肾移植后妊娠并分娩四例及文献回顾

发布时间：2018-02-08 11:26

本文关键词： 肾移植妊娠分娩产科并发症移植肾功能新生儿预后　出处：《浙江大学》2016年硕士论文　论文类型：学位论文

【摘要】：目的肾移植是临床上治疗终末期肾病的理想方法,成功的肾移植患者有较高的长期生存率。对于患有终末期肾病的育龄期妇女,肾移植是恢复其生育能力的有效方法。在我国,由于肾移植后妊娠并分娩病例数少,目前文献多为散在的个例报道,尚缺乏对该疾病的系统性认识,且由于该疾病的学科综合性,需要妇产科医生、肾脏科医生、助产士等共同参与,因此增加了临床工作的难度,更加需要多学科交叉的理论基础。本文报道我院肾移植后妊娠并分娩病例四例,并结合相关文献报道,旨在总结归纳肾移植后妊娠并分娩的多方面问题。方法回顾性分析我院联众病案系统内记录的4例肾移植后妊娠并分娩患者的临床资料,了解其临床特点,结合复习相关文献,探讨肾移植后的妊娠时机把握、避孕方式选择、妊娠对移植肾的影响、免疫抑制剂对胎儿的影响及剂量调整问题、辅助生育技术的应用问题、产科并发症、对新生儿结局的影响等多方面问题。结果本文报道的4例患者,为25-29岁育龄期女性,其中一例移植前无生育史,移植后8年有一次自然流产史,其余3例均无生育史。移植-妊娠间隔从2年余至10年不等.其中3例并发妊娠期高血压疾病,其中1例并发子痫前期。其中3例患者发生移植肾功能不全,分娩前后监测最高血肌酐值分别为143umol/L. 160.9umol/L、188.2umol/L,其余1例移植肾功能良好。4例患者中2例住院期间行肾脏B超检查,其中1例术后查肾脏B超未见明显正常肾脏回声,腹腔积液,另1例术前查肾脏B超示：右侧移植肾积水,集合系统分离1.5cm,肾盂宽1,Ocm。其中2例有二次入院病史,第一次入院分别因‘停经26+4周,阴道流血3小时”及“孕32周,先兆早产”保胎,另外2例因待产入院.4例住院天数5-9天不等,术后住院天数为4-7天。4例患者的免疫抑制方案均为他克莫司、硫唑嘌啉、强的松的配伍,剂量各有不同。本文报道的4例患者均采用剖宫产方式终止妊娠,其中3例早产,1例足月产。新生儿Apgar评分均为10分/10分,lmin/Smin.新生儿有2例入住新生儿科,原因分别为“早产儿,哺乳欠佳”及“早产儿,呼吸困难”,采用人工喂养及支持治疗后均顺利出院,最长及最短住院时间分别为12天及4天。新生儿预后均良好。经肾内科及积极围产治疗,所有围产期肾功能异常、血压升高、蛋白尿产妇均在产后1月恢复正常。结论肾移植后妊娠并分娩在临床上并不多见,只要掌握适当的妊娠时机,肾移植后妊娠妇女做好充分产前检查及妊娠期随访,通过肾脏科医生及产科医生通力合作,肾移植后妊娠并分娩对孕产妇和新生儿是相对安全的,围产期相关肾脏病理改变可在短期内恢复正常。
[Abstract]:Objective Renal transplantation is an ideal method for the treatment of end-stage nephropathy. Successful renal transplantation patients have a high long-term survival rate. For women of childbearing age with end-stage renal disease, renal transplantation is an effective method to restore their fertility. Due to the small number of cases of pregnancy and delivery after kidney transplantation, most of the literatures are scattered case reports, and lack of systematic understanding of the disease, and because of the comprehensive discipline of the disease, the need for obstetricians and gynecologists, kidney doctors, The involvement of midwives increased the difficulty of clinical work and increased the need for a multidisciplinary theoretical basis. This paper reports four cases of pregnancy and delivery after kidney transplantation in our hospital, and combined with related literature reports. Methods the clinical data of 4 cases of pregnancy and delivery after renal transplantation were analyzed retrospectively. To explore the timing of pregnancy after renal transplantation, the choice of contraceptive methods, the effect of pregnancy on the transplanted kidney, the influence of immunosuppressant on fetus and its dose adjustment, the application of assisted fertility technology, and the complications of obstetrics. Results there were 4 cases of women aged 25-29 years old who had no history of childbearing before transplantation and a history of spontaneous abortion 8 years after transplantation. The other 3 cases had no history of childbearing. The interval between transplantation and pregnancy ranged from 2 years to 10 years. Among them, 3 cases were complicated with hypertensive disorder complicating pregnancy, 1 case was complicated with preeclampsia, and 3 cases had renal allograft insufficiency. The highest serum creatinine values before and after delivery were 143umolL / L160.9umol/ L ~ (188.2) umolr / L, and 2 of the other 4 cases of renal allograft function were examined by B-ultrasound during hospitalization. One case was found to have no obvious normal kidney echo and peritoneal effusion after operation. The other one was examined by B-ultrasonography before operation: right transplanted hydronephrosis, collecting system separation 1.5 cm, pyelobronchial width 1% Ocm. Among them, 2 cases had a history of second admission, the first admission was due to '264 weeks of menopause, 3 hours of vaginal bleeding' and'32 weeks of pregnancy, 'respectively. The other 2 patients were hospitalized for 5 to 9 days, and the immunosuppressive regimen was tacrolimus, thiazoprine and prednisone for 4 to 7 days. All the 4 cases were terminated by cesarean section, among which 3 cases were preterm and 1 case was term delivery. The Apgar score of newborn was 10 / 10 min / min 路min. 2 cases of neonates were admitted to neonatal paediatrics, the reason was "premature infant," Poor breast-feeding and "premature infants, dyspnea" were successfully discharged after artificial feeding and supportive treatment. The longest and shortest hospital stay was 12 days and 4 days respectively. The prognosis of newborns was good. All perinatal patients with abnormal renal function, elevated blood pressure and proteinuria returned to normal on January. Conclusion pregnancy and delivery after renal transplantation are rare in clinic. Pregnant women after kidney transplantation were given full prenatal examination and follow-up during pregnancy. Through the cooperation of kidney doctors and obstetricians, pregnancy and delivery after kidney transplantation were relatively safe for pregnant women and newborns. Perinatal renal pathological changes can return to normal in a short time.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R699.2;R714.2

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