticoids. With absence adequate therapy the development of pregnancy is disrupted most often by the type of non-developing pregnancy; In the second and third trimesters, intrauterine fetal death is possible.

An extremely important aspect of working with patients with recurrent miscarriage is prenatal diagnosis. In the first trimester at 9 weeks, a chorionic villus biopsy can be performed to determine the karyotype of the fetus to exclude chromosomal pathology. In the second trimester, to exclude Down's disease (if the study was not carried out in the first trimester), it is recommended for all pregnant women with habitual loss history of pregnancy, conduct a study of the levels of human chorionic gonadotropin, estradiol and alpha-fetoprotein in the mother’s blood. Studies are carried out at 17-18 weeks. An increase in human chorionic gonadotropin above the normative parameters for this period, a decrease in estradiol and alpha-fetoprotein is suspicious for Down's disease in the fetus. With these indicators, in all women, and after 35 years, regardless of the parameters obtained, it is necessary to perform amniocentesis to evaluate the fetal karyotype. In addition to this analysis, in everyone with hyperandrogenism and a burdened medical history with suspected adrenogenital syndrome (if the spouses have HLAB14, B35-B18 in possible carriers of the gene adrenogenital syndrome in the family) we conduct a study of the levels of 17-hydroxyprogesterone in the blood. If this parameter increases in the blood, amniocentesis is performed and the level of 17OP is determined in amniotic fluid. Increased levels 17OP in amniotic fluid ah indicate the presence of adrenogenital syndrome in the fetus.

The most informative test in assessing the course of pregnancy, the condition of the embryo, fetus, placenta is ultrasonography. In most cases, ultrasound can detect pregnancy from 3 weeks and indicate the location of pregnancy in the uterus or outside it. The fertilized egg at this time is a rounded formation, free of echostructures, located in the upper or middle third uterine cavity. At 4 weeks of pregnancy, it is possible to identify the contours of the embryo. Enlargement of the uterus according to ultrasound data begins from the 5th week, formation of the placenta - from 6-7 weeks. Valuable information about the nature of the pregnancy can be obtained by measuring the uterus, ovum, embryo. Simultaneous determination of the size of the uterus and fertilized egg allows us to identify some pathological conditions. At normal sizes fertilized egg, there is a decrease in the size of the uterus with its hypoplasia. An increase in the size of the uterus is observed with uterine fibroids. On early stages pregnancy is determined by multiple births. Based on size and condition yolk sac you can judge how pregnancy proceeds in its early stages. Sonography is one of the most important methods for diagnosing undeveloped pregnancy. The contours are unclear and the size of the fetal egg is reduced, the embryo is not visualized, there is no cardiac activity or motor activity.

However, it is impossible to rely on a single study; especially in the early stages of pregnancy, dynamic monitoring is necessary. If repeated studies confirm these data, then the diagnosis of a non-developing pregnancy is reliable.

In more late dates Signs of threatened interruption due to the condition of the myometrium may be noted.

Often, if there is bloody discharge areas of placental abruption are determined, the appearance of echo-negative spaces between the wall of the uterus and the placenta, indicating the accumulation of blood.

Malformations of the uterus during pregnancy are detected better than outside it. Isthmic-cervical insufficiency is diagnosed if there is already a change in the cervix and prolapse of the membranes.

An extremely important aspect of ultrasound is the detection of fetal malformations. Identification of features of the condition of the placenta, localization, size, presence or absence of placentitis, structural anomalies, presence or absence of placental edema, infarction, degree of placental maturity, etc.

Amount of amniotic fluid: polyhydramnios can occur with fetal malformations and infection; oligohydramnios is a sign of placental insufficiency. Extremely important aspect the presence of placental abruption, retrochorial hematomas, the phenomenon of “migration” of the placenta.

