妊娠期急性脂肪肝临床诊治经验总结

Summary of clinical diagnosis and treatment experience about patient suffering from Acute Fatty Liver of Pregnancy

目的通过对南京医科大学附属苏州医院(苏州市立医院北区)妊娠期急性脂肪肝患者临床资料进行总结分析,为临床诊治提供经验参考.方法对患者临床症状、病情发展以及诊疗过程各环节进行分析.结果患者无黄疸和皮肤瘙痒,首发症状上腹痛、便秘腹泻交替半月、恶心呕吐一周.因胎心监护异常,入院24小时内行急诊剖宫产术.术中见自发血肿,输注血浆、纤维蛋白原和凝血酶原复合物.术后1天患者PLT72×109/L、T3.67mmol/L,PT14.4s、TT24.9s、APTT57.8s、Fib0.89g/L、D-D6830μg/L、ALB23.3g/L、K+4.56mmol/L,出现血小板减少、低血糖、肝肾功能异常、凝血功能异常、低蛋白血症、高钾血症,进行血浆置换治疗.术后第4天Hb53g/L、尿量450-300mL、粪潜血+,次日PO252.7mmHg、SaO288.2%、HCO3-17.4mmol/L、pH7.4,超声示:大量胸腔积液,右侧胸腔液性暗区最深79mm、左侧胸腔液性暗区最大径112mm,实施人工肝治疗,母婴结局良好.结论妊娠35周出现消化道症状,应警惕妊娠期急性脂肪肝,监测血常规、肝肾功能和凝血指标.尽早识别和诊断、及时终止妊娠、多学科合作、综合治疗是关键.产后加强监护,对症支持治疗,维持内环境稳定,予以血浆置换和成分输血并严密控制液体量.如果病情进展,尽早转诊ICU;若出现多器官功能损害,及时实施人工肝治疗.

Ob ject ive By analyzing and summarizing the clinical data on patient who suffered from Acute Fatty Liver of Pregnancy in our hospital,to provide empirical reference for clinical diagnosis and treatment.Methods Analyzed each link about clinical symptoms,disease progression,diagnosis and treatment.Results Patient didn't suffer from jaundice and skin itch,the first symptoms were upper abdominal pain,constipation and diarrhea alternating half a month,nausea and vomiting for a week.Emergency cesarean section was executed within 24 hours after admission because of abnormal fetal heartbeat.Spontaneous hematoma was found during operation,then transfusion blood plasma,fibrinogen,prothrombinase complex were administered.The first day after surgery,the blood indicators presented PLT72×10^(9)/L,T3.67mmol/L,PT14.4s,TT24.9s,APTT57.8s,Fib0.89g/L,D-D6830μg/L,ALB23.3g/L,K^(+)4.56mmol/L.Patient manifested a serial of symptoms such as th rombocytopenia,hypoglycemia,hepatic and kidney dysfunction,coagulation disorders,hypoproteinemia,hyperkalemia.We applied plasma exchange therapy.On the fourth day after surgery,patient occurred HB53g/L,Urine volume 450-300ml,occult blood test+.The next day P0252.7mmHg,Sa0288%,HCO_(3)^(-),17.4mmol/L,pH7.4,and Ultrasonic examination manifested massive pleural effusion,which the maximum diameter of right pleural fluid dark area was 79mm and the left was 112mm.After artificial liver treatment,the outcomes of maternal and neonatal turned out to be good.Conc lus ion Once occurring gastrointestinal symptoms at 35 gestational weeks,should alert Acute Fatty Liver of Pregnancy,should monitor blood indicators of blood routine,function of liver and kidney,coagulation function.Early identification and diagnosis AFLP as soon as possible,terminating pregnancy timely,multidisciplinary collaboration,comprehensive treatment,all these are the key to success rescue.Enhancing postpartum custody,symptomatic and supportive treatment,maintaining homeostasis,intensively controlling fluid volume when apply plasma exchange and component transfusion.If disease progressing,transfer patient into ICU quickly,and when MODS happens,apply Artificial LiverTreatment in time.