过氧化物酶增殖体激活受体α、氧固醇7α羟化酶及雌激素受体间调控关系及其与孕鼠肝内胆汁淤积发生的相关性

目的 探讨过氧化物酶增殖体激活受体α(PPARα)、氧固醇7α羟化酶(CYP7B1)、雌激素受体(ER)α及ERβ之间的调控关系与孕鼠肝内胆汁淤积发生的相关性.方法 选择清洁级SD孕鼠80只,随机分为4组,每组20只,自孕第13天起:对照组孕鼠皮下注射精制植物油2.0ml·kg-1·d-1;低剂量组孕鼠皮下注射17-α-乙炔雌二醇(1.0 mg·kg-1·d-1);中剂量组孕鼠皮下注射17-α-乙炔雌二醇(1.25 mg·lg-1·d-1);高剂量组孕鼠皮下注射17-α-乙炔雌二醇(1.5 mg·kg-1·d-1).4组孕鼠于妊娠第21天处死后提取肝脏组织.应用酶联免疫吸附试验检测各组孕鼠血清中丙氨酸转氨酶(ALT)、门冬氨酸转氨酶(AST)、总胆酸(TBA)及胆红素(BIL)水平;应用实时定量PCR技术检测各组孕鼠肝脏组织中PPARα mRNA、CYP7B1 mRNA、ERα mRNA及ERβ mRNA的表达水平.结果 (1)生化指标:对照组孕鼠ALT、AST、TBA及BIL水平分别为(41.1±2.8)U/L、(44.4±3.6)U/L、(26.4±5.6)μmol/L、(2.8±0.2)U/L,低剂量组孕鼠分别为(48.2±3.4)U/L、(47.9±3.7)U/L、(36.4±4.2)μmol/L、(4.2±0.2)U/L,中剂量组孕鼠分别为(70.4±5.3)U/L、(68.4±5.6)U/L、(64.3±3.8)μmol/L、(6.2±1.2)U/L,高剂量组孕鼠分别为(72.4±7.6)U/L、(70.2±3.8)U/L、(72.4±7.8)μmol/L、(8.2±2.2)U/L.低剂量组、中剂量组、高剂量组孕鼠ALT、AST、TBA、BIL水平明显高于对照组(P<0.05);中剂量组、高剂量组孕鼠各生化指标水平明显高于低剂量组(P<0.05).(2)ERαmRNA及ERβmRNA表达水平:ERαmRNA的表达水平在低剂量组(0.76±0.02)、中剂量组(0.99±0.04)和高剂量组(1.21±0.01)孕鼠肝脏组织中呈逐渐升高趋势(P<0.05),并明显高于对照组(0.65±0.01),分别与对照组比较,差异均有统计学意义(P<0.05);ERβ表达水平在4组孕鼠间分别比较,差异均无统计学意义(P>0.05).(3)CYP7B1 mRNA及PPARα mRNA表达水平:CYP7B1 mRNA的表达水平在低剂量组(0.93±0.01)、中剂量组(0.99±0.06)和高剂量组(1.22±0.04)孕鼠肝脏组织中呈逐渐升高趋势(P<0.05),并明显高于对照组(0.75±0.02),分别与对照组比较,差异均有统计学意义(P<0.05);PPARα mRNA表达水平在低剂量组(0.83±0.05)、中剂量组(0.71±0.02)和高剂量组(0.64±0.03)孕鼠肝脏组织中呈逐渐降低趋势(P<0.05),并明显低于对照组(1.35±0.05),分别与对照组比较,差异均有统计学意义(P<0.05).结论 随着雌激素剂量的增加,PPARα表达水平降低,对CYP7B1表达的抑制作用解除,而导致CYP7B1表达水平升高;而CYP7B1有促进ERα高表达的作用,最终由ERα介导了雌激素诱导的肝内胆汁淤积的发生.提示PPARα、CYP7B1及ER的异常表达,是调控雌激素诱导孕鼠肝内胆汁淤积的发生机制之一.     

