妊娠期生殖道感染所致产科脓毒症合并羊水栓塞分析并文献复习

Obstetric sepsis due to reproductive tract infection during pregnancy combined with amniotic fluid embolism:a case report and literature review

目的探讨妊娠期生殖道感染(RTI)所致产科脓毒症合并羊水栓塞(AFE)患者的临床表现、诊断、治疗及预后,并进行相关文献复习。方法选择2021年9月,于成都市第五人民医院住院、分娩的1例临床诊断为妊娠期生殖道光滑念珠菌感染所致产科脓毒症合并AFE患者为研究对象。采用回顾性研究方法,收集本例患者的临床病例资料,并对其临床表现、诊断及治疗经过进行分析。以“妊娠期生殖道感染”“产科脓毒症”“羊水栓塞”“reproductive tract infection during pregnancy”“obstetric sepsis”“amniotic fluid embolism”为关键词,在中国生物医学文献数据库(CBM)、中国知网(CNKI)、维普中文科技期刊数据库、万方数据知识服务平台及PubMed与Ovid Medline数据库中,检索妊娠期RTI所致产科脓毒症合并AFE相关文献。文献检索时间设定为上述数据库建库至2021年10月。总结妊娠期RTI所致产科脓毒症合并AFE患者的临床表现、诊断与治疗。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。结果①本例患者分娩年龄为38岁,2021年9月8日7:20 am,因“停经31^(+1)周,反复阴道流血12^(+)h,加重2 h”,于病例收集医院住院治疗。入院时,胎儿超声检查结果提示,宫内单活胎、头位、胎盘前置;患者血常规提示,白细胞计数、中性粒细胞百分比均增高,分别为11.6×10^(9)/L与94.5%;阴道分泌物病原体培养与鉴定结果提示,光滑念珠菌感染。入院当天9:40 am,患者体温为37.9℃,采取头孢呋辛抗感染治疗、硫酸镁保护胎儿中枢神经系统、地塞米松促胎肺成熟等对症支持治疗。入院第2天,为进一步明确感染源,持续面罩吸氧下拟进行胸部CT时,患者突发呼吸困难,阴道大量羊水流出,10 min后,患者全身发绀、瘫软,四肢厥冷、牙关紧闭、意识丧失,立即进行气管插管、心电监护提示:脉搏为120次/min,血压为74 mmHg/42 mmHg(1 mmHg=0.133 kPa),脉搏血氧饱和度(SpO_(2))为70%,胎心率为57次/min,立即采取急诊剖宫产术分娩。术中母体血常规检查结果提示:血红蛋白为116 g/L(正常),血小板计数为35×10^(9)/L(低于正常参考值);凝血酶原时间为19.9 s,国际标准化比值为1.72,部分凝血活酶时间>180.0 s,凝血酶时间>180.0 s,纤维蛋白原降解产物为189.65μg/mL(均高于正常参考值);纤维蛋白原为0.49 g/L(低于正常参考值)。胸腔积液及血液病原体培养结果均提示,革兰阴性杆菌呈阳性。临床拟诊为脓毒症引起休克,AFE、弥散性血管内凝血(DIC)。遂对其进行全子宫切除术+左侧输卵管切除术(右侧输卵管既往已被切除)。术后转入重症监护病房,在多学科团队协作下,采取连续性肾脏替代疗法(CRRT)稳定内环境、输血治疗、管理血容量、升高血压,糖皮质激素抗炎、抗免疫,曲前列尼尔降低肺动脉压,亚胺培南西司他丁抗感染,抑制胃酸分泌,间断进行血液净化治疗减轻炎症反应,体外膜肺氧合(ECMO)改善氧供及亚低温治疗等。由于患者同时合并产科脓毒症与AFE,病情进展迅速,于产后23 d因抢救无效死亡。②按照本研究制定的文献检索策略进行文献检索结果显示,无一例关于妊娠期RTI所致产科脓毒症合并AFE患者救治的文献报道。结论妊娠期RTI发生率高,但是RTI后突发AFE的病例报道罕见。临床对妊娠期RTI孕产妇积极、规范抗感染治疗,可预防产科脓毒症及AFE。对于妊娠期RTI所致产科脓毒症合并AFE患者的治疗,因涉及多器官功能衰竭(MOF),需要多学科团队协作改善患者预后。

