妊娠合并急性胰腺炎的临床特点与诊治策略

Clinic Feature of Acute Pancreatitis in Pregnancy and Strategy in Diagnosis and Treatmenet

目的:探讨妊娠合并急性胰腺炎(AP)的临床特征和诊治策略。方法:回顾分析31例妊娠合并AP患者的临床资料,其中重症急性胰腺炎(SAP)7例,轻症急性胰腺炎(MAP)24例。入院后均先接受非手术综合治疗。结果:因胎儿宫内窘迫急诊行剖宫产3例,术中1例MAP未扰动胰腺仅行腹腔引流,2例SAP行小网膜囊灌洗和腹腔引流,其中1例合并胆囊结石加行胆囊切除术。1例SAP积极非手术治疗效果差,行急诊胰腺坏死组织清除、胰周引流术,同时行剖宫产娩出死亡早产儿。其余患者均在AP病情好转后终止妊娠,全组在住院期间终止妊娠共13例(41.9%),胎儿(新生儿)死亡2例(6.5%),母亲无死亡。结论:妊娠合并AP多见于晚孕期,胆道疾病和高脂血症等是其主要病因。临床表现不甚典型,上腹痛伴上中腹部固定压痛,血淀粉酶和脂肪酶升高以及B超发现异常等具有重要诊断意义。合并MAP者常可安全地维持妊娠,合并SAP者亦以内科治疗为主,必要时早期手术,术中先行剖宫产。是否终止妊娠应个体化处理,优先保证孕妇安全,必要时果断终止妊娠。终止方法首选剖宫产,术中根据胰腺炎病因和术中发现做相应外科处理。经过恰当的诊治,妊娠合并AP可望获得良好预后。

Objective：To study the clinic feature of acute pancreatitis in pregnancy and strategy in diagnosis and treatment. Methods： Thirty-one cases of acute pancreatitis in pregnancy admitted from Jan 1997 to Nov 2006 were reviewed. There were 7 cases of severe acute pancreatitis （SAP） and 24 cases of mild acute pancreatitis （MAP） in this group, and all patients conceived non-operation medical treatment first after hospitalization. Results： Uterine-incision delivery in emergency was performed in 3 cases due to fetal distress in uterus. One case of MAP merely conceived abdominal cavity drainage without perturbation on pancreas, while catheters were put in lesser sac in 2 cases of SAP and lavation were adopted after operation. Cholecystectomy was selected because of cholecystolithiasis in one patient. One patient conceived emergency operation due to poor outcome of medical treatment, in which clearance of necrotic tissue in pancreas and peri-pancreas drainage was performed after uterine-incision delivery. The termination of pregnancy was selected in 13 cases during hospital stay, 2 cases of death occurred in fetus or neonate with no death in mothers. Conclusion： Acute pancreatitis develops mainly in late stage of pregnancy and its primary causes are disease in biliary tract and hyperlipemia. Clinical manifestation of this disease is not typical enough. Epigastric pain with fixed tenderness on upper-mid-abdomen, elevation of amylase or lipase in serum and some specified signs in examination by ultrasound are important evidences in diagnosis. Acute pancreatitis in pregnancy should receive conservative therapy, pregnancy could be maintained securely in those patients accompanying with MAP. Early operation is essential in a few patients suffering from SAP, in which uterine-incision delivery should be performed at first. Individualization in decision of termination of pregnancy is reasonable, but it must be kept in mind that the safety of mother should be ensured chiefly. The best way to terminate pregnancy is uterine-incision delivery, surgical treatment can be choosen according to the etiological factor of pancreatitis and finding in exploration. It is concluded that acute pancreatitis in pregnancy can gain well prognosis via correct diagnosis and treatment.