妊娠合并鞍区占位择期神经外科手术后的母婴结局分析

Maternal and infant outcomes after elective neurosurgery for occupying lesions in saddle area during pregnancy

目的探讨妊娠合并鞍区占位择期行神经外科手术患者的妊娠结局。方法回顾性分析2017年6月至2018年2月在上海交通大学医学院附属瑞金医院收治的妊娠合并鞍区占位并行手术治疗的5例患者的临床资料,包括手术孕周、围术期管理、手术方式及术后并发症、妊娠结局及病理类型等。结果(1)5例患者均因妊娠期进行性加重的视力损伤为主诉就诊,均经头颅MRI(平扫)发现鞍区占位,考虑存在视神经压迫,继续期待治疗有视神经萎缩、致盲风险,手术指征明确。其中2例孕晚期手术,3例孕中期手术;脑膜瘤2例,垂体大腺瘤2例,垂体脓肿1例。5例手术顺利,仅1例术后出现少量脑脊液鼻漏症状(术后3个月左右好转),余4例均未出现并发症。5例患者术后视力均较术前有明显改善。术后随访4~12个月,鞍区占位未复发。(2)5例中,4例均妊娠至足月或近足月分娩,其中3例(包括1例臀位妊娠,1例瘢痕子宫、双胎妊娠,1例妊娠期高血压疾病、血压控制不佳)因产科因素行剖宫产终止妊娠,1例阴道分娩,产后42d随访子宫复旧良好;另1例因垂体脓肿术后用药放弃妊娠,于孕20周行乳酸依沙吖啶羊膜腔注射引产。5例新生儿生后1、5、10min Apgar评分均为10分,外观均未见畸形,生后随访4~12个月生长发育均正常。结论对于妊娠合并鞍区占位患者,应权衡利弊,根据患者具体情况,选择个体化的治疗方案。若期待治疗至分娩后手术可能引起不可逆转的影响,甚至威胁生命安全,则应由多学科合作,于孕中晚期择期行鞍区占位切除手术是相对安全可行的。

Objective To investigate the perinatal outcomes after elective neurosurgery in pregnant women complicated by space-occupying lesions in saddle area. Methods Clinical data were retrospectively collected and analyzed from five gravidas with space-occupying lesions in saddle area, who underwent neurosurgery at Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from June 2017 to February 2018, including gestational age, perioperative management, surgical procedures, postoperative complications, pregnancy outcomes and pathological results. Results (1) Progressively deteriorated impaired vision was the chief complaint of all five patients. Space-occupying lesions in saddle area were detected by cranial MRI (plain scan). The surgical indication was clear as there was compression on optic nerve and a risk of blindness due to optic nerve atrophy. Two patients were operated in the third trimester and three in the second trimester. Postoperative pathology showed there were two cases with meningioma, two with pituitary macro adenoma and one with abscess of pituitary. Only one patient had mild postoperative cerebrospinal fluid rhinorrhea, which was improved three months later, and no complications were reported in the other four cases. All five patients had obvious improvement of vision after surgical intervention and no relapse was reported during a follow-up of 4-12 months.(2) Four gravidas continued their pregnancies to full or nearly full term, among which three underwent cesarean section due to obstetrical indications (one breech pregnancy, one twin pregnancy with scarred uterus and one complicated by hypertensive diseases of pregnancy with poor blood pressure control) and one delivered vaginally. Postpartum involution of the uterus was well in all of the four cases 42 d after delivery. The women with pituitary abscess terminated the pregnancy due to intraamniotic injection of ethacridine lactate at 20 weeks of gestation. Five neonates were all born with Apgar scores of 10 at 1, 5 and 10 min without any visible defects at birth and all grew and developed normally at 4-12 months after birth. Conclusions For gravidas with space-occupying lesions in saddle area, it is necessary to weigh the pros and cons and choose an individualized treatment plan. Resection of saddle area lesions in the second or third trimester backed by a multi-disciplinary team is a safe and feasible procedure if postponing the operation until delivery may cause irreversible or even life-threatening consequences.