Objective To explore the clinical manifestations,diagnosis,treatment and prognosis of patients with obstetric sepsis due to reproductive tract infection(RTI)during pregnancy combined with amniotic fluid embolism(AFE),and review relevant literature.Methods A patient who was clinically diagnosed as obstetric sepsis due to RTI during pregnancy combined with AFE and hospitalized and delivered in Chengdu Fifth People′s Hospital in September 2021 was selected as research subject.Clinical data of this patient were collected by retrospective study method,and her clinical manifestations,diagnosis and treatment were analyzed.Literature about obstetric sepsis due to RTI during pregnancy combined with AFE were retrieved with key words of"reproductive tract infection during pregnancy""obstetric sepsis"and"amniotic fluid embolism"both in Chinese and English,based on China Biology Medicine(CBM),China National Knowledge Infrastructure(CNKI),VIP,Wanfang Data Service Platform,PubMed and Ovid Medline database.Literature retrieval time was set from the establishment of above databases to October 2021.Clinical manifestations,diagnosis and treatment of obstetric sepsis due to RTI during pregnancy combined with AFE were summarized.The procedures followed in this study were in line with the requirements of World Medical Association Declaration of Helsinki revised in 2013.Results①This patient was 38 year old at childbirth who admitted to case collected hospital due to"menopause 31^(+1) week,recurrent vaginal bleeding 12^(+) h,aggravation 2 h"at 7:20 am on September 8,2021.On admission,results of fetal ultrasonography indicated that intrauterine single live fetus with head presentation,and placenta previa;maternal blood routine examination indicated that white blood cell count and percentage of neutrophils both were increased,which were 11.6×10^(9)/L and 94.5%,respectively;vaginal secretion culture and identification results indicated that the patient was infected with Candida glabrata.At 9:40 am on the day of admission,the patient′s body temperature was 37.9℃,and cefuroxime was given for anti-infective therapy,magnesium sulfate was used to protect fetal central nervous system,and dexamethasone was used to promote fetal lung maturity.On the second day after admission,when chest CT was planned to be performed under continuous mask oxygen inhalation to further clarify the source of infection,the patient had sudden dyspnea and a large amount of vaginal amniotic fluid flowed out,and 10 minutes later,she developed cyanosis all over the body with cold limbs,paralysis,lockjaw and loss of consciousness.Endotracheal intubation was immediately performed,and ECG monitoring suggested that pulse was 120 times/min,blood pressure was 74 mmHg/42 mmHg(1 mmHg=0.133 kPa),pulse oxygen saturation(SpO_(2))was 70%,fetal heart was 57 times/min,and emergency cesarean section was performed immediately.Intraoperative blood routine examination showed that hemoglobin was normal with 116 g/L and platelet count was 35×10^(9)/L,which was lower than the normal reference value;prothrombin time was 19.9 s,international standardized ratio was 1.72,partial thromboplastin time was>180.0 s,thrombin time was>180.0 s,fibrinogen degradation product was 189.65μg/mL,which all were lower than the normal reference values,and fibrinogen was 0.49 g/L,which was higher than the normal reference value.Results of pleural fluid culture and blood culture showed positive of gram-negative bacilli,and septic shock was considered.Total hysterectomy and left salpingectomy were performed for the diagnosis of septic shock caused by sepsis,AFE and disseminated intravascular coagulation(DIC).After operation,she was transferred to intensive care unit.With cooperation of a multidisciplinary team,she was treated by continuous renal replacement therapy(CRRT)to stabilize internal environment,blood transfusion for supplement of blood components,management of blood volume,and increase blood pressure,and glucocorticoids for anti-inflammatory and anti-immune treatment.She was also treated by treprostinil to reduce pulmonary arterial pressure,imipenem and cilastatin for anti-infective treatment,suppression of gastric acid secretion,continuous blood purification to reduce inflammation reaction,and extracorporeal membrane oxygenation(ECMO)to improve oxygen supply and hypothermia treatment,and so on.Because the patient was complicated with septic shock and AFE,and the disease progressed rapidly and was very critical,she died 23 days after delivery due to ineffective rescue.②According to literature retrieval strategy developed in this study,literature retrieval results showed that there was not a single case of obstetric sepsis due to RTI during pregnancy combined with AFE,so there was no diagnosis and treatment report of related cases so far.Conclusions Incidence of RTI during pregnancy is high,but case reports of AFE after RTI are rare.Clinical treatment for patients with RTI during pregnancy should be identified as soon as possible,and actively standardized anti-infection treatment should be taken to reduce the occurrence of obstetric sepsis and AFE.For the treatment of patients with obstetric sepsis due to RTI during pregnancy combined with AFE,a multidisciplinary team is needed to effectively improve patients′prognosis for patients′multiple organ failure(MOF).