实验室指标监测对HELLP综合征合并颅内静脉窦血栓形成和肝包膜下血肿破裂的指导意义

A report on one patient with HELLP syndrome complicated by intracranial venous sinus thrombosis and sub-hepatic hematoma rupture and guiding significance of monitoring laboratory indexes

HELLP综合征(溶血、肝酶升高、血小板减少)是子痫前期的严重并发症,其病理学改变的中心环节是血管内皮细胞损伤导致继发性微血管血栓形成.回顾性分析天津市第五中心医院收治的1例HELLP综合征并发颅内静脉窦血栓形成(CVST)和肝包膜下血肿破裂患者的临床资料及治疗措施.患者女性,31岁,孕26周,因突发头痛伴呕吐于2017年5月23日入院,入院时患者一般情况可,双眼视物模糊,血管性血友病因子(vWF)抗原增高;磁共振成像(MRI)和数字减影血管造影(DSA)证实CVST,给予静脉窦取栓及溶栓治疗后患者一般情况良好;5月24日突发血压下降,心率加快,腹腔诊断性穿刺抽出不凝血,考虑存在腹腔活动性出血,在全麻下行剖腹探查可见肝包膜破裂出血,遂行肝包膜修补术+肝周纱布填塞术止血,产科会诊为胎死宫内,因患者凝血功能障碍,暂未行剖宫产取胎.术后转入重症监护病房(ICU).实验室检查显示肝酶异常,综合诊断为HELLP综合征合并CVST和肝包膜下血肿破裂,给予机械通气、镇痛镇静、积极液体复苏、器官功能保护、抗感染、纠正内环境紊乱、营养支持、纠正低蛋白血症、硫酸镁解痉、预防下肢深静脉血栓形成等治疗及血浆置换,患者住院81 d后康复出院.后期随访已恢复正常生活.总结本例患者的救治经验:密切动态监测实验室指标并持续评估患者出凝血状态是抢救成功的关键;血栓弹力图(TEG)可以对凝血功能进行综合评价,在一定程度上可弥补传统实验室检查凝血功能的不足,能为临床决策提供更为精准的评估凝血状态的指标,对危重症产妇的出凝血治疗具有指导意义.

HELLP syndrome(hemolysis,elevated liver enzymes and thrombocytopenia)is a serious complication of preeclampsia.The central link of its pathological changes is the formation of secondary micro-vascular thrombosis due to damage of vascular endothelial cells.The clinical data and treatment of a patient with HELLP syndrome complicated with intracranial venous sinus thrombosis and sub-hepatic hematoma rupture admitted to Tianjin Fifth Central Hospital were retrospectively analyzed.The patient was 31-year-old female,admitted to hospital on May 23,2017 with sudden headache and vomiting,her general condition was fair at admission,the binocular vision was blurred,and the von Willebrand factor(vWF)antigen was increased;by magnetic resonance imaging(MRI)and digital subtraction angiography(DSA),the intracranial venous sinus thrombosis was confirmed.After intravenous sinus thrombectomy and thrombolysis,the patient's general condition was good.On May 24,the patient's blood pressure dropped suddenly,heart rate increased,and abdominal cavity diagnostic puncture showed the blood was not coagulated,the existence of active abdominal bleeding being considered.Under general anesthesia,laparotomy showed liver capsule rupture and bleeding,thus the liver capsule repair and gauze packing around the liver were immediately performed to stop bleeding.Obstetric consultation found the fetal death in uterus,and because of coagulation dysfunction,no cesarean section was performed.The patient was transferred to intensive care unit(ICU).Laboratory examination showed abnormal liver enzymes,and the comprehensive diagnosis was HELLP syndrome complicated with intracranial venous sinus thrombosis and rupture of hepatic sub-capsular hematoma.Treatments such as mechanical ventilation,analgesia and sedation,active fluid resuscitation,organ function protection,anti-infection,correction of internal environment disorder,nutritional support,correction of hypo-proteinemia,magnesium sulfate spasmolysis,prevention of deep venous thrombosis of lower extremities and plasma exchange were given.After 81 days of hospitalization,the patient was discharged,and later during follow-up she had resumed to normal life.The treatment experience of this case was summarized,indicating that close monitoring of laboratory indicators and continuous evaluation of the patient's coagulation status are the key points to the successful rescue of this patient.The thrombo-elastography(TEG)can comprehensively evaluate the coagulation function,to a certain extent,it can make up for the shortcomings of traditional coagulation laboratory tests,and can provide more accurate inchcators for evaluating coagulation status for clinical decision-making,which has guiding significance for the treatment of bleeding and blood coagulation in critically ill pregnant women.