An extremely important method for assessing the condition of the fetus is the Doppler assessment of uteroplacental and fetal placental blood flow, its correspondence to gestational age. Studies are carried out from 20-24 weeks of pregnancy with an interval of 2-4 weeks depending on the condition of the fetus. The spectra of blood flow velocity curves of the left and right uterine arteries, the umbilical cord artery and the middle cerebral artery fetus The assessment of blood flow velocity curves is carried out by analyzing the maximum systolic (MSSV) and end-diastolic blood flow velocity (EDSV) with the calculation of angle-independent indicators: systole-diastolic ratio, resistance index (IR) according to the formula:

IR = MSK - KDSK / MSK

Where the index (IR) is an informative indicator characterizing the peripheral resistance of the vascular system under study.

Cardiotocography - monitoring of the condition of the fetus is carried out starting from the 34th week of pregnancy with an interval of 1-2 weeks (according to indications).

Analysis of the contractile activity of the uterus can be carried out using a cardiac monitor, since the CTG recording can be carried out simultaneously with the recording contractile activity uterus, and can also be carried out by hysterography and tonusometry.

Hysterograms are recorded on a one- or three-channel dynamouterograph. For quantitative assessment of hysterograms, the device is equipped with a calibration device, the signal of which corresponds to 15 g/cm 2 . Registration is carried out with the pregnant woman lying on her back. On the front abdominal wall The sensor of the device is fixed in the area of the uterine body using a belt. The duration of a separate study is 15-20 minutes. Hysterograms are processed using qualitative and quantitative analysis, taking into account the duration, frequency, amplitude of an individual contraction.

Tonuometry - a tonumeter developed by A.Z. Khasin is used. et al. (1977). The device is made in the form of two cylinders of different diameters. Cylinder bigger size hollow. The second cylinder is smaller; the reference mass is located inside the first and can move relative to it. The degree of movement of the movable cylinder depends on the compliance of the support on which it is installed and the area of the end part of the inner cylinder. The depth of immersion of the movable cylinder into the underlying base is marked on the measuring scale of the tonemeter and is expressed in conventional units. The measurement is taken with the woman lying on her back. The device is installed along the midline of the abdomen on the anterior abdominal wall in the projection zone of the uterus. Uterine tone is measured in arbitrary units. When the tone meter readings are up to 7.5 c.u. The tone of the uterus is considered normal, and more than 7.5 c.u. regarded as an increase in the basal tone of the uterus.

Of course, an experienced clinician, when palpating the uterus, can tell whether it is toned or not, but when determining the effectiveness different methods therapy, when assessing different groups Observations do not require clinical conclusions, but an accurate digital reflection of the process, so this assessment method is very convenient, especially in antenatal clinics.

Other research methods necessary to assess the course of pregnancy: assessment of hemostasiogram, virological, bacteriological examination, grade immune status are carried out in the same way as during the study before pregnancy.

Daily monitoring blood pressure. Hemodynamic disturbances contribute to complications during pregnancy. Arterial hypertension is registered in 5-10% of pregnant women. Arterial hypotension occurs in 4.4% to 32.7% of pregnant women. An excessive decrease in blood pressure leads to hypoperfusion of the myocardium, brain, and skeletal muscles, which often contributes to complications such as dizziness, fainting, weakness, fatigue, etc. Long-term hypertension, as well as hypotension, has an adverse effect on the course of pregnancy. The method of daily blood pressure monitoring (ABPM) in pregnant women allows one to more accurately determine hemodynamic parameters than just a single determination of blood pressure.

The ABPM device is a portable sensor, weighing about 390 g (including batteries), which is attached to the patient’s belt and connected to the shoulder cuff. Before starting the measurement, the device must be programmed using a computer program (i.e., enter the required intervals for measuring blood pressure, sleep time). The standard ABPM technique involves measuring blood pressure over a 24-hour period at 15-minute intervals during the day and 30-minute intervals at night. Patients fill out a monitoring diary, in which they note the time and duration of periods of physical and mental activity and rest, the time of going to bed and waking up, the moments of meals and medications, the appearance and cessation of various changes well-being. These data are necessary for the doctor’s subsequent interpretation of ABPM data. After completing a 24-hour measurement cycle, the data is transferred via an interface cable to a personal computer for subsequent analysis, outputting the results to a monitor display or printer and storing them in a database.

