文摘

医疗和外科疾病在怀孕可以非常具有挑战性的产科医生妇科医生即使在资源富裕国家。达到准确的诊断和admininstering适当的管理是很困难的在一个持续的怀孕。涉及从其他学科专家的重要性(多学科治疗)在怎么强调都不为过。我们提出一个有趣的十二指肠溃疡穿孔的情况下怀孕的患者,回顾文献,讨论了鉴别诊断和评估这个罕见的疾病的管理原则。

1。介绍

消化性溃疡疾病在怀孕和pureperium(手)是罕见。怀孕了几个困难消化性溃疡的诊断和管理。首先手的症状(恶心、呕吐上腹不适)在怀孕也很常见,其次诊断测试的手一般人群(上消化道系列x射线和esophagogastroduodenoscopy还)仅在妊娠表现非常犹豫,第三在普通人群中一些药物用于手(例如,米索前列醇)在妊娠禁忌。不过及时诊断和及时管理前脚在怀孕是必不可少的并发症会导致相当重要的为病人发病甚至死亡。我们提出一个有趣的案例在产褥期的十二指肠溃疡穿孔。

2。情况下

27岁初次分娩的患者呈现给我们单位当她38-week怀上了投诉的反复发作呕吐、全身不适、背痛、和模糊的下腹部不适。怀孕已经平淡无奇。她参加产前诊所当她怀孕10周预订预约。她没有重大病史,没有药物治疗。预订血液测试以及超声波扫描(同时预订和20周)是正常的。承认在38周怀孕是她第一次进入医院。在入学体检她看起来相当不舒服。她的体温是36°C。血压和脉搏是正常的。她的腹部是软,不温柔。 Uterine fundal height was consistent with gestational age. Cardiotocography (CTG) demonstrated a reassuring fetal heart pattern. A presumptive diagnosis of urinary tract infection was made. Blood sample was obtained for FBC (full blood count), serum urea and electrolytes (U&E), Liver function tests (LFT), and C-reactive protein (CRP). A mid-stream urine sample was sent for culture and sensitivity, and she was started on antiemetics and antibiotics. The blood tests showed a serum potassium of 3.4 mmol/l (3.5–5.5 mmol/l) and a raised CRP of 25 mg/L (1–10 mg/L). In spite of regular antiemetics, the patient’s vomiting became worse, occurring more frequently and becoming increasingly bile stained. The abdominal pain also became more localized to the upper abdomen. Uterine contractions ensued the same day, and she had ventouse delivery early hours of next morning on account of persistent decelerations of fetal heart rate on the CTG (cardiotocography) at full cervical dilatation. after delivery, the patient’s upper abdominal pain and vomiting continued. She also developed quite significant tenderness in the epigastrium. General surgeons were asked to see the patient. Blood tests were repeated; an abdominopelvic ultrasound scan and a chest X-ray were requested. The ultrasound scan showed a collection of fluid in the right upper quadrant of the abdomen (measuring about 8.5 × 3 cm). The fluid appeared to surround the liver and gall bladder. Liver, gall bladder, and kidneys looked normal. Uterus and ovaries looked normal. Chest X-ray was normal. Other than an increase in CRP to 131 mg/L, all the blood tests (FBC, U&E, LFT) remained normal. Based on the worsening clinical condition and these investigations, a diagnostic laparoscopy was performed. Laparoscopy revealed copious amount of pus and extensive adhesions around the stomach. Laparotomy (with a midline incision) was performed. This revealed an anterior perforation of the 2nd part of the duodenum. The perforation was repaired. An omental patch (Graham’s patch) support was created. A Nasogastric tube was left in after the operation, and the patient was kept nil by mouth for 24 hours. The patient made an uneventful postoperative recovery and was discharged home on the 7th postoperative day. She was discharged on omeprazole for a month, and clarithromycin/metronidazole for a week.

