处理罕见临产合并粘连性巨脾患者1例报道

张欣蔚 付安冉 姜雅倩 王麦建

[关键词] 巨脾;粘连性巨脾;妊娠;临产

[中图分类号] R675.6          [文献标识码] C          [文章编号] 1673-9701（2021）21-0151-04

Report on a case of treatment for a rare parturition complicated with adhesive megalosplenia

ZHANG Xinwei1   FU Anran1   JIANG Yaqian1   WANG Maijian2

1.Department of Gynecology and Obstetrics， Affiliated Hospital of Binzhou Medical University， Binzhou   256600， China; 2.Department of Gastrointestinal Surgery， Affiliated Hospital of Zunyi Medical University， Zunyi   563000， China

[Abstract] Adhesive megalosplenia is extremely rare in clinic， and its operation is difficult and risky. If it is a female patient， there is usually a process of gestation. In late gestation， the megalosplenia may impact the production and even endanger her life. The treatment of simple adhesive megalosplenia is very difficult in clinic， and it is more difficult to operate when adhesive megalosplenia complicated with late gestation. A parturition complicated with congenitally adhesive megalosplenia was admitted to our hospital. An extraperitoneal cesarean section was adopted， and the cesarean section was successfully performed. Finally， the patient recovered and was discharged from hospital. The operation for parturition complicated with adhesive megalosplenia has not been reported before， and it was the first time for us. Meanwhile， the effect was satisfying. Therefore， it was reported in this paper.

[Key words] Megalosplenia; Adhesive megalosplenia; Gestation; Parturition

在普外中脾切除術非常常见，但对于巨脾及脾周围粘连患者的切除仍颇具困难。广泛粘连性巨脾主要见于晚期血吸虫病肝硬化门脉高压症的患者。血吸虫病肝纤维化可导致门脉高压合并巨脾，患者均有不同程度的肝损害，表现为凝血酶原时间延长、血小板减少、低蛋白血症及腹水[1]。粘连性巨脾手术难度大、风险高。孕妇可在妊娠期间合并各种外科疾病，临床上约1/500的妊娠期患者需要进行非产科外科手术[2]。由于妊娠期解剖和生理的改变，妊娠合并外科疾病的临床特点与非孕期有些不同，妊娠与外科疾病相互影响，易造成误诊，应引起妇产科和外科医生的高度重视。当粘连性巨脾合并晚期妊娠时，手术处理难度更大，治疗及诊断不及时往往导致严重并发症、增加患者病死率。

1 资料与方法

1.1 一般资料

患者，女，25岁，因“停经38+5周，规律性腹痛伴阴道流液1 h”于2013年2月27日收入遵义医科大学附属医院产科。既往无妊娠及流产病史，曾明确诊断先天性巨脾2年，既往无贫血、无频发感染、自发出血表现。入院产科情况：神志清晰，精神良好，生命体征平稳，扪及宫缩，2次/10 min，持续25～30 s，强度+—++，宫高30 cm，腹围93 cm，胎位ROA，胎心140次/min，头先露，浮。骨盆外侧量因身材矮小未侧。骨盆内测量：可触及骶骨岬，入口前后径10 cm，骶棘韧带3 cm，骶耻内径12 cm，坐骨棘间径6 cm，坐骨结节间径8.5 cm，耻骨弓角度>90°，骶尾关节活动好，跨耻征阳性。肛查：宫颈管长1 cm，宫口松1指，先露头-3，坐骨棘不凸，尾骨不翘，骶尾关节活动可。阴道窥诊：后穹窿见液池，色清，pH>7。腹部情况：腹部明显膨隆，下腹部深压痛，余腹无压痛，无反跳痛肌紧张，肠鸣音正常。触诊脾脏下缘位于耻骨联合上4 cm，内侧缘位于右侧锁骨中线内1 cm，叩诊浊音。辅助检查：产科彩超：头位，晚孕，单活胎，双顶径89 mm，股骨长71 mm，羊水指数119 mm。腹部彩超常规：脾脏下缘达脐下4横指，表面光滑，内部回声均匀。血常规提示：白细胞、血红蛋白、血小板均在正常范围内。凝血功能正常。入院诊断：①38+5周妊娠临产孕1产0;②ROA;③先天性巨脾;④骨盆狭窄;⑤跨耻征阳性。入院后根据骨盆内测量结果，考虑骨盆入口临界狭窄，中骨盆狭窄，不能经阴道分娩，评估具备剖宫产手术指征并联系我科做好台上会诊准备，完善术前准备后急诊行剖宫产。