When carrying out ABPM, the following quantitative indicators are analyzed:

Arithmetic averages of systolic, diastolic, mean arterial pressure and pulse rate (mm Hg, beats per minute).

Maximum and minimum blood pressure values in different periods days (mmHg).

Temporary hypertensive index - the percentage of monitoring time during which the blood pressure level was above the specified parameters (%).

Temporary hypotensive index - the percentage of monitoring time during which the blood pressure level was below the specified parameters (%). Normally, time indexes should not exceed 25%.

The daily index (the ratio of the daily average to the nightly average) or the degree of nighttime decrease in blood pressure and pulse rate is the difference between the daily and average nightly indicators, expressed in absolute numbers (or as a percentage of the daily average). For normal circadian rhythm blood pressure and pulse rate are characterized by at least a 10% decrease during sleep and a daily index of 1.1. A decrease in this indicator is usually characteristic of chronic renal failure, hypertension of renal, endocrine origin, hypertension during pregnancy and preeclampsia. Inversion of the daily index (its negative value) is detected in the most severe clinical options pathology.

The hypotension area index is the area limited below by a graph of pressure versus time, and above by a line of threshold blood pressure values.

Variability of SBP, DBP and heart rate, most often assessed by standard deviation from average size. These indicators characterize the degree of target organ damage in hemodynamic disorders.

Daily blood pressure monitoring in an obstetric clinic has a high diagnostic and prognostic significance. Based on the results of blood pressure monitoring used in the miscarriage clinic, the following conclusion can be drawn:

Daily monitoring of blood pressure in pregnant women makes it possible to identify and assess the severity of blood pressure much more informatively than with episodic measurements. arterial hypotension and hypertension.

Almost half of patients with miscarriage (45%) experience hypotension not only during early stages, but also throughout the entire period of pregnancy.

Despite the fact that recently in the world literature the problem of hypotension as pathological condition is debated and there is no clear final opinion regarding its nature, adverse influence hypotension on the course of pregnancy and condition intrauterine fetus obviously. We have identified a close relationship between hypotension and the presence of placental insufficiency in patients with a history of miscarriage, and in the presence of severe hypotension, more pronounced fetal suffering is also noted, confirmed by objective methods of functional diagnostics.

All pregnant women noted the “effect white coat", masking the true level of blood pressure, leading to erroneous diagnosis of hypertension and unjustified antihypertensive therapy, further aggravating the condition of the patient and the fetus.

Repeated daily monitoring of blood pressure throughout pregnancy will allow timely detection of not only initial signs changes in blood pressure in patients, but also to improve the quality of diagnosis of placental insufficiency and intrauterine fetal suffering.

Further study of the course of pregnancy, the condition of the patient and the fetus using this method will allow a deeper approach to the issues of pathogenesis arterial hypertension, hypotension during pregnancy, placental insufficiency. Daily monitoring blood pressure during pregnancy has not only diagnostic and prognostic, but also therapeutic significance, because allows you to determine your individual therapeutic tactics, its effectiveness, thereby reducing the incidence of pregnancy complications and improving the outcome of childbirth for the fetus.

The karyopyknotic index is a colpocytological indicator that reflects the percentage of the number of exfoliated mature cells to the rest in a vaginal smear. The results allow us to judge the estrogen saturation of the body. The CRPD is determined within the framework cytological examination hormonal background. The results are used to assess ovarian function, diagnose infertility, threatened miscarriage, disorders menstrual cycle, hormonal changes during menopause. For the study, material from a urogenital smear is used. The indicators are determined using the cytological method. The normal values depend on the phase of the monthly cycle: 7-10 days - 20-25%, 14 days - 60-85%, 25-28 days - 30%. Preparation of results takes 1 business day. In total, 16 addresses were found in Moscow where this analysis could be done.

