A Crisis in Late Pregnancypdf.docx

1、A Crisis in Late Pregnancypdf翻译内容：一篇来自新英格兰杂志的个案报道。专 业：南方医院妇产科。原 文：Desai AS, Chutkow WA, Edelman E, et al. A crisis in late pregnancy. N Engl J Med. 2009 Dec 3; 361(23):2271-7. A Crisis in Late PregnancyA 31-year-old woman in the 37th week of an uncomplicated pregnancy presented to the emergency depa

2、rtment with sudden onset of severe bitemporal headache and shortness of breath. Her medical history was notable for hypothyroidism and pernicious anemia (both treated). She had had four previous pregnancies: the first was terminated therapeutically for elective reasons, the next two resulted in spon

3、taneous abortions, and the fourth resulted in the birth of a healthy girl, delivered vaginally, 3 years earlier. The patient had never smoked and did not drink alcohol or use illicit drugs. Her family history was unremarkable.一位31岁孕周为37周的无合并症的孕妇由于突然发作的剧烈双颞部头痛和呼吸浅短送往急诊科。她有甲状腺功能减退和恶性贫血的特殊病史（均经治疗）。她以前有

4、过4次妊娠：第一次因为选择性的治疗原因而终止，接下来两次自然流产，3年前第四次妊娠经阴道娩出一健康女婴。病人无吸烟饮酒以及使用非法药物史。家族史无特殊。Shortness of breath in the third trimester of pregnancy has a broad differential diagnosis. This symptom may simply reflect increased minute ventilation due to central chemoreceptor alterations or mechanical interference wit

5、h diaphragmatic expansion by the gravid uterus. However, pathologic causes must also be considered, such as volume overload, anemia, and infection. Pulmonary embolism, supraventricular or ventricular arrhythmias, heart failure, coronary-artery dissection, and aortic dissection, as well as complicati

6、ons associated with pregnancy such as preeclampsia and peripartum cardiomyopathy, are among the “must not miss” diagnoses and should be ruled out.妊娠晚期呼吸短促有着广泛差异的诊断。这一症状可能只是简单地造成由于中央化学感受器改变或者由于扩大的妊娠子宫压迫膈肌的机械影响导致每分钟通气量增加。此外，还需考虑病理性的原因，例如容量超负荷，贫血，感染，肺栓塞，室上性或室性心律失常，心力衰竭，冠脉夹层，主动脉夹层以及和妊娠有关的并发症，如先兆子痫和围产期心肌

7、病，这些都属于“绝不能遗漏”的诊断，需要一个个排除。The patient was in apparent respiratory distress and reported that she felt like she was “drowning.” She reported no fever, cough, chest pain, nausea, vomiting, visual changes, abdominal pain, contractions, or vaginal bleeding. On examination, she was afebrile. Her pulse wa

8、s 120 beats per minute, blood pressure was 180/110 mm Hg, respiratory rate was 32 breaths per minute, and oxygen saturation was 70% while she was breathing ambient air. She was unable to lie flat without having more difficulty breathing. Funduscopic examination was normal. Jugular venous pressure wa

9、s estimated at 15 cm of water. Auscultation of the lungs was notable for bibasilar rales. Cardiovascular examination revealed tachycardia, a summation gallop, and a grade 2/6 apical holosystolic murmur. The apical cardiac impulse was diffuse but not displaced. Her abdomen was gravid and not tender t

10、o palpation. The extremities were warm, with no petechiae or edema. Mild uterine contractions were noted every 5 minutes. On pelvic examination, her cervix was 1 cm dilated and 80% effaced, with the head at 2 cm. Doppler examination revealed normal fetal heart tones at a rate of about 130 beats per

11、minute, with moderate variability.病人有明显的呼吸窘迫症状，她感觉她“溺水”了。她没有发热，咳嗽，胸痛，恶心，呕吐，视觉改变，腹痛，子宫收缩以及阴道流血。检查过程中，她没有发热，脉搏120次/分，血压180/110mmHg，呼吸32次/分，呼吸空气时氧饱和度70%。她不能平卧，否则呼吸更加困难。眼底检查正常。颈内静脉压力估计为15cm水柱。肺部听诊显著bibasilar啰音。心血管检查显示心动过速，重迭奔马律，2/6级心尖全收缩期杂音。心尖脉冲为弥漫性而不是移位的。腹部为妊娠子宫占据，没有触诊。四肢温暖，无瘀斑和水肿。每5分钟轻度子宫收缩。盆腔检查：宫口开1c

