妊娠期肾病综合征合并穿透型胎盘植入一例并文献复习

Penetrating Placenta Implantation in Nephrotic Syndrome of Pregnancy: A Case Report and Literature Review

摘要: 目的：探讨妊娠期肾病综合征合并穿透型胎盘植入的临床特点及处理，以提高该疾病的诊疗水平，改善母婴结局。方法：回顾性分析青岛大学医学院附属医院收治的1例妊娠期肾病综合征合并穿透型胎盘植入患者的诊治过程及其预后，并结合相关文献对该疾病进行分析。结果：本例患者33岁，行肾脏穿刺确诊为“膜性增生性肾小球肾炎”，先后给予环孢素、环磷酰胺、甲泼尼龙等治疗，后长期应用“泼尼松、他克莫司、阿司匹林”。孕35周5天行超声检查提示：胎盘植入评分10分，完全型前置胎盘并胎盘植入。遂于孕36周4天时行腹主动脉球囊阻断术 + 剖宫产术 + 胎盘植入子宫楔形切除术 + 子宫修补术 + 盆腔粘连分解术，手术顺利，产妇及新生儿预后良好。结论：妊娠期肾病综合征合并穿透型胎盘植入发生率较低，但处理棘手，妊娠过程中有膜性肾病病情快速进展，病情不可逆，出现急性肾脏功能衰竭、感染、血栓及栓塞、蛋白质及脂肪代谢紊乱甚至危及孕妇生命，死亡。而穿透性胎盘植人患者胎盘剥离时，血窦长期开放，出血可极为凶险，常危及产妇生命，且穿透型胎盘植入易侵及膀胱，这将加重肾病综合征对孕产妇的影响。这需要临床多学科综合治疗，根据患者所处妊娠阶段、意愿状态选择最佳的治疗时机及治疗方案以改善母婴不良结局。

Abstract: Objective: To investigate the clinical characteristics and management of nephrotic syndrome com-plicated with penetrating placenta implantation during pregnancy, so as to improve the diagnosis and treatment level of nephrotic syndrome and improve maternal and infant outcomes. Methods: The diagnosis, treatment and prognosis of a patient with nephrotic syndrome of pregnancy compli-cated with penetrating placenta implantation admitted to the Affiliated Hospital of Qingdao Univer-sity Medical College were retrospectively analyzed, and the disease was analyzed based on relevant literature. Results: The 33-year-old patient was diagnosed as membranous proliferative glomeru-lonephritis by renal puncture. She was successively treated with cyclosporine, cyclophosphamide and methylprednisolone, followed by long-term treatment with “prednisone, tacrolimus, aspirin”. Ultrasound examination at 35 weeks and 5 days of gestation indicated that placenta previa was complete and placenta was implanted. At 36 weeks and 4 days of gestation, abdominal aortic bal-loon occlusion + cesarean section + placental implantation hysterectomy + uterine repair + pelvic adhesiolysis were performed. The operation was successful and the puerpera and newborn had a good prognosis. Conclusion: The incidence of nephrotic syndrome in pregnancy with penetrating placenta implantation is low, but it is difficult to deal with it. The disease of membranous nephrop-athy in pregnancy progresses rapidly and is irreversible, resulting in acute renal failure, infection, thrombosis and embolism, protein and fat metabolism disorder and even death of pregnant women. In patients with penetrating placenta implantation, when the placenta is detached, the blood si-nuses are open for a long time, and bleeding can be extremely dangerous, which often endangers the life of the maternal. Moreover, penetrating placenta implantation is prone to invade the blad-der, which will aggravate the influence of nephrotic syndrome on the maternal. This requires clini-cal multidisciplinary comprehensive treatment to select the best treatment timing and treatment plan according to the patient’s pregnancy stage and willing state to improve the adverse outcomes of mother and child.