妊娠期有症状泌尿系结石导致的脓毒血症的研究进展

Research Progress on Sepsis Caused by Symptomatic Urinary Tract Stones during Pregnancy

妊娠期有症状泌尿系结石是产科患者住院最常见的非产科指征之一,而妊娠期有症状泌尿系结石导致的脓毒血症可显著增加孕产妇发病率和死亡率。妊娠期有症状泌尿系结石导致的脓毒血症是一种严重的疾病,多因妊娠期特殊的生理改变诱导结石的发生与妊娠前上尿路“安静”结石延续所致。通常以腰部胀痛为主,合并上尿路感染者较多,部分发展成肾积脓、败血症。妊娠期黄体酮分泌增加,输尿管生理性扩张积水、局部免疫力及内脏神经敏感性降低,痛阈及易感性升高,处理不当会导致持续肾绞痛、肾功能持续性损害、感染性休克、胎膜早破、早产、流产、死胎等并发症,对孕妇和胎儿造成严重危害;如何选择兼顾孕妇与胎儿安全性的诊疗方法,长期困扰着泌尿外科与产科医生。尽管近年输尿管软镜与钬激光的出现,为妊娠期输尿管结石治疗带来了机会,但是否及时引入放射性检查与介入性诊疗操作还是存在较多争议。妊娠合并输尿管结石近年报道逐渐增多,发病年龄平均27岁左右,80%~90%发生在妊娠中期(12~28周)及晚期(>28周);经产妇发生率为初产妇4倍,两侧发生率几乎相同,发生率是肾结石的2倍;孕前有结石病史者占24%~30%;“结石带地区”如美国南部、中国南方的发生率相对较高,主要为草酸钙和感染性结石;总体发病率约为1/1500,与非妊娠期输尿管结石发病率比较没有显著性差异,说明妊娠状态并不增加输尿管结石的发病率。由于妊娠期输尿管解剖及生理的改变,同时考虑到对胎儿的潜在危险性,临床上对于妊娠期输尿管结石的诊断及治疗存在较大困难,一直以来对泌尿外科、产科以及影像科医师来说是一个棘手的问题。因此,我们将通过最新文献从病因、危险因素、诊断方法、并发症及治疗方法等方面对妊娠期有症状泌尿系结石导致脓毒血症进行阐述。

Symptomatic urinary calculus during pregnancy is one of the most common non obstetric signs for obstetric patients to be hospitalized. Sepsis caused by symptomatic urinary calculi during pregnancy can significantly increase the incidence rate and mortality of pregnant women. Sepsis caused by symptomatic urinary tract stones during pregnancy is a serious disease, often caused by special physiological changes during pregnancy that induce the occurrence of stones and the continuation of “quiet” stones in the upper urinary tract before pregnancy. Usually, lower back pain is the main symptom, and there are more cases of upper urinary tract infections, some of which may develop into renal abscess and sepsis. Increased secretion of progesterone during pregnancy, physiological dilation and hydronephrosis of the ureter, decreased local immune and visceral nerve sensitivity, increased pain threshold and susceptibility. Improper management can lead to complications such as persistent renal colic, sustained renal function damage, septic shock, premature rupture of membranes, premature birth, miscarriage, stillbirth, etc., causing serious harm to pregnant women and fetuses;How to choose a diagnosis and treatment method that balances the safety of pregnant women and fetuses has long been a challenge for urologists and obstetricians. Although the emergence of ureteroscopy and holmium laser in recent years has brought opportunities for the treatment of gestational ureteral stones, there is still much controversy over whether to timely introduce radiation examinations and interventional diagnostic and therapeutic procedures. In recent years, reports of pregnancy complicated with ureteral stones have gradually increased, with an average age of around 27 years old. 80%~90% of cases occur in the middle (12~28 weeks) and late stages of pregnancy (>28 weeks). The incidence rate of multiparous women is four times that of primiparous women, and the incidence rate is almost the same on both sides, which is twice that of kidney stones. 24%~30% of cases have a history of stones before pregnancy. The incidence rate of “stone belt” areas such as the southern United States and southern China is relatively high, mainly calcium oxalate and infectious stones;The overall incidence rate is about 1/1500, which is not significantly different from the incidence rate of ureteral calculi in non pregnancy, indicating that pregnancy does not increase the incidence rate of ureteral calculi. Due to changes in the anatomy and physiology of the ureter during pregnancy, as well as the potential danger to infants, there are significant difficulties in the diagnosis and treatment of ureteral stones during pregnancy in clinical practice. This has always been a challenging issue for urologists, obstetricians, and radiologists. Therefore, we will elaborate on the causes, risk factors, diagnostic methods, complications, and treatment methods of sepsis caused by symptomatic urinary tract stones during pregnancy through the latest literature.