The karyopyknotic index is a colpocytological indicator that reflects the percentage of the number of exfoliated mature cells to the rest in a vaginal smear. The results allow us to judge the estrogen saturation of the body. CPI is determined as part of a cytological study of hormonal levels. The results are used to assess ovarian function, diagnose infertility, threatened miscarriage, menstrual irregularities, and hormonal changes during menopause. For the study, material from a urogenital smear is used. The indicators are determined using the cytological method. The normal values depend on the phase of the monthly cycle: 7-10 days - 20-25%, 14 days - 60-85%, 25-28 days - 30%. Preparation of results takes 1 business day.

Colpocytology – complex laboratory tests aimed at studying rejected vaginal epithelial cells, changing their composition and ratio in different periods of the cycle. The karyopyknotic index is one of the studied indicators. It is based on the phenomenon of karyopyknosis - the process of maturation of epithelial cells, expressed by a decrease in cell nuclei and wrinkling of membranes. Pyknotic cells have nuclei less than 6 µm in diameter. RPI – the ratio of the number of cells with pyknotic nuclei to the number of cells with non-pyknotic nuclei. The indicator is expressed as a percentage and correlates with the concentration of estrogen.

Indications

The karyopyknotic index reflects estrogen saturation and ovarian functionality. Used to determine the day of ovulation and assess hormonal levels during reproductive age. Within the framework of colpocytology, the test is indicated in the following situations:

Menstrual irregularities. The definition of CPI is prescribed for amenorrhea, opsomenorrhea, oligomenorrhea, dysfunctional uterine bleeding. The result identifies changes in estrogen synthesis as the cause of cycle instability.
Infertility. The test is carried out for the purpose of confirmation/refutation hormonal reasons infertility, ovulation determination.
Complicated pregnancy. The study is used to monitor the pregnancy process in women at risk ( endocrine pathologies, miscarriages and premature births in the anamnesis), reveals the threat of spontaneous abortion.
Menopausal syndrome. Fading reproductive function accompanied by a decrease in estrogen levels, manifested by hot flashes, sweating, headaches, rapid heartbeat, and emotional instability. The analysis is performed to diagnose the syndrome.
Pathologies of sexual development in girls. The test is prescribed to assess the function of the ovaries and adrenal glands in case of prematurity or delayed puberty, manifested by early onset/absence of menstruation, small size of the uterus, and mammary glands.
Hormonal therapy. The study is performed to monitor treatment with estrogen drugs, determine the dosage, and the duration of the course of therapy.

Preparing for analysis

The material for the study is a smear taken from the anterolateral surface of the vagina. Preparation for the procedure consists of a number of rules:

A week before the study, you should consult with your doctor about the need to temporarily discontinue medications - hormonal drugs, antibiotics.

Two days before the procedure, sexual intercourse and the use of vaginal suppositories, douching, drinking alcohol, spicy food.

During the last hour you should refrain from urinating.

It is important to tell your doctor the exact date started menstrual bleeding. In case of inflammatory diseases of the vagina, uterine bleeding, the analysis is not performed - a large number of leukocytes, endometrial fragments reduces the accuracy of diagnosis.

A smear is taken by scraping the vaginal wall with an applicator or spatula. Biomaterial is being processed special drugs, more intensely staining the pyknotic nuclei. Using a microscope, the number of pyknotic and non-pyknotic cells is counted and the percentage is determined.

Normal values

Test data is expressed as a percentage. Norms of karyopyknotic index with undisturbed acid-base balance determined by the phase of the menstrual cycle:

Follicular (after bleeding, 7-10 days of the cycle) – 20-25%.
Ovulatory (12-15 days) – 60-85%.
The end of the luteal phase (25-28 days) – 30-35%.

