張欣蔚 付安冉 姜雅倩 王麥建

[關(guān)鍵詞] 巨脾;粘連性巨脾;妊娠;臨產(chǎn)

[中圖分類號(hào)] R675.6? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] C? ? ? ? ? [文章編號(hào)] 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(shù)非常常見，但對(duì)于巨脾及脾周圍粘連患者的切除仍頗具困難。廣泛粘連性巨脾主要見于晚期血吸蟲病肝硬化門脈高壓癥的患者。血吸蟲病肝纖維化可導(dǎo)致門脈高壓合并巨脾，患者均有不同程度的肝損害，表現(xiàn)為凝血酶原時(shí)間延長、血小板減少、低蛋白血癥及腹水[1]。粘連性巨脾手術(shù)難度大、風(fēng)險(xiǎn)高。孕婦可在妊娠期間合并各種外科疾病，臨床上約1/500的妊娠期患者需要進(jìn)行非產(chǎn)科外科手術(shù)[2]。由于妊娠期解剖和生理的改變，妊娠合并外科疾病的臨床特點(diǎn)與非孕期有些不同，妊娠與外科疾病相互影響，易造成誤診，應(yīng)引起婦產(chǎn)科和外科醫(yī)生的高度重視。當(dāng)粘連性巨脾合并晚期妊娠時(shí)，手術(shù)處理難度更大，治療及診斷不及時(shí)往往導(dǎo)致嚴(yán)重并發(fā)癥、增加患者病死率。

1 資料與方法

1.1 一般資料

患者，女，25歲，因“停經(jīng)38+5周，規(guī)律性腹痛伴陰道流液1 h”于2013年2月27日收入遵義醫(yī)科大學(xué)附屬醫(yī)院產(chǎn)科。既往無妊娠及流產(chǎn)病史，曾明確診斷先天性巨脾2年，既往無貧血、無頻發(fā)感染、自發(fā)出血表現(xiàn)。入院產(chǎn)科情況：神志清晰，精神良好，生命體征平穩(wěn)，捫及宮縮，2次/10 min，持續(xù)25～30 s，強(qiáng)度+—++，宮高30 cm，腹圍93 cm，胎位ROA，胎心140次/min，頭先露，浮。骨盆外側(cè)量因身材矮小未側(cè)。骨盆內(nèi)測(cè)量：可觸及骶骨岬，入口前后徑10 cm，骶棘韌帶3 cm，骶恥內(nèi)徑12 cm，坐骨棘間徑6 cm，坐骨結(jié)節(jié)間徑8.5 cm，恥骨弓角度>90°，骶尾關(guān)節(jié)活動(dòng)好，跨恥征陽性。肛查：宮頸管長1 cm，宮口松1指，先露頭-3，坐骨棘不凸，尾骨不翹，骶尾關(guān)節(jié)活動(dòng)可。陰道窺診：后穹窿見液池，色清，pH>7。腹部情況：腹部明顯膨隆，下腹部深壓痛，余腹無壓痛，無反跳痛肌緊張，腸鳴音正常。觸診脾臟下緣位于恥骨聯(lián)合上4 cm，內(nèi)側(cè)緣位于右側(cè)鎖骨中線內(nèi)1 cm，叩診濁音。輔助檢查：產(chǎn)科彩超：頭位，晚孕，單活胎，雙頂徑89 mm，股骨長71 mm，羊水指數(shù)119 mm。腹部彩超常規(guī)：脾臟下緣達(dá)臍下4橫指，表面光滑，內(nèi)部回聲均勻。血常規(guī)提示：白細(xì)胞、血紅蛋白、血小板均在正常范圍內(nèi)。凝血功能正常。入院診斷：①38+5周妊娠臨產(chǎn)孕1產(chǎn)0;②ROA;③先天性巨脾;④骨盆狹窄;⑤跨恥征陽性。入院后根據(jù)骨盆內(nèi)測(cè)量結(jié)果，考慮骨盆入口臨界狹窄，中骨盆狹窄，不能經(jīng)陰道分娩，評(píng)估具備剖宮產(chǎn)手術(shù)指征并聯(lián)系我科做好臺(tái)上會(huì)診準(zhǔn)備，完善術(shù)前準(zhǔn)備后急診行剖宮產(chǎn)。