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脾肾论治胎漏
胎动
不安
经验
浅析
王珂颖
浙江中医药大学学报2023年2月第47卷第2期胎漏、胎动不安,为女性妊娠期的常见疾病,此病名最早出现在脉经及诸病源候论中,表现为妊娠期阴道出现少量流血,淋漓不净或时作时止,其中不伴有腰部酸痛、小腹坠胀者为“胎漏”,出现腰部酸痛、小腹坠胀者为“胎动不安”。两者类似于西医的“先兆流产”,多发生在妊娠早期,若及时诊治,仍有较大概率继续妊娠,若不能及时得到诊治或诊治不当,则易致小产、堕胎。随着社会快速发展,生活节奏加快,工作压力增大,研究表明,先兆流产的发病率逐年升高,女性生殖健康问题日益突出1。先兆流产的发病机制较为复杂,西医多认为与免疫、遗传、内分泌等因素有关,中医历代医家对胎漏、胎动不安的治疗也有较多论述。国家级名中医何若苹教授,为首届国医大师何任教授的学术继承人,至今从事中医临床工作近40年。作为全国老中医药专家学术经验继承工作指导老师,何教授擅长诊治内、妇科以及肿瘤等疾病,临床疗效良好,尤其对胎漏、胎动不安的治疗积累了相当丰富的经验,形成了自身独特的临床思路及诊治方法。现将何教授从脾肾论治胎漏、胎动不安的临床经验介绍如下,以飨同道。1病因病机古代医家对胎漏、胎动不安的病因已有较多论述,圣济总录妊娠门提出:“妊娠之人若触冒JOURNAL OF ZHEJIANG CHINESE MEDICAL UNIVERSITY VOL.47NO.2 Feb.2023国医传承何若苹从脾肾论治胎漏、胎动不安的经验浅析王珂颖1何若苹21.浙江中医药大学第三临床医学院杭州3100532.浙江中医药大学附属第三医院摘要:目的总结何若苹教授从脾肾论治胎漏、胎动不安的经验。方法通过跟诊学习,整理相关临床医案,从病因病机认识、辨证论治、方药运用三个方面,分析何教授治疗胎漏、胎动不安的临床经验,并佐以医案。结果何教授认为,胎漏、胎动不安的病因病机主要为肾虚脾弱,亦不可忽视气血亏虚、血热气结等,治疗以补肾健脾为根本大法,佐以清热滋阴、开郁顺气,并以古方为依据,结合自己多年经验自拟安胎方,辨证审因,随证加减,中西合参。所附医案,何教授辨为脾肾亏虚证,治以益肾健脾为主,选用安胎方加减,取得良好疗效。结论何教授从脾肾论治胎漏、胎动不安,在补肾健脾的基础上灵活遣方,疗效确切,临床实用,值得学习与推广。关键词:胎漏;胎动不安;先兆流产;脾肾;自拟经验方;医案;名医经验;何若苹中图分类号:R271文献标志码:A文章编号:1005-5509(2023)02-0157-04DOI:10.16466/j.issn1005-5509.2023.02.008HE Ruopings Clinical Experience in Treating Fetal Leakage and Fetal Irritability from the Perspective of the Kidney andSpleen WANGKeying1,HERuoping21.TheThirdClinicalMedicineSchool,ZhejiangChineseMedicalUniversity,Hangzhou(310053),China;2.The Third Affiliated Hospital of Zhejiang Chinese Medical UniversityAbstract:ObjectiveTo summarize the clinical experience of Professor HE Ruoping in treating fetal leakage and fetal irritability fromthe perspective of the kidney and spleen.MethodsThrough following Professor HEs clinical work and sorting out clinical medicalrecords,Professor HEs clinical experience in treating fetal leakage and fetal irritability from etiology,pathogenesis,treatment ideas andmedication characteristics was analyzed,and one medical case was attached for evidence.ResultsProfessor HE believes that thepathogenesis of fetal leakage and fetal irritability is mainly attributed to kidney and spleen deficiency,Qi and blood deficiency,blood-heat and Qi accumulation,the fundamental treatment is to tonify the kidney and strengthen the spleen,with clearing heat andnourishing Yin,relieving depression and regulating Qi.As a physician for years,Professor HE has summed up many years of clinicalexperience and formulated self-made empirical formula Antai Decoction,based on ancient prescriptions,and sought etiological factorsaccording to clinical manifestations,modified