During pregnancy, the reference values of the analysis are different. They depend on the period:

I trimester – 0-18%.
II trimester – 0-10%.
III trimester – 0-3%.
Before childbirth – 15-40%.

During menopause and postmenopause, CPI values range from 0 to 80%. Their interpretation is made taking into account other colpocytology tests.

Increasing value

The CPI increases with an excess of estrogen - hyperestrogenemia. The violation indicates a number of pathologies:

Endocrine diseases. Estrogen saturation increases with polycystic ovary syndrome, hormone-secreting tumors and ovarian cysts, hyperthecosis, pathologies of the adrenal glands, autoimmune thyroiditis, hypothyroidism, CTG-producing tumors of various locations.
Risk of spontaneous abortion. During pregnancy, an increase in test values reveals the threat of miscarriage or premature birth.
Precocious puberty. The karyopyknotic index increases with excessive activity of the adrenal glands and ovaries; in girls under 8-10 years of age, it confirms accelerated puberty.
Obesity. Adipose tissue contains an enzyme that converts androgens into estrogens.
Diseases of the gastrointestinal tract. The level of estrogen hormones increases due to disruption of their binding and excretion.
Taking medications. Hyperestrogenemia develops while taking hormonal, anti-tuberculosis and hypoglycemic drugs, barbiturates, and antidepressants.

Decrease in indicator

A decrease in CPI reveals estrogen deficiency - hypoestrogenemia. A downward deviation of the result is determined in a number of cases:

Inflammatory diseases of the genital organs. Among women reproductive age a decrease in estrogen manifests itself in chronic severe colpitis and vaginitis.
Irregularities of the monthly cycle. Irregular bleeding, scanty discharge, spotting, premenstrual syndrome expressed.
Delayed sexual development. Low CPI in girls 16 years of age and older reveals ovarian hypofunction, accompanied by the absence or weak expression of secondary sexual characteristics, late offensive menarche.
Pathologies of the pituitary gland. Violation of estrogen synthesis is determined by pituitary dwarfism, cerebral-pituitary cachexia, necrosis of the anterior pituitary gland.
Reception medicines. Estrogen deficiency can develop due to improper use of hormonal drugs, antidepressants, and nootropics.

Treatment of abnormalities

Karyopyknotic index is an indicator of estrogen saturation. The test allows you to detect an excess or deficiency of female sex hormones and is used for diagnosis reproductive health women monitoring pregnancy. The gynecologist and endocrinologist are responsible for interpreting the results and prescribing therapy.

The method is based on the fact that the degree of keratinization of the vaginal epithelium depends on the saturation of the body with estrogenic hormones. The vaginal wall is lined with stratified squamous epithelium, in which five layers are distinguished: the first two deepest layers are represented by basal and parabasal cells, which have round shape, a small value with a relatively large nucleus surrounded by a rim of protoplasm; the third layer refers to the cells intermediate type, which are larger than the cells of the basal layers, contain a medium-sized nucleus and significant amount basophilic protoplasm; the fourth and fifth layers form the surface cells of the multilayered epithelium; they are large polygonal formations with a small nucleus and acidophilic protoplasm. The colpocytological method belongs to the category of exfoliative, since desquamated cells are examined. There are two ways to collect material: contents posterior arch vagina is taken with a wooden spatula and smeared on a glass slide, or using a long pipette, a small amount is washed from the posterior fornix saline solution, sucking out the contents and applying it to a glass slide. In virgins last method preferable. The smear can be processed depending on the further method of examination: either simple staining, or polychrome, or staining of the dried smear with luminescent dyes.

