合并HBV感染的妊娠期糖尿病患者并发症和妊娠结局的影响因素及抗病毒治疗对孕期病情活动患者妊娠结局的影响

Influencing factors of complications and pregnancy outcomes in patients with gestational diabetes mellitus complicated with HBV infection and effect of antiviral therapy on pregnancy outcomes in patients with active pregnancy disease

目的探讨合并HBV感染的妊娠期糖尿病(GDM)患者并发症和妊娠结局的影响因素及抗病毒治疗对病情活动患妊娠结局的影响。方法选择350例合并HBV感染的GDM孕妇,根据肝功能是否正常分为HBV感染组236例和乙肝组114例,并纳入100例单纯GDM患者为GDM组。比较3组患者入院时ALT、AST、总胆红素、总胆汁酸水平、HBeAg阳性率,以及不良妊娠结局及并发症发生情况。将129例HBeAg阳性且肝功能异常者中接受抗病毒治疗的71例纳入抗病毒治疗组,其余妊娠32周前仅接受保肝治疗的58例纳入保肝治疗组,比较两组治疗后肝功能及HBeAg变化情况。采用Logistic回归模型分析影响合并HBV感染的GDM患者并发症发生及妊娠结局的危险因素。结果GDM组、HBV感染组、乙肝组入院时的ALT、AST、总胆红素、总胆汁酸、HBeAg阳性率均依次升高(均P<0.05);乙肝组妊娠期肝内胆汁淤积症、产后出血、胎儿宫内窘迫发生率均高于其他两组(均P<0.05)。抗病毒治疗组肝功能恢复率、HBV-DNA转阴率均高于保肝治疗组,不良妊娠结局发生率低于保肝组(均P<0.05)。多因素非条件Logistic回归分析结果显示,ALT>40 U/L、AST>35 U/L、总胆红素>20.5μmol/L、总胆汁酸>10.0μmol/L、HBeAg阳性是合并HBV感染的GDM患者并发症和不良妊娠结局发生的危险因素(均P<0.05)。结论ALT>40 U/L、AST>35 U/L、总胆红素>20.5μmol/L、总胆汁酸>10.0μmol/L、HBeAg阳性时,合并HBV感染的GDM患者发生并发症及不良妊娠结局风险增加,而病情活动且孕晚期抗病毒治疗者风险降低。

Objective To explore the influencing factors of complications and pregnancy outcomes in patients with gestational diabetes mellitus(GDM)complicated with HBV infection as well as the effect of antiviral therapy on pregnancy outcomes in patients with active pregnancy disease.Methods A total of 350 pregnant women with GDM complicated with HBV infection were selected and divided into HBV infection group(n=236)and hepatitis B group(n=114)according to their liver function condition,and 100 patients with simple GDM were enrolled as GDM group.ALT,AST,total bilirubin and total bile acid levels,HBeAg-positive rate at admission,as well as adverse pregnancy outcomes and incidence of complications were compared among the three groups.A total of 71 out of 129 HBeAg-positive patients with abnormal liver function,who received antiviral therapy,were enrolled in the antiviral therapy group,the remaining 58 cases only received hepatoprotective therapy before 32 weeks of pregnancy were enrolled in the hepatoprotective therapy group,and liver function and HBeAg variance after treatment were compared between the two groups.Logistic regression model was used to analyze the risk factors affecting incidence of complications and pregnancy outcomes in GDM patients complicated with HBV infection.Results ALT,AST,total bilirubin,total bile acid,and HBeAg-positive rate at admission all increased in turn in the GDM group,the HBV infection group and the hepatitis B group(all P<0.05);the incidence rates of pregnancy intrahepatic cholestasis,postpartum hemorrhage and intrauterine distress in the hepatitis B group were higher than those in the other two groups(all P<0.05).The antiviral therapy group had higher recovery rate of liver function,higher negative seroconversion rate of HBV-DNA and lower incidence rate of adverse pregnancy outcomes than the hepatoprotective therapy group(all P<0.05).Multivariate unconditional Logistic regression analysis results showed that ALT>40 U/L,AST>35 U/L,total bilirubin>20.5μmol/L,total bile acid>10.0μmol/L,and HBeAg positive were the risk factors for developing complications and adverse pregnancy outcomes in GDM patients complicated with HBV infection(all P<0.05).Conclusion With ALT>40 U/L,AST>35 U/L,total bilirubin>20.5μmol/L,total bile acid>10.0μmol/L or HBeAg positive,GDM patients complicated with HBV infection are at increased risk for developing complications and adverse pregnancy outcomes,whereas those receiving antiviral therapy in the third trimester and having active disease are at decreased risk.