妊娠期急性脂肪肝患者的麻醉管理及围手术期处理方式分析

Retrospective analysis of anesthetic and perioperative management in patients of acute fatty liver of pregnancy

目的回顾性分析妊娠期急性脂肪肝患者的临床特征，讨论该类患者围手术期处理和麻醉管理方式。方法回顾北京大学第三医院2007年1月至2015年12月合并妊娠期急性脂肪肝的产科患者12例，收集临床特点、术前检查、分娩方式、剖宫产患者的麻醉方式、产妇及胎儿转归等资料，进行统计分析。结果12例患者中，初次妊娠占91．7％，双胎妊娠占50％，1例患者合并子痫前期。临床症状及体征主要有恶心6例（54．5％）、呕吐5例（45．5％）、黄疸5例（45．5％）、乏力3例（27．3％）、上腹不适2例（18．2％）、纳差2例（18．2％）及反酸1例（9．1％）。实验室检查以肝功能受损及低血糖为主。11例术前诊断的患者中，10例行剖宫产术（1例椎管内麻醉、9例全身麻醉），1例阴道分娩。除1例产后转入我院并得以诊断的患者死亡外，其他患者均治愈出院。18例新生儿中有6例因早产、低体重、宫内窘迫或生后窒息等人儿科治疗，新生儿均存活。结论妊娠期急性脂肪肝为产妇严重合并症之一，早期诊断，及时终止妊娠可改善预后。行剖宫产术的麻醉选择应综合考虑患者肝功能、凝血功能及分娩紧急性，个体化处理。

Objective To retrospectively analyze the clinical characteristics of patients with acute fatty liver of pregnancy （AFLP） , and to discuss perioperative and anesthetic management. Methods A retrospective review was conducted on the records of pregnant patients with a diagnosis of acute fatty liver of pregnancy in Peking University Third Hospital from January 2007 to December 2015. 12 cases were identified. The clinical features, preoperative laboratory findings, types of delivery, anesthetic techniques for cesarean section, and the outcomes of parturients and fetus were collected and analyzed. Results Among the 12 cases, 91.7% were primigravid, 50% had twin pregnancies, and one was diagnosed with concomitant preeelampsia. The common clinical features included nausea （6 cases, 54.5% ）, vomiting （5 cases, 45.5% ）, jaundice （5 cases, 45.5% ）, malaise （3 cases, 27.3% ）, epigastrie discomfort （2 cases, 18.2% ） , anorexia （2 cases, 18.2% ） and regm＇gitation （ 1 case, 9. 1% ） . Laboratory tests mainly showed impaired hepatic function and hypoglycemia. Cesarean deliveries were performed in 10 of the 11 patients diagnosed antepartum. Cesarean section was performed under neuraxial anesthesia （1 case） or general anesthesia （9 cases）. The patient transferred to our center after delivery and diagnosed postpartum died. All the patients diagnosed antepartum survived. 6 out of the 18 fetuses were transferred to the pediatric department due to preterm, low birth weight, intrauterine restriction or asphyxiation, and were all survived. Conclusions AFLP is one of the most severe complications in parturients. Prognosis can he improved with early diagnosis and prompt termination of pregnancy. Hepatic function, coagulation status and urgency of delivery should be well considered to choose the appropriate anesthetic method, and anesthetic management should be individualized.