妊娠期急性脂肪肝不同终止妊娠时机对妊娠结局的影响

目的:探讨改善妊娠期急性脂肪肝预后的有效方法。方法:选取本科室2004年1月-2011年6月住院治疗的30例妊娠期急性脂肪肝患者为延迟组,入院后保肝治疗,尽量延长孕周,若肝肾功减退则终止妊娠。选取2011年7月-2015年10月住院治疗的30例确诊后立即终止妊娠的妊娠期急性脂肪肝患者作为立即组。对两组临床资料进行回顾性对比研究,包括临床表现、实验室检查、诊断治疗、预后转归等。同时以发病至终止妊娠时限分组,发病至终止妊娠间隔3d的为早期干预组,发病至终止妊娠3~7d的为中期干预组,发病至终止妊娠7d的为晚期干预组,比较不同时段对该病的诊断时间及术前处理对妊娠结局的影响。结果:终止妊娠后48h,立即组丙氨酸氨基转移酶(ALT)(127±11.3)U/L,天冬按酸氨基转移酶(AST)(201±11.7)U/L,总胆红素(TBIL)(218±12.5)μmol/L,直接胆红素(DBIL)(87.8±9.56)μmol/L,总蛋白(TP)(30.4±3.67)g/L,凝血酶原时间(PT)(17.5±1.57)s,活化部分凝血活酶时间(APTT)(37.8±6.11)s,延迟组ALT(218±12.5)U/L,AST(286±14.2)U/L,TBIL(183±13.2)μmol/L,DBIL(141±10.9)μmol/L,TP(23.9±3.01)g/L,PT(23.3±2.13)s,APTT(49.0±9.01)s,P值分别为0.012,0.035,0.022,0.040,0.039,0.049,0.045,差异均有统计学意义;立即组术中出血量(325±147.8)ml,术后24h出血量(405±161.2)ml,延迟组术中出血量(557±182.2)ml,术后24小时出血量(613±197.9)ml,P值分别为0.006,0.008,差异均有统计学意义;早期诊治的妊娠期急性脂肪肝患者肝功能、凝血功能均得到更好的改善,产后出血量明显减少,减少了孕产妇病死率的发生,但孕产妇严重并发症、新生儿窒息率及围生儿病死率差异无统计学意义(P0.05)。结论:早期诊断、确诊AFLP后48h之内及时终止妊娠、终止妊娠前后输注血浆或冷沉淀补充凝血因子、多学科综合治疗是改善妊娠期急性脂肪肝预后的有效方法。

Influence of different pregnancy terminating time for pregnant women with acute fatty liver on pregnancy outcome

Objective:To explore the effective method to improve the prognosis of pregnant women with acute fatty liver.Methods:From January 2004 to June 2011,30 pregnant women with acute fatty liver were in group A,who had been treated by protected liver function and prolonged the gestational age as far as possible after in hospital.And terminate pregnancy conducted as soon as their liver or kidney function declined.From July 2011to October2015,30 cases of pregnant women with acute fatty liver were in group B,whose terminate pregnancy conducted immediately after in hospital.In this retrospectively study,symptoms,laboratory examination,diagnosis,treatment,and prognosis of patients were compared between the two groups.According to time of acute fatty liver onset to termination,the included patients were divided into three groups,which were early intervention group (pregnancy terminated within three days),mid intervention group (pregnancy terminated at 3-7 days),and later intervention group (pregnancy terminated after 7 days).And pregnancy outcomes were compared among the three groups.Results:At 48 hours after termination of pregnancy,ALT(127±11.3 U/L),AST(201±11.7 U/L),TBIL(218± 12.5μmol/L),DBIL(87.8±9.56μmol/L),TP(30.4±3.67 g/L),PT (17.5±1.57 s),and APTT(37.8±6.11 s) were in the group B,and ALT (218±12.5 U/L),AST(286± 14.2 U/L),TBIL(183 ± 13.2μmol/L),DBIL (141 ± 10.9μmol/L),TP(23.9 ± 3.01 g/L),PT (23.3±2.13 s),and APTT(49.0±9.01 s) were in the group A,there were significant difference (P =0.01,0.04,0.02,0.04,0.04,0.05,0.05).The volume of bleeding intra operative and post operation 24 hours were 325 ± 147.8ml and 405±161.2ml in group B,which were significant lower than those (557±182.2ml,613±197.9ml)in group A(P =0.006,0.008).Liver function,blood clotting function,postpartum hemorrhage,and mortality of patients in early diagnosis and treatment group were significant better,but maternal complications,asphyxia and mortality rate of neonatal had no significant difference among the groups(P＞0.05).Conclusion:Early diagnosis and timely termination of pregnancy within 48h after diagnosis of AFLP is important.Infusion of plasma or cryoprecipitate giving clotting factor before and after terminating pregnancy,and multidisciplinary treatment is an effective way to improve the prognosis of patients with acute fatty liver.