12、m，宫颈管消失80%，头先露S-2.多普勒超声检查示胎心正常，130次/分，中度变异。Her physical examination suggests biventricular heart failure. Although malignant hypertension could account for the headache and heart failure, her funduscopic examination does not reveal papilledema or hemorrhages. It would be helpful to review any blood-

13、pressure measurements obtained before pregnancy and to know whether her previous pregnancies were complicated by similar bloodpressure lability. Preeclampsia would explain the headache and hypertension and remains the most likely diagnosis, although severe pulmonary edema is not typical of this cond

14、ition. In the absence of a preexisting cardiomyopathy, the severe hypertension alone would not be expected to precipitate acute heart failure in a young person. If there is an underlying cardiomyopathy, it has to be relatively recent in onset, since the heart does not appear to be enlarged on physic

15、al examination.她的体格检查表明双心室心衰。尽管恶性高血压可以解释头痛和心衰，她的眼底检查却没有显示乳头水肿或出血。回顾孕前的血压测量情况并得知她以前的妊娠过程是否伴有类似的血压升高将是有利的。先兆子痫可以解释头痛和高血压，这也是最有可能的诊断，尽管重度肺水肿不是典型症状。如果没有先前存在的心肌病，重度高血压本身应该不会在一个年轻人身上引起急性心衰。如果有了基础的心肌病，它一定与最近的发作有关，但在体检时心脏似乎没有扩大。Her blood pressure needs to be controlled, and she requires supplemental oxygen

16、and intravenous loop diuretics. Despite the tachycardia, I would avoid giving her a beta-blocker because of its negative inotropic effects. Since vasodilation is often helpful in patients with acute heart failure (particularly when there is severe hypertension), treatment with hydralazine, nifedipin

17、e, or nitroglycerin may be useful and would not be contraindicated in pregnancy; hemodynamic monitoring is also warranted. I would order an electrocardiogram and an urgent echocardiogram, as well as measurements of arterial blood gases and cardiac biomarkers. Urinalysis should be carried out to see

18、whether the patient has proteinuria; the combination of hypertension of recent onset and proteinuria would be diagnostic of preeclampsia, in the absence of another cause of the hypertension. Unusual disorders that should be considered in a younger woman include human immunodeficiency virus infection

19、 with associated cardiomyopathy or an underlying collagen vascular disease such as systemic lupus erythematosus, which might explain her previous spontaneous abortions and might cause a cardiomyopathy due to myopericarditis.需要控制她的血压。她还需要供氧和静脉注射袢利尿剂。尽管心动过速，我想避免给她-阻断剂，因为有负性肌力作用。由于血管舒张往往有助于治疗急性心衰（尤其是当有

20、严重高血压时），孕期使用肼苯达嗪，硝苯地平，或硝酸甘油可能是有用的，没有禁忌。还需要进行血流动力学监测。我开了心电图和急诊超声心动图，以及动脉血气和心脏生物标记物检测。应该进行尿液分析观察病人是否有尿蛋白；在没有其它原因引起高血压的情况下，结合近期发作的高血压和蛋白尿可以诊断先兆子痫。年轻的女性还需考虑的不寻常疾病包括人免疫缺陷病毒感染相关的心肌病或底层胶原血管疾病，如系统性红斑狼疮，这可以解释她先前的自然流产，和心肌心包炎可能导致的心肌病。An electrocardiogram showed sinus tachycardia with ST-segment elevations in l

21、eads I and aVL and inferolateral ST-segment depressions suggestive of myocardial ischemia (Fig. 1). A chest radiograph obtained with abdominal shielding revealed bilateral alveolar infiltrates, which were consistent with pulmonary edema. Computed tomography of the head performed without the administ

22、ration of contrast material revealed no intracranial hemorrhage or cerebral edema.心电图显示窦性心动过速与I和aVL导联上的ST段抬高和外侧ST段压低提示心肌缺血（图一）。腹部双侧屏蔽的胸部X光显示肺泡浸润，这与肺水肿的表现是一致的。没有平扫CT示没有发现颅内出血或脑水肿。The results of initial laboratory tests were as follows: sodium level, 134 mmol per liter; potassium level, 5.4 mmol per l