the formula according to differentiated pattern,and combined therapy of Chinese andwestern medicine.In the attached medical case,Professor HE identified the syndrome as deficiency of the kidney and spleen,and thetreatment mainly focused on tonifying the kidney and strengthening the spleen,modified Antai Decoction was adopted,and the curativeeffect was quite good.ConclusionProfessor HE treats fetal leakage and fetal irritability from the perspective of the kidney and spleen,flexibly applies formulas based on tonifying the kidney and strengthening the spleen.The treatment has definite curative effect and isclinically practical,which is worth learning and promoting.Key words:fetal leakage;fetal irritability;threatened abortion;kidney and spleen;self-made empirical formula;medical record;ex-perience of famous doctor;HE Ruoping通信作者:何若苹,E-mail:157浙江中医药大学学报2023年2月第47卷第2期风寒,饮食生冷,及喜怒劳动之过,悉致胎动。”2陈素庵3在妇科补解胎前杂症门卷之三指出,胎动不安大抵为“冲任二脉血虚、受胎不实”所致,亦有“饮酒过度”“房事太多”“暴怒伤肝”“风入阴户”“因击而触”“用力过度伤筋”等病因。历代中医对其病机的总体认识为冲任损伤,胎元不固,如万氏妇人科提出胎漏下是气虚血虚,胞中有热,下元不固4;陈自明5妇人大全良方中认为“或怒伤肝火,或脾气虚弱”,表明肝脾二脏的损伤亦能致病。何教授根据古籍经典结合多年临床经验认为,此病的发生根本原因在肾、脾二脏的虚损,亦有气血虚弱、血热、气结等。1.1肾气不固,冲任损伤,胞宫失藏脉贯曰:“肾主藏精,精血调和,交会孕子之征也。”6素问 上古天真论提出“肾者主水,受五脏六腑之精而藏之”“二七而天癸至,任脉通,太冲脉盛,月事以时下,故有子”“二八,肾气盛故能有子”。何教授认为,肾作为水脏,又为先天之本,藏先天生殖之精,是孕育胎儿的物质基础,只有男女两性生殖之精充足,才能孕育胎儿于胞宫之中。“肾气-天癸-冲任-胞宫”是女性生长生殖过程中重要的轴线,其中胞宫为女子经孕胎产的场所,与肾及冲任二脉密切相关。肾气充盛,汇聚气血于冲任二脉,冲任流通,方能固胎气养胎元。王冰对此注释为:“任脉、冲脉皆奇脉也。肾气全盛,冲任流通,经血渐盈,应时而下冲为血海,任主胞胎,二者相资,故能有子。”若先天之精不充,导致胎儿禀赋不足,或房劳、久病伤肾,则胎元无法受肾气维系,胞宫不固,易致胎漏、胎动不安。1.2脾气不足,气血虚弱,胞胎不安女子的经带胎产均以气血为本。脾为后天之本,气血生化之源,且中焦如沤,脾气充足健运,精微物质才可化为气血输送至胞宫。萧慎斋7曾曰:“妊娠以十二经脉养胎。全赖气血以充养胎元,而气血之旺,惟以脾胃水谷之气化精微而生血气为长养胎元之本。”何教授认为,气血为胎儿长养的基础,饮食不节,多思多虑,劳逸失度均可导致脾气亏虚,胎无气可载,无血可养,则易萎易堕。且脾主升清,使气血上行,女子经带胎产的按时而行有赖于此,若脾气虚,无法维系胞宫,会导致胎元不固而殒堕。1.3邪热动血,气郁失调,胎元易堕女子受孕后阴血易聚集于下焦以养胎元,若阴虚火旺上扰冲任,或有内外等因感受热邪,热邪侵入冲任,血热不宁,血运失常,热迫血行,血溢于脉外,则胞宫及冲任固摄失司,胎动不安。女子以肝为先天,肝藏血又主疏泄,血载气,孕时精血充盛,女子易因阴气浮溢,虚火扰动心神,情绪不稳,肝疏泄不及,此时肝血不能载气运行,易致气结。气为血之帅,气机郁结不能行血统血,或郁而化热或瘀滞或血溢脉外。冲脉通于足厥阴肝经,任脉与肝经交会,情志气机与冲任胞宫密切相关,气结、气郁会导致冲任失调,胞脉失养,胎元不固。2治疗特色2.1补肾健脾,载养胎元肾所藏之精,是孕育胎元的物质基础,脾提供充足的气血,以助胎儿润养。脾肾先后天相互滋生,肾得脾土精微充养,肾精才能充盛;脾赖肾阳温煦,水液精微得以健运,傅山8曾曰“补先后二天之脾与肾,正所以固胞胎之气与血”,指出先天肾精及后天脾气相互调摄,才使胎儿载养得当。何教授诊疗以补肾健脾益气为根本大法,临证四十年不断总结临床经验,在“所以载丸”合“泰山磐石散”的基础上化裁出“安胎方”。“所以载丸”是清代名医陈修园9在女科要旨中创制的,用以治疗“胎气不安,不长,妇人半产,或三四月或四五月按期不易者”的方子,功效为益气护胎助肝肾。“泰山磐石散”有补肾健脾、益气养血之效。研究表明,泰山磐石散能较显著地升高血清孕酮和-人绒毛促性腺激素(human chorionic gonadotropin,-HCG)水平10,从而能够稳固胎儿,促进胚胎发育,有效避免先兆流产、滑胎等疾病。“安胎方”由黄芪、白术、党参、生地黄、当归、炒白芍、川芎、续断、黄芩、苏梗、苎麻根、炙甘草组成。方中党参、黄芪、白术均为补脾气之要药,何教授多用党参、黄芪为补气药对,党参偏于阴,擅长补中;黄芪偏于阳,擅长实表,二者一阴一阳,表里同治,更彰益气之功。白术健脾益气,金匮要略提到“妊娠养胎,白术