血浆置换在妊娠期重症肝病患者治疗中的应用价值

Value of plasma exchange in the treatment of patients with severe liver disease in pregnancy

目的：探讨血浆置换在妊娠期重症肝病患者治疗中的作用及安全性。方法回顾性分析2009年3月至2013年11月在中山大学附属第三医院外科ICU接受诊治的28例妊娠期重症肝病患者临床资料。根据患者治疗方案分为治疗组与对照组，其中治疗组12例，年龄21～28岁，中位年龄25岁；对照组16例，年龄18～29岁，中位年龄24岁。所有患者均签署知情同意书，符合医学伦理学规定。入组患者均分娩后转入外科ICU，予以抗感染、抗病毒、护肝、利胆、补充人血白蛋白和丙种球蛋白、输注凝血物质等治疗。治疗组在上述治疗的基础上予以新鲜同型血浆置换治疗。比较两组临床检验指标和临床疗效，观察治疗组血浆置换后的不良反应情况。两组患者检验指标比较采用t检验，率的比较采用χ^2检验。结果治疗组患者治疗后血TB、ALB、Scr、空腹血糖（FPG）、凝血酶原活动度（PTA）和动脉血乳酸（Lac）分别为（197±69）μmol/L、（30±7）g/L、（111±42）μmol/L、（5.7±2.4）mmol/L、（55±24）%、（2.3±0.6）mmol/L，对照组相应为（299±113）μmol/L、（24±6）g/L、（165±82）μmol/L、（3.7±1.7）mmol/L、（33±11）%（、4.4±1.5）mmol/L，治疗组较对照组明显改善（t=-3.453，2.389，-4.892，2.798，6.079，-3.339；P〈0.05）。治疗组有效率为92%（11/12），明显高于对照组的56%（9/16）（χ2=4.215，P〈0.05）。治疗组患者中1例输注血浆后出现一过性低血压，予小剂量血管活性药物调控，1h后血压恢复正常。结论血浆置换能改善妊娠期重症肝病患者的临床检验指标，提高临床疗效，是一种安全、有效的治疗方法。

Objective To investigate the therapeutic effect and safety of plasma exchange in the treatment of patients with severe liver disease in pregnancy. Methods Clinical data of 28 patients with severe liver disease in pregnancy in Surgical Intensive Care Unit （SICU）, the Third Afifliated Hospital of Sun Yat-sen University from March 2009 to October 2013 were analyzed retrospectively. According to the therapeutic schedule, the patients were divided into treatment group （n=12, age range：21 to 28 years old, median age：25 years old） and control group （n=16, age range：18 to 29 years old, median age：24 years old）. The informed consents of all patients were obtained and the ethical committee approval was received. All patients were transferred to SICU after childbirth and received treatments of anti-infection, anti-virus, liver protection, reducing jaundice, supplying human albumin and gamma globulin, infusing blood coagulation and so on. And patients in treatment group received the treatment of exchange of homotype fresh plasma on the basic of the above treatments. The differences between 2 groups in clinical examination indicators and therapeutic effect were compared. The adverse reactions after plasma exchange in treatment group were observed. The examination indicators of 2 groups were compared using t test and the ratios were compared using Chi-square test. Results The blood total bilirubin （TB）, albumin （ALB） , serum creatinine （Scr）, fasting blood glucose （FPG） , prothrombin time activity （PTA） and arterial lactic acid （Lac） were （197±69）μmol/L, （30±7）g/L, （111±42）μmol/L, （5.7±2.4）mmol/L, （55±24）%, （2.3±0.6）mmol/L respectively in treatment group and were （299±113）μmol/L, （24±6）g/L, （165±82）μmol/L, （3.7±1.7）mmol/L, （33±11）%, （4.4±1.5）mmol/L respectively in control group. The indicators in treatment group were signiifcantly improved compared with those in control group （t=-3.453, 2.389,-4.892, 2.798, 6.079, -3.339; P〈0.05）. The effective rate in treatment group （92%,11/12） was signiifcantly higher than that in control group （56%,9/16） （ χ^2=4.215, P〈0.05）. One case in treatment group suffered transitional hypotension after plasma infusion and the blood pressure returned to normal 1 h later after giving a small dose of vasoactive drugs. Conclusions Plasma exchange can improve the clinical examination indicators and therapeutic effect of patients with severe liver disease in pregnancy. It is a safe and effective treatment.