The reaction of the vaginal epithelium (the level of saturation of the body with sex hormones) is assessed using a ten-point scale by Schmitt (1954), including the following gradations: 1, 1-2, 2-1, 2, 3-2, 2-3, 3, 3-4, 4-3, 4, in which reaction 1 indicates a sharp lack of estrogen hormones, and reaction 4 indicates a high content of hormones. In addition to the numerical assessment of the reaction, it is also important to determine the type of smear, which can be androgenic, follicular, luteal. The last division is very important to take into account, since with the same degree of estrogen saturation, for example, reaction 3-4, the smear can be either follicular or luteal type. In addition, it is also mandatory to determine the percentage of cells in the vaginal smear of various layers of multilayered epithelium. Most widespread received a study of the karyopyknotic index (KPI), i.e., calculation of the ratio of keratinized cells of the superficial layers with a pyknotic nucleus to other cells of the smear. For this purpose, 100 or 200 cells are counted in a smear. Most high performance KPI correspond most high content estrogens (Fig. 7, 8).

Rice. 7. Graphic representation of the excretion of estrogen fractions during a normal menstrual cycle (according to E.I. Petranyuk). a - estrone excretion; b - estradiol; c - estriol.

Rice. 8. Fluctuations in the karyopyknotic index during the two-phase menstrual cycle (according to Zinser).

In a normal menstrual cycle, at the beginning of it, the third reaction of the vaginal smear is usually detected. The smear contains cells of the intermediate layer of various sizes, located, as a rule, separately from each other (estrogenic type), CPI - within 20-25%; by the time of ovulation, the 3rd-4th or 4th-3rd reaction is determined, the epithelial cells become large, polygonal with a small, sometimes pyknotic nucleus, with pale colored protoplasm, located separately or in small groups; after ovulation (exposure to progesterone), the cells are located in large groups, clusters, have tucked edges (scaphoid cells) - a picture appears characteristic of the so-called luteal type of smear; The CPI at the time of ovulation reaches 60-80%.

The diagnostic value of colpocytological examination is very high and is confirmed by the results comparative studies when using other methods (I. D. Arist, 1961; M. G. Arsenyeva, 1963, etc.). The most complete picture of the phases of the menstrual cycle is provided by a dynamic examination of smears.

With bleeding, with inflammatory lesions vagina and cervix, the colpocytology method cannot give an exact answer about the degree of hormonal saturation of the body, and therefore, in recent years, in such cases (as well as in virgins), they have resorted to examining urine sediment (urocytogram), since epithelial cells urinary tract During the menstrual cycle, they undergo regular changes that are in accordance with the degree of saturation of the body with estrogen. For cytological examination of urine sediment, it is recommended to use the first portion of morning urine, then the urine is filtered through cotton wool and the elements deposited on the cotton wool are smeared on a glass slide; The staining method is the same as when processing a vaginal smear. The smear is assessed by the number of keratinized, keratinized, intermediate, basal and non-nuclear elements (Fig. 9).

Rice. 9. Urocytogram for a two-phase menstrual cycle (according to Castellanos, Sturgis).

By horizontal axis- day of the month and day of the cycle, vertically - percentage cells: a - keratinized; b - keratinizing; c - intermediate; g -basal, a - non-nuclear.

1. Smear for general cytology.

Purpose: diagnostic

Objectives: taking smears from the urethra, cervical canal, vagina for bacterioscopic and colpocytological studies

Indications: determination of the state of vaginal biocenosis, diagnosis inflammatory diseases

Equipment: soap, gloves, gynecological chair, mirrors, clean dry glass slide, bacteriological loop, Volkman spoon, warm saline solution (37˚C), containers with disinfectant solutions, direction indicating full name. patient, age, nature and date of material collection.