23、iter; chloride level, 109 mmol per liter; bicarbonate level, 15 mmol per liter; blood urea nitrogen level, 11 mg per deciliter (3.9 mmol per liter of urea); creatinine level, 0.9 mg per deciliter (80 mol per liter); white-cell count, 21,800 per cubic millimeter; hemoglobin level, 14 g per deciliter;

24、 platelet count, 356,000 per cubic millimeter; albumin level, 4.0 g per deciliter; total bilirubin level, 0.5 mg per deciliter (8.6 mol per liter); alkaline phosphatase level, 127 U per liter; alanine aminotransferase level, 74 U per liter; uric acid level, 4.0 mg per deciliter (238 mol per liter);

25、prothrombin time, 12.3 seconds (international normalized ratio, 0.9); creatine kinase level, 1353 U per liter, with an MB fraction of 2.3%; and troponin I level, 23.2 U per liter (normal value, 0.1). Urinalysis was notable for 3+ protein by dipstick. Arterial blood gas measurements with the patient

26、breathing 100% oxygen revealed a pH of 7.42, a partial pressure of carbon dioxide of 27 mm Hg, and a partial pressure of oxygen of 48 mm Hg.初步化验结果表明如下: Na 134mmol/L，K 5.4mmol/L，Cl 109 mmol/L，HCO3 15 mmol/L; BUN 11mg/dl (3.9 mmol/L，尿液)，Cr 0.9mg/dl (80mol/L);WBC 21800/mm3, HGB 14g/dl,PLT 356,000/mm3;

27、ALB 4.0g/ dl，TBIL 0.5 mg/dl（8.6mol/dl），ALP 127 U/ml, AST 74 U/mL, UA 4.0 mg/dl（238mol/L）;PT 12.3秒（国际标准化比值，0.9）；Cr，1353 U/L（2.3MB分数）、Tr I级，23.2 U/mL（正常值，0.1 U/mL）。尿液试纸分析突出结果是蛋白（+）。病人吸入100%氧气时，动脉血气测量示PH 7.42，PCO2 27mmHg，PO2 48mmHg。 The impressive regional ST-segment changes are not characteristic of a

28、cute myocarditis and thus raise concern about ischemia. Coronary-artery dissection may occur late in pregnancy and can cause acute heart failure. An echocardiogram is warranted urgently, since the finding of a circumscribed lateral wall-motion abnormality would increase concern about an acute corona

29、ry syndrome and prompt urgent referral for diagnostic coronary angiography (with appropriate shielding to protect the fetus). Should this patient be found to have global left ventricular dysfunction, a coronaryartery problem would be much less likely, and angiography could be deferred in favor of me

30、dical stabilization.显著的区域ST段变化并不是急性心肌炎的特点，因此需提高对缺血的关注。冠状动脉夹层可能会发生在孕晚期，并可能导致急性心衰。超声心动图需要紧急执行，因为限制性侧壁运动异常会增加对一种急性冠脉综合征的关注，并提示需要急行诊断性冠脉造影(适当的屏蔽保护胎儿)。如果这个病人被发现左室功能不全，冠脉发生问题的可能性小，造影可能影响病人病情稳定性。The high hemoglobin level is consistent with hemoconcentration, which is typical of preeclampsia. The elevated w

31、hite-cell count may reflect an acute stress reaction or an underlying infection. The pattern of biomarker findings that is, a normal creatine kinase MB fraction and a high troponin I level suggests either a late presentation of myocardial infarction (since troponin stays elevated longer than creatin

32、e kinase MB does after an acute ischemic event) or myocarditis (since troponins are more sensitive than is creatine kinase MB for picking up low-grade inflammation within the heart). Still, given this patients severe hypertension and significant proteinuria, my primary concern is preeclampsia. Immed

33、iate administration of magnesium sulfate for prophylaxis against seizures is warranted, and the fetus should be delivered as soon as possible.高血红蛋白水平与血液浓缩一致，这是先兆子痫的典型表现。白细胞计数增加可能反映出急性应激反应或潜在感染。生物标志物结果即CK_MB正常，Tr_I水平高表明是晚期心肌梗死(急性缺血性事件后Tr_I升高时间比CK_MB长)或心肌炎(心肌轻度炎症时, Tr较CK_MB敏感)。不过，由于这个病人严重的高血压和显著的蛋白尿，我主要考虑先兆子痫，立即予硫酸镁预防子痫发作，并应尽快娩出胎儿。