3所示。讨论和评估

多种流行病学研究支持前脚的发生率降低(消化性溃疡疾病)的怀孕和pueperium [1]。

一些理论解释怀孕期间前脚的发生率明显下降。解释了罕见的1945年,Horwich怀孕的消化性溃疡关联与增加前pituitary-like荷尔蒙的分泌胃酸过少尿(2]。它也表明,女性妊娠激素(尤其是孕激素)减少溃疡形成的速率增加胃粘液的合成。增加等离子体在怀孕hitasmine(胎盘组胺酶合成所致)增加产妇组胺代谢,从而减少胃酸分泌在怀孕期间(3]。避免产生溃疡的因素,如吸烟、酒精和非甾体抗炎药(非甾体类抗炎药)可能有助于减少妊娠期布丁的。

尽管所有这些原因前脚发生在怀孕和pueperium。诊断通常是在怀孕后期了灾难性的后果。在1962年的文献综述,保罗等人描述14例十二指肠溃疡穿孔在怀孕14女人失去了生命的所有4]。

手的症状是模仿其他常见的胃肠道疾病在怀孕(如胃食管返流疾病,恶心和呕吐的怀孕,妊娠剧吐,和胆囊炎)。红衣主教前脚的症状是疼痛,恶心和呕吐。疼痛通常是上腹部,晚上更糟糕。在存在妊娠子宫(特别是当工党随之而来)对本地化疼痛的病人可能会很困难。在我们的病人,小腹疼痛最初本地化!与返流性疾病的痛苦不是躺着或加剧了与返流有关。尽管恶心和呕吐发生在正常妊娠的50% - -80%,是罕见的细致谨慎这些症状持续超过妊娠。怀孕的恶心和呕吐是经典早上最强烈而前脚症状更糟的在夜里和白天餐后。手与增加妊娠症状也变得更糟,因此通常在第三阶段最严重。偶尔手可能会出现吐血。 Uncomplicated PUD produces minimal physical signs. When complicated physical signs are often present, abdominal tenderness (or even guarding), rebound tenderness, and fecal occult blood may be present.

管理应该是多学科涉及产科医生、肠胃科、外科医生。

基线调查应包括全血细胞计数、血清尿素和电解质,肝功能检测,血清淀粉酶。腹部超声评价有助于排除cholelithiases和胆石胰腺炎。尽管腹部x射线一般在怀孕禁忌,他们必须被执行时涉嫌胃肠道穿孔评估气腹的存在。及时诊断和治疗的孕产妇和胎儿的利益远远大于任何胎儿致畸性或儿童癌症的风险。一些研究显示,当表示(例如,患者的胃肠道出血或胃出口梗阻)esophagogastroduodenoscopy(还)是安全的对胎儿和母亲(5]。当疑似胃肠道穿孔时,还是禁忌。这是因为内窥镜插管包含穿孔可以转换成自由腹腔内穿孔从而促进腹腔内泄漏污染的肠道的内容。

轻微症状病人的手,生活方式的改变(避免高脂肪食物、咖啡因、吸烟、酒精、和非甾体抗炎药)或药物如抗酸药或组胺受体拮抗剂,例如,可以使用雷尼替丁。手术时穿孔成了强制性的怀疑。早期手术改善孕产妇和胎儿的预后。液体复苏和纠正电解质失衡应制定了手术前。十二指肠穿孔手术通常涉及格雷厄姆补丁关闭(主要与网膜的补丁支持闭包)。早产患者在诊断时,剖腹手术可能导致早产,因此肌肉的类固醇政府必须考虑胎儿肺成熟。

术后抗生素应该至少持续了一个星期。治疗手必须开始,一直持续到病人的随访诊所。我们的病人开始奥美拉唑PPI(质子泵抑制剂)。这些代理是高度有效的治疗十二指肠溃疡,可以使用一次病人了。他们的安全然而目前在怀孕是未经证实的,因为缺乏临床数据。明确后续指令之前必须给定放电。

4所示。结论

消化性溃疡疾病的并发症发生在怀孕(尽管很少)。通常当他们发生时,诊断是很晚了导致严重的发病率。在上面的例子中,我们试图突出主要特征寻找诊断复杂的手在怀孕。我们还概括了在怀孕十二指肠溃疡穿孔的管理。我们希望这个会增加卫生工作者的意识这一罕见的并发症十二指肠溃疡的怀孕。