Methodology:

a) Write out the direction.

b) Wash your hands with soap and dry, put on gloves.

c) Place the patient on a gynecological chair in the dorso-gluteal position with the legs apart and bent in hip joints feet.

d) Initially, material is taken from the urethra, then the cervical canal and vagina.

e) Collection of material from the urethra. Insert the bacteriological loop into the urethra 2-3 cm, move the plane of the “eye” of the loop towards the opening, lightly pressing on the back and side walls of the urethra. Remove the loop and place it on the surface of the glass slide, moving it several times with light pressure.

f) Insert the speculum in a closed state to the entire depth of the vagina, open it and fix it in this position with a lock.

g) Collection of material from the vagina to prepare a native smear. Insert a bacteriological loop into the posterior or lateral vaginal fornix and take material. Apply a few drops of warm saline solution to the slide. Vaginal discharge mix with a drop of saline solution, cover with a coverslip and send to the laboratory.

h) Collection of material from the cervical canal. Insert the Volkmann spoon into the cervical canal 1-2 cm and rotate several times. Apply the resulting material to a glass slide and make a thin, even smear in the form of a horizontal stroke. Air dry.

i) Remove the speculum from the vagina.

j) Soak all used material: gloves, tools, soft equipment in a disinfectant solution.

k) Wash your hands with soap and dry.

2. Papanicolaou smear (Paptest) - method morphological analysis, based on the study and evaluation of cellular material. The method makes it possible to assess the structure and cellular level of damage to tissues caught in the smear. Cytological criteria are based on the severity of signs of cellular atypia.

Revealing morphological features cells characterizing a specific pathological process.

Indications:

Screening for cervical cancer (cervical cancer).

Preparing for the study:

During the day before the test, you should not douche or use vaginal preparations. It is advisable to abstain from sexual intercourse for 1-2 days before the test. You cannot take material for research during menstruation.

To obtain the material, the following instruments are used: Eyre's spatula (for taking smears from the surface of the ectocervix), Volkmann spoon, screenet, endobranche (for taking endocervix cervical smears and etc.).

To obtain optimal cytological results, samples should be taken separately from the ectocervix and endocervix. The material is taken before bimanual examination.

After inserting the speculum into the vagina, remove discharge from the surface of the cervix with a cotton swab. The tip of an Eyre spatula is inserted into the external uterine os, and the cellular composition from the exocervix (from stratified squamous epithelium) and from the junction of the endocervix and exocervix (from the zone of metaplastic epithelium). Then a special brush (cer-brash) is inserted into the cervical canal by 1-2 cm and material is taken from the walls of the cervical canal with a rotational movement. The resulting material is distributed thin layer on the surface of fat-free glass slides marked according to the place of collection. The smears are air dried.

Interpretation of results: classification of cervical smears according to Papanicolaou

First class - no atypical cells, normal cytological picture.

The second class is a change in the morphology of cellular elements caused by inflammatory process in the vagina and/or cervix.

The third class is single cells with abnormalities of the cytoplasm and nuclei.

Fourth class - separate cells with clear signs malignancy: increased nuclear mass, cytoplasmic abnormalities, nuclear changes, chromosomal aberrations.

Fifth class - a large number of atypical cells are observed in the smear.

3. Method of taking smears for hormonal cytology.

The dynamics of changes in colpocytological parameters reflects the total fluctuation in the level of ovarian hormones in the body throughout the menstrual cycle. The method allows you to assess the level of estrogen, progestogen, and, in some cases, androgen saturation of the body.

The material is taken from the anterior fornix with a spatula or swab and evenly applied to a glass slide. A series of smears are taken in the dynamics of the menstrual cycle with a focus on its middle (ovulation dates): 4-9, 10-13, 14-15, 16-20, 21-28 days of the cycle. After polychrome staining, the ratio of parabasal, intermediate and superficial cells, expressed in the maturation index (MI), is examined in the smear. Karyopyknotic index (KPI) is the percentage of cells with small, pyknotic nuclei per 100 surface cells. Eosinophilic index (EI) - the percentage of eosinophilically stained cells of the superficial layers per 100 superficial cells. The maximum values of all three indicators at the time of ovulation: IS 0/15/85%, CPI - 80.7 ± 9.3, EI - 75.4 ± 0.6.