妊娠晚期链球菌中毒性休克综合征2例报道及文献复习

Streptococcal toxic shock syndrome in third trimester:a report of two cases and literature review

目的分析妊娠晚期化脓性链球菌所致链球菌中毒性休克综合征(streptococcal toxic shock syndrome,STSS)的临床特点,提高临床医师对此病的认识。方法回顾性分析济南市妇幼保健院收治的2例及在中国知网和PubMed数据库检索1997年1月至2018年12月文献报道的资料详细且诊断明确的9例妊娠晚期(孕28~42周)健康孕妇突发STSS的临床资料。结果本院收治的2例病例均为经产妇,冬季发病,早期症状无特异性。入院时均已发生弥散性血管内凝血,1例入院时胎心慢,很快胎心消失;另1例入院时已胎死宫内。2例孕妇均死亡,血培养均提示A族链球菌感染。检索到中文文献1篇,英文文献5篇,共9例病例。所有11例病例均非高危妊娠,无胎膜早破;其中10例血或组织培养化脓性链球菌阳性,1例链球菌毒素阳性;10例有发热,3例早期有呼吸道感染症状;腹痛、水样腹泻为常见症状;均有多脏器功能障碍、弥散性血管内凝血;冬春季多发。9例孕产妇于暴发性症状出现后36 h内死亡;2例孕产妇存活,住院天数分别为90 d和25 d,发现胎心减慢即刻手术,新生儿生后均夭折。胎/婴儿中7例死胎,1例死产,3例活产,其中仅1例存活(其母生后90 min出现呼吸心脏骤停)。结论妊娠晚期化脓性链球菌引起的STSS病情进展迅速,病死率高,临床医师对临床表现和病情进展快速的早期识别是STSS早期诊断、及时治疗的关键,早诊断、早治疗有助于改善母胎结局。

Objective To analyze the clinical characteristics of streptococcal toxic shock syndrome(STSS)caused by Streptococcus pyogenes(S.pyogenes)in the third trimester to improve clinical awareness of this disease.Methods A retrospective study was conducted to analyze the clinical data of two patients with STSS caused by S.pyogenes in Jinan Maternal and Child Health Care Hospital and nine reported cases of healthy pregnant women infected with S.pyogenes at 28-42 gestational weeks with detailed data retrieved from Chinese National Knowledge Infrastructure and PubMed database from January 1997 to December 2018.Results The two cases admitted to our hospital were both multiparas,with onset in winter and no specific symptoms in early stage.Disseminated intravascular coagulation(DIC)was developed in both cases on admission.In one case,the fetal heart rate was reduced and disappeared soon after admission.The other patient was diagnosed as stillbirth on admission.Both patients died and blood culture revealed infection of group A streptococcus.Nine previous cases were reported in one Chinese and five English articles.No high-risk pregnancy or premature rupture of membranes was reported in these 11 cases.Among the 11 cases,ten were positive for S.pyogenes indicated by blood or tissue culture and one was positive for streptococcal toxin.Ten cases had high fever and three presented with respiratory symptoms in early stage.Abdominal pain and watery diarrhea were common symptoms and all patients developed multiple organ dysfunction and DIC.Cases occurred in winter or spring were more common.Nine women died within 36 h after the onset of fulminant symptoms.Only two survived and hospitalized for 90 d and 25 d,respectively,after emergent cesarean section indicated by reduced fetal heart rate.Unfortunately,both neonates died after birth.For the babies,there were seven intrauterine fetal deaths,one stillbirth and three live births,but only one survived(whose mother developed respiratory cardiac arrest 90 min after delivery).Conclusions STSS caused by S.pyogenes in pregnant women exacerbates rapidly with a high mortality.Early identification of clinical manifestations and rapid progress of the disease are crucial for early diagnosis and treatment,which may help improve maternal and fetal outcomes.