子痫并发溶血、肝酶升高、低血小板计数患者的发病特点及临床结局分析

Clinical outcomes and characteristics of concurrent eclampsia and hemolysis, elevated liver enzymes,and low platelets syndrome

目的 探讨子痫并发溶血、肝酶升高、低血小板计数（HELLP）综合征患者的发病特点及临床结局.方法 选择1999年12月至2008年12月广州医学院第三附属医院妇产科收治的子痫患者76例,根据子痫有无并发HELLP综合征分为并发HELLP综合征组和未并发HELLP综合征组.76例子痫患者入院后均正规使用硫酸镁控制子痫抽搐和预防子痫再发作.采用回顾性分析方法对两组患者的一般资料（包括年龄、孕周、抽搐后血压等）、并发症、血生化指标、重症监护室（ICU）转入率、辅助呼吸支持率、转入ICU时格拉斯歌昏迷评分（GCS评分）、CT或磁共振成像（MRI）检查、孕妇死亡率等临床资料进行对比分析.结果 （1）一般临床资料：76例子痫孕妇中,并发HELLP综合征者17例（并发HELLP组）,发生率为22%（17/76）,未并发HELLP综合征者59例,发生率为78%（59/76）.并发HELLP组孕妇抽搐后收缩压[（182±20）mm Hg（1 mm Hg=0.133 kPa）],较未并发HELLP组[（159±21）mm Hg]显著升高,两组比较,差异有统计学意义（P＜0.05）.而两组孕妇的年龄、发病孕周、分娩孕周、规律产前检查率、抽搐后舒张压等比较,差异无统计学差异（P＞0.05）.（2）血生化指标：并发HELLP组孕妇天冬氨酸转氨酶[（879±337）U/L]、丙氨酸转氨酶[（344±83）U/L]、乳酸脱氢酶[（2245±294）U/L]、尿素氮[（14±9）mmol/L]及肌酐[（140±92）μmol/L]水平明显高于未并发HELLP组[分别为（90±27）U/L、（43±11）U/L、（485±61）U/L、（7±3）mmol/L及（83±28）μmol/L],两组分别比较,差异有统计学意义（P＜0.01,P＜0.05）;并发HELLP组孕妇血小板计数[（38±13）×109/L]明显低于未并发HELLP组[（172±46）×109/L],两组比较,差异有统计学意义（P＜0.01）.（3）临床结局：并发HELLP组死亡率（6/17）显著高于未并发HELLP组（3%,2/59）,两组比较,差异有统计学意义（P＜0.05）.并发HELLP组孕妇的ICU转入率（13/17）、辅助呼吸支持率（9/17）及GCS评分≤8分发生率（8/17）明显高于未并发HELLP组[分别为（34%,20/59）、（24%,14/59）及（12%,7/59）]两组比较,差异有统计学意义（P＜0.05）.并发HELLP组孕妇脑静脉血栓形成和脑出血的发生率（8/17）明显高于未并发HELLP组（7%,4/59）,两组比较,差异有统计学意义（P＜0.05）.并发HELLP组6例死亡孕妇中有5例死于脑出血,未并发HELLP组中死亡的2例均死于脑出血.8例死亡孕妇均行CT或MRI检查,7例诊断为脑出血.结论 子痫并发HELLP综合征在临床中并不少见,一旦发生其病情严重,脑出血等并发症发生率高,死亡风险高.因此,应高度重视对HELLP综合征患者的子痫发作的预防.

Objective The purpose was to describe the outcomes and characteristics of the obstetric patients with concurrent eclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome （HELLP） syndrome. Methods We retrospectively collected the materials between December 1999 and December 2008 in Obstetric Critical Care Center of Guangzhou. There were 76 patients in rolled then they were divided into two groups according to with or without HELLP syndrome. All the patients were injected Magnesium Sulfate to control seizure and to prevent the recurring of seizure. We analyzed the characteristics （such as age, gestational weeks, blood pressure after seizure）, complications, biochemistry markers, the rate for intensive care unit （ICU） admittion, the need for mechanical ventilation, the Glasgow coma score （GCS） when admitted into ICU, computed tomography scan （CT） or magnetic resonance imaging （MRI）,death rate of maternal and others, then compared between the two groups. Results （ 1 ） General data：There were 17 patients admitted with both eclampsia and HELLP syndrome, and 59 patients admitted eclampsia without HELLP syndrome. The incidence of eclampsia with HELLP syndrome was 22% （17/76）.In eclampsia with HELLP syndrome group, the systolic blood pressure was higher and the rate of preterm also was higher [ （182 ± 20） mm Hg （1 mm Hg=0. 133 kPa）vs. （159± 21 ） mm Hg, P ＜ 0. 05 ]. But in regard to the age, gestational weeks, the rate of regular prenatal care and diastolic blood pressure, there were no differences between the two groups. （2） Biochemistry markers： the aspartate transaminase （AST）, lanine transaminase （ALT）, blood urea nitrogen and creatinine were significantly increased in eclampsia with HELLP syndrome group than eclampsia without HELLP syndrome group [ （879 ± 337） U/L vs. （90 ± 27）U/L, （344 ±83） U/Lvs. （43 ±11）U/L, （2245 ±294） U/L vs. （485 ±61）U/L, （14 ±9） mmol/L vs.（7 ± 3） mmol/L, （ 140 ± 92） μmol/L vs. （83 ± 28 ） μmol/L, P ＜ 0. 01, P ＜ 0. 05 ], and the platelet was lower in eclampsia with HELLP syndrome group [ （38 ± 13） × 109/L vs （ 172 ±46） × 109/L, P ＜0. 01 ].（3） Clinical outcomes： The maternal death rate was 35% （6/17） in eclampsia with HELLP syndrome patients, and significantly higher than the rate in eclampsia without HELLP syndrome group （3%, 2/59）（P ＜ 0. 05 ）. There were more patients admitted to ICU and more patients who need mechanical ventilation in eclampsia with HELLP syndrome （13/17 vs. 34%, 9/17 vs. 24/, P ＜0. 05）, also more patients with GCS ≤8 in eclampsia with HELLP syndrome when admitted to ICU （ 8/17 vs. 7/59, P ＜ 0. 05 ）, compared to the eclampsia without HELLP syndrome group. There were more patients complicated with cerebral venous thrombosis and cerebral hemorrhage in eclampsia with HELLP syndrome group than other group （8/17 vs.7%, P ＜ 0. 05 ）. Five of six patients died of cerebral hemorrhage in eclampsia with HELLP syndrome group,while other two missing cases in eclampsia without HELLP syndrome group all died of cerebral hemorrhage.The all missing cases were performed CT or MRI and seven （7/8） of them showed cerebral hemorrhage.Conclusion The incidence of concurrent eclampsia and HELLP syndrome was not rare, it happened seriously and with more mortalities, such as cerebral hemorrhage, and also the maternal mortality rate was significantly higher. It should be warning that the obstetrician should take great attention for these women,and consider life support treatment for them.