妊娠期重症甲型H1N1流感肺炎病例特点分析

Clinical features of severe H1N1 influenza in pregnant women

目的 探讨妊娠期重症甲型H1N1流感肺炎患者的临床特点,提高对妊娠期重症甲型H1N1流感肺炎的认识.方法 分析我院2009年11月26日至12月20日收治的15例妊娠期重症甲型H1N1流感肺炎患者临床资料.结果 15例患者平均年龄24岁,平均孕周32周,白细胞总数平均值（6.76±3.30）×109/L[（1.30～14.60）×109/L],2例低于4×109/L,最低1.3×109/L;3例高于10×109/L,最高14.6×109/L.中性粒细胞比率（87.62±4.00）%[（79.40～92.90）%],均高于正常.淋巴细胞绝对值（0.70±0.24）×109/L[（0.20～1.20）×109/L],13例（86.7%）低于1×109/L.单核细胞计数平均值（0.10±0.13）×109/L[（0～0.4）×109/L],13例（86.7%）低于0.2 × 109/L,6例计数为0.12例患者检查T淋巴细胞亚群CD4/CD8中有6例（54.5%）〈1.4,其中5例〈1.CDl9相对值21.09±10.39（12～47）,其中6例（40%）〉18.CD16＋56相对值为8.45±3.83（3～15）,4例（26.7%）〈8,其余所有测定值接近低限.14例患者血乳酸脱氢酶平均（400.84±262.84）U/L[（0.80～850.00）U/L],其中10例（71.4%）增高.肌酸激酶（512.47±1250.67）U/L[（25～5088）U/L],4例患者（26.6%）高于正常值,同时伴有同工酶升高.15例中4例（26.7%）血钾〈3.5 mmol/L.12例患者免疫相关检查中有4例（33.3%）补体CA〉0.36g/L,1例（6.7%）〈0.09 g/L;4例（33.3%）C3〈0.75 g/L;免疫球蛋白及免疫复合物大致正常.15例患者放射影像均确定存在多发、多叶肺炎,主要呈间质样改变或大片实变渗出.需要机械通气辅助呼吸的病例影像学特点为双肺弥漫大面积实变影,连续监测进展迅速,符合ARDS影像学表现.4例出现少量胸腔积液,1例合并少量心包积液.患者中有2例晚期妊娠孕妇胚胎死亡,7例及时终止妊娠者病情稳定.结论 妊娠期妇女是甲型H1N1病毒感染的高危人群,并易迅速发展成为ARDS.妊娠期免疫耐受可能参与重症H1N1流感肺炎肺部损伤过程.

Objective To investigate the clinical characteristics of severe patients with influenza A H1N1. Methods Fifteen prenant pneumonia patients with influenza A H1N1 were selected from November 26 to December 20,2009. Results The average age of all patients was 24 years old,with an average gestational age of 32 weeks. Leukopenia was observed in 13. 3% of IS patients,and lymphopenia in 86. 7%. Data on the ratio of CD4 cells to CD8 cells were available for 12 patients,54. 5% of whom had an abnormal CD4：CD8 ratio（〈 1. 4）. Ten of the 14 patients（71. 4%）had increased serum lactate dehydrogenase levels,which were above 245 U per liter. Four patients （26. 6%） had elevated creatine kinase levels at admission. 4 cases of 15 patients （26. 7%） had decreased serum potassium levels,which were below 3.5 mmol per liter. Four patients （33. 3%）had C4 levels higer than 36 g per liter,and 4 cases had C3 less than 0.75 g per liter. All 15 patients had radiologically confirmed pneumonia with bilateral patchy alveolar opacities, affecting three or four lung quadrants. Findings on chest radiographs were consistent with the acute respiratory distress syndrome in all patients requiring mechanical ventilation. 4 cases were found a small amount of pleural effusion, of which 1 case was combined a small amount of pericardial effusion. Respiratory distress requiring intubation and mechanical ventilation developed in 9 patients within the first 24 hours after admission, who were all pregnant women. Two of them in the third trimester died, and 7 cases who were timely terminated pregnancy were in stable condition. Conclusions Pandemic influenza A（HIM） may pose an increased risk of severe illness in pregnant women, and it is easy to develop rapidly into adult respiratory distress syndrome. The pregnancy immunological tolerance may be involved in the severe lung injury process of H1N1 influenza pneumonia.