Ⅰ型糖尿病高危妊娠剖宫产术后腹腔感染并子宫穿孔诊治体会

Diagnosis and treatment experience of postpartum abdominal infection combined with uterine perforation in high-risk pregnancy with typeⅠdiabetes

山东第一医科大学附属青州医院于2016年2月12日收治1例Ⅰ型糖尿病高危妊娠剖宫产术后合并腹腔脓肿、子宫穿孔、脓毒性休克、急性呼吸窘迫综合征(ARDS)患者,既往有Ⅰ型糖尿病史30余年,应用胰岛素治疗血糖控制不佳,最高达20.2 mmol/L。妊娠40周剖宫产术后8 d,因发热、腹痛2 d,伴渐进性呼吸困难于2016年2月15日由妇产科转入重症监护病房(ICU)。查体显示体温38℃,呼吸频率34次/min,血压86/50 mmHg(1 mmHg≈0.133 kPa);实验室检查显示白细胞计数(WBC)16.56×10^9/L,血红蛋白(Hb)85 g/L,血小板计数(PLT)90×10^9/L,血糖15.4 mmol/L,糖化血红蛋白(HbA1c)0.101;动脉血气分析显示吸氧状态下pH值7.23,动脉血氧分压(PaO2)56 mmHg,动脉血二氧化碳分压(PaCO2)31 mmHg,氧合指数169 mmHg,动脉血乳酸(Lac)2.7 mmol/L;胸腹部CT显示肺小叶间隔增厚,心包积液,肠腔积气,腹腔脓肿。治疗上给予扩容、纠酸、应用升压药及吸氧等抗休克;甲硝唑500 mL+0.9%生理盐水持续腹腔灌洗;早期给予替加环素联合头孢哌酮舒巴坦抗感染;密切监测并控制血糖;给予营养支持纠正低蛋白血症,并给予胸腺五肽及丙种球蛋白增强机体免疫力。经过及时、严格、标准的集束化检测和治疗,取得较好的疗效,患者休克逐渐纠正、氧合改善、呼吸窘迫症状减轻,经治疗49 d后最终于2016年4月1日痊愈出院。

On February 12,2016,Qingzhou Hospital Affiliated to the First Medical University of Shandong Province admitted a high-risk pregnant patient with typeⅠdiabetes who had a cesarean section and suffered from a series of complications including abdominal abscess,uterine perforation,septic shock,and acute respiratory distress syndrome(ARDS).The patient had typeⅠdiabetes for more than 30 years.The application of insulin treatment had poor effect on blood glucose control,and the blood glucose was up to 20.2 mmol/L.At 40 weeks of gestation,cesarean section was performed,and after 8 days the patient was transferred from department of obstetrics and gynecology to intensive care unit(ICU)on February 15,2016 due to fever and abdominal pain,accompanied by progressive dyspnea.Physical examination showed that the body temperature was 38℃,respiratory frequency was 34 times/min,and blood pressure was 86/50 mmHg(1 mmHg≈0.133 kPa).Laboratory examination showed that white blood cell count(WBC)was 16.56×10^9/L,hemoglobin(Hb)was 85 g/L,platelet count(PLT)was 90×10^9/L,blood glucose was 15.4 mmol/L,and glycosylated hemoglobin(HbA1c)was 0.101.Arterial blood gas analysis showed that under the condition of oxygen inhalation,pH was 7.23,arterial partial pressure of oxygen(PaO2)was 56 mmHg,arterial partial pressure of carbon dioxide(PaCO2)was 31 mmHg,oxygenation index was 169 mmHg,and the arterial blood lactate(Lac)was 2.7 mmol/L.Chest and abdomen CT showed thickening of interlobular septum,pericardial effusion,air accumulation in the intestinal cavity and abdominal abscess.In treatment,anti shock treatment such as volume expansion,acid correction,pressure boosting drugs and oxygen inhalation were given;metronidazole 500 mL+0.9%normal saline was continuously given by abdominal lavage;tegacyclin combined with cefoperazone sulbactam was given for anti-infection at early stage;blood glucose was closely monitored and controled;Nutritional support was given to provide energy,correct hypoproteinemia,and thymopentin and gamma globulin were given to enhance immunity.After timely,strict and standard cluster testing and treatment,the patient achieved good results.The shock was gradually corrected,oxygenation was improved,respiratory distress was reduced,and after 49 days of treatment,the patient was finally recovered and discharged on April 1,2016.