妊娠合并脑病的临床诊治

Clinical diagnosis and treatment of pregnancy complicated encephalopathies

目的分析妊娠合并脑病的临床特点、诊治及预后。方法 2007年4月至2017年12月首都医科大学附属北京天坛医院收治的42例妊娠合并脑病患者进行回顾性总结,其中合并颅内静脉窦血栓28例、海绵状血管瘤9例、脑胶质瘤5例。结果 (1)临床表现:25例确诊妊娠期和产褥期颅内静脉窦血栓患者中,首发症状22例(88%)是头痛,2例(8%)言语不利、视物模糊,1例(4%)以突发恶心、呕吐为主。9例妊娠合并海绵状血管瘤患者,3例(33%)无症状,4例(44%)出现脑出血,2例(22%)继发癫痫。妊娠合并脑胶质瘤的临床表现主要是颅内压增高及神经功能缺失。(2)治疗及预后:25例妊娠期和产褥期颅内静脉窦血栓患者,5例(20%)入院后经脱水、降颅压、抗凝等积极治疗病情危重,出现脑疝征象,家属放弃治疗;其余20例(80%)病情好转出院。9例妊娠合并海绵状血管瘤患者中,7例(78%)在妊娠期保守治疗,妊娠过程顺利,妊娠37～38周行剖宫产;1例(11%)在妊娠20周行海绵状血管瘤切除术,于妊娠36周行剖宫产;1例(11%)在妊娠34周出现海绵状血管瘤出血,症状逐渐加重,36周行剖宫产。5例妊娠合并脑胶质瘤患者中,1例剖宫产术后10 d发现脑胶质瘤患者因瘤巨大、位置深家属放弃治疗;1例妊娠中期发现脑胶质瘤,在妊娠25周行开颅手术,病理胶质母细胞瘤,妊娠34周行剖宫产;3例为脑胶质瘤术后3～11年,病理胶质母细胞瘤,术后随诊无复发妊娠,37～39周行剖宫产。结论妊娠合并这三种脑部疾病临床少见,临床表现无特异性,处理棘手,需多学科协作,制定个体化治疗方案。

Objective To analyze the clinical features, diagnosis, treatment and prognosis of pregnancy complicated with encephalopathy. Methods 42 cases of pregnancy complicated with encephalopathy admitted to our hospital from April 2007 to December 2017 were retrospectively reviewed, including 28 cases of intracranial sinus thrombosis, 9 cases of cavernous hemangioma, and 5 cases of glioma. Results(1) Clinical manifestations: Among the 25 patients with confirmed intracranial venous sinus thrombosis during pregnancy and puerperium, of the first symptoms 22(88%) were headaches, 2 cases(8%) were unfavorable blurred vision, and 1 case(4%) with sudden nausea and vomiting. Of the 9 patients with cavernous hemangioma of pregnancy, 3(33%) were asymptomatic, 4(44%) had cerebral hemorrhage, and 2(22%) had secondary epilepsy. The clinical manifestations of pregnancy with glioma were mainly increased intracranial pressure and loss of nerve function.(2) Treatment and prognosis: 25 cases were gestational and puerperal intracranial venous sinus thrombosis. 5 cases(20%) gave up treatment after treated with dehydration, intracranial pressure, anticoagulation and other active treatment of critical illness, when cerebral palsy signs appears. The remaining 20 cases(80%) were better and discharged. Of the 9 patients with cavernous hemangioma of pregnancy, 7(78%) were conservatively treated during pregnancy, and the pregnancy process were safe. The cesarean section was performed at 37 to 38 weeks of gestation;1 case(11%) with hemangioma resection was spongy at 20 weeks of gestation. and underwent cesarean section at 36 weeks of gestation;1 case(11%) showed cavernous hemangioma hemorrhage at 34 weeks of gestation, the symptoms gradually worsened with cesarean section at 36 weeks. Of the 5 patients with gestational glioma, one patients with glioma were found to have a large and deep tumor and gave up treatment 10 days after cesarean section;1 case of glioma was found in the middle of pregnancy, craniotomy was performed at 25 weeks of gestation, pathology showed glioblastoma, and under went cesarean section at 34 weeks of gestation;3 cases of glioma 3 to 11 years after operation, pathological results were astrocytoma, and follow-up without recurrence, 37 to 39 weeks underwent caesarean section. Conclusions Pregnancy with these three kinds of brain diseases are rare in clinical practice, the clinical manifestations are non-speciíc, and the treatment is tricky. It requires multidisciplinary collaboration to develop individualized treatment plans.