妊娠期急性脂肪肝孕产妇诊疗及其妊娠结局

Diagnosis and treatment of acute fatty liver during pregnancy and its pregnancy outcomes

目的探讨妊娠期急性脂肪肝(AFLP)孕产妇临床特征及其妊娠结局。方法选择2013年1月至2023年1月烟台毓璜顶医院收治的26例AFLP孕产妇为研究对象。这26例AFLP孕产妇中,发生感染,弥散性血管内凝血(DIC),急性肾功能衰竭(AKF),多器官功能障碍综合征(MODS)及血肿者分别为9、6、7、5、3例,将其分别纳入研究组1~5(n=9、6、7、5、3),其余则分别纳入对照组1~5(n=17、20、19、21、23)。收集26例AFLP孕产妇的一般临床资料、实验室检查结果、并发症发生情况、治疗方案等临床病例资料,并采用成组t检验或Wilcoxon秩和检验,对5种方式分组的孕产妇临床资料进行组间比较。本研究遵循的程序符合烟台毓璜顶医院伦理委员会要求,通过该伦理委员会批准(审批文号:2024-438)。结果①26例AFLP孕产妇的临床表现以恶心(18例,69.2%),皮肤黄染(16例,61.5%),呕吐(12例,46.2%),腹部不适(12例,46.2%),纳差(9例,34.6%)为主;初产妇为21例(80.8%),双胎妊娠为6例(23.1%),剖宫产术分娩者为25例(96.2%)。②研究组1孕产妇血清总胆红素(TBIL)水平显著高于对照组1,差异有统计学意义(Z=-2.29,P=0.022)。研究组2凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、D-二聚体水平,均较对照组2显著延长、增高,纤维蛋白原(Fib)水平较对照组2显著降低,并且差异均有统计学意义(Z=-2.50、P=0.013,t=4.88、P=0.001,t=2.08、P=0.048,Z=-3.23、P=0.001)。研究组3尿素、肌酐水平均显著高于对照组3,差异均有统计学意义(Z=-2.46、P=0.014,t=1.78、P=0.001)。研究组4尿素、肌酐水平均显著高于对照组4,Fib水平显著低于对照组4,差异均有统计学意义(Z=-2.28、P=0.004,t=4.33、P=0.001,Z=-1.99、P=0.047)。研究组5孕产妇PT、APTT、血清TBIL水平、血浆输注量及凝血功能恢复正常时间,均较对照组5显著延长、增高,差异均有统计学意义(Z=-1.97、P=0.049,Z=-2.21、P=0.027,Z=-1.97、P=0.049,Z=-2.07、P=0.039,Z=-2.20、P=0.028)。③对26例(100.0%)孕产妇均采取保肝、预防感染治疗。其中,23例(88.5%)采取纠正凝血功能障碍治疗,9例(34.6%)采取抗感染治疗,8例(30.8%)采取纠正电解质异常治疗,6例(23.1%)转入重症监护病房(ICU),2例(7.7%)采取血液滤过治疗,2例(7.7%)采取胸、腹腔穿刺引流,2例(7.7%)采取血浆置换,1例(3.8%)采取腹壁血肿清除术。26例孕产妇经治疗后,均痊愈出院。④26例AFLP孕产妇分娩的32例新生儿中,2例为胎死宫内;30例活产儿均转入新生儿科,经治疗后,均顺利出院。结论AFLP孕产妇临床表现多为消化道症状。AFLP的早期诊断和尽早终止妊娠及产科多学科团队(MDT)协作,对有效救治AFLP孕产妇至关重要。

Objective To explore the clinical characteristics and perinatal management of pregnant women with acute fatty liver of pregnancy(AFLP).Methods Twenty-six pregnant women with AFLP who were admitted to Yantai Yuhuangding Hospital from January 2013 to January 2023 were selected as research subjects.Among these 26 pregnant women with AFLP,there were 9,6,7,5 and 3 cases with infection,disseminated intravascular coagulation(DIC),acute kidney failure(AKF),multiple organ dysfunction syndrome(MODS),and hematoma,respectively,and they were included in the study groups 1-5(n=9,6,7,5,3),and the rest were included in control group 1-5(n=17,20,19,21,23).The general clinical data,laboratory examination results,complications,treatment plans and other clinical data of 26 pregnant women with AFLP were retrospectively collected,and were compared by independent-samples t test and Wilcoxon rank sum test between different complication groups and control groups.The procedures followed in this study were in accordance with the regulations of the Ethics Committee of Yantai Yuhuangding Hospital,and was approved by the Ethics Committee(Approval No.2024-438).Results①Among 26 pregnant women with AFLP,the main clinical manifestations were nausea(18 cases,69.2%),xanthochromia(16 cases,61.5%),vomiting(12 cases,46.2%),abdominal discomfort(12 cases,46.2%),and poor appetite(9 cases,34.6%).There were 21 cases of primipara(80.8%),6 cases of twin pregnancy(23.1%)and 25 cases of cesarean section delivery(96.2%).②The level of serum total bilirubin(TBIL)in study group 1 was significantly higher than that in control group 1,and the difference was statistically significant(Z=-2.29,P=0.022).The prothrombin time(PT),activated partial thromboplastin time(APPT)and D-dimer level in study group 2 were significantly longer and higher than those in control group 2,while fibrinogen(Fib)level in study group 2 was significantly lower than that in control group 2,and all the differences were statistically significant(Z=-2.50,P=0.013;t=4.88,P=0.001;t=2.08,P=0.048;Z=-3.23,P=0.001).The levels of urea and creatinine in study group 3 were significantly higher than those in control group 3,and the differences were statistically significant(Z=-2.46,P=0.014;t=1.78,P=0.001).The levels of urea and creatinine in study group 4 were significantly higher than those in control group 4,and the level of Fib in study group 4 was significantly lower than that in control group 4,and the differences were statistically significant(Z=-2.28,P=0.004;t=4.33,P=0.001;Z=-1.99,P=0.047).PT,APTT,serum TBIL level,plasma transfusion volume and coagulation function recovery time in study group 5 were significantly longer or higher than those in control group 5,and the differences were statistically significant(Z=-1.97,-2.21,-1.97,-2.07,-2.20;P=0.049,0.027,0.049,0.039,0.028).③All 26 cases(100.0%)of pregnant women were treated with liver protection and infection prevention.And 23 cases(88.5%)were treated with correction of coagulation therapy,9 cases(34.6%)were treated with anti-infective therapy,8 cases(30.8%)were treated with correction of electrolyte therapy,6 cases(23.1%)were transferred to intensive care unit(ICU),and 2 cases(7.7%)were treated with hemofiltration.Thoracic and abdominal puncture drainage was performed on 2 cases(7.7%),plasma exchange was performed on 2 cases(7.7%),and removal of abdominal wall hematoma was performed on 1 case(3.8%).26 cases of pregnant women were cured and discharged from hospital after treatment.④Among the 32 newborns of 26 AFLP pregnant women,2 cases were intrauterine death,and the other 30 cases of live-born infants were transferred to neonatology department and discharged successfully after treatment.Conclusions The clinical manifestations of AFLP pregnant women are mostly gastrointestinal symptoms.Early diagnosis of AFLP,early termination of pregnancy and management by multi-disciplinary team(MDT)in obstetrics are the key to rescue AFLP.