孕鼠体内高胆酸水平对胎鼠心肌组织的影响

目的 初步探讨孕鼠高胆酸环境对胎鼠心脏结构的影响.方法 选择清洁级雌性SD大鼠30只,随机分成3组,每组各10只.妊娠第13～20天,A组孕鼠每天腹腔内注射胆酸溶液5.5 mg/(kg·d)(高胆酸组),B组注射胆酸溶液1.4 mg/(kg·d)(低胆酸组),C组注射生理盐水1 ml(对照组).3组孕鼠均于孕第21天处死,测定母胎血中总胆汁酸(total bile acid,TBA)和心肌肌钙蛋白I(cardiac troponin I,cTnI)的浓度.取胎鼠的心脏组织,分别行光镜和电镜观察心肌细胞的改变.结果 (1)三组孕鼠和胎鼠血TBA浓度分别A组(22.32±8.12)8mol/L,(28.84±8.06)μmol/L;B组为(9.77±3.56),μmol/L,(9.34±3.54)/μmol/L;C组为(3.60±1.78)μmol/L,(3.95±1.19)μmol/L.三组间分别进行母鼠和胎鼠的两两比较差异均有统计学意义(P<0.01).(2)胎鼠死胎率在A、B、C三组中分别是30.11%,16.85%,7.05%,两两比较有统计学意义(P<0.05).(3)A组胎鼠的cTnI值为(19.98±7.75)ng/ml;B组(11.41±3.64)ng/ml;C组(4.38±1.19)ng/ml,两两比较有统计学意义(P<0.01).(4)光镜下胎鼠心肌病变积分:A组为1.92±0.43,B组为1.36±0.37,C组为0.44±0.12.两两比较有统计学意义(P<0.01).(5)电镜下胎鼠心肌细胞中,A组线粒体的数密度比C组小(P<0.05),而平均体积比C组大(P<0.05).B组线粒体的平均体积比C组大(P<0.05),但数密度与C组相比无差异.A组胎鼠肌原纤维的数密度和平均体积均比C组小(P<0.05).B组胎鼠肌原纤维的数密度比C组小(P<0.05),平均体积无差异.(6)母血TBA、胎鼠TBA、胎血cTnI值及胎鼠心肌病变积分之间两两比较均呈正相关(P<0.01).结论 孕鼠体内高胆酸水平对胎鼠心肌组织损伤明显,孕鼠体内高胆酸可造成胎鼠心肌组织损伤,胎鼠血清cTnI与TBA呈正相关.     

母鼠人巨细胞病毒感染致胎鼠脑、肺和肝脏的损害

目的 探讨母鼠人巨细胞病毒(HCMV)感染对胎鼠脑、肺和肝脏的损害情况.方法 将30只10周龄健康昆明鼠按雌雄比1:1配对,分为感染组(20只)和对照组(10只),均雌雄各半.感染组雌鼠妊娠前3 d腹腔内接种1×106半数组织培养感染量病毒悬液0.5 ml,对照组雌鼠分别接种等量的人胚成纤维细胞培养上清液.然后交配受孕并于孕19 d剖宫取出胎鼠.感染组共获胎鼠15只;对照组获得健康胎鼠36只,随机抽取15只纳入本研究.检测胎鼠脑、肺、肝脏组织HC-MV DNA和病理改变并进行病毒分离.两组间计数资料比较用χ2检验.结果 感染组胎鼠病毒分离阳性率分别为:脑73.3%(11/15)、肝脏53.3%(8/15)、肺脏60.0%(9/15);对照组3种组织病毒分离阳性率均为0(P<0.05).感染组胎鼠HCMV DNA阳性率分别为:脑93.3%(14/15)、肝脏93.3%(14/15)、肺脏86.7%(13/15);对照组HCMV DNA阳性率均为0(P<0.05).病理检测结果显示感染组胎鼠的脑、肺、肝脏组织结构损伤严重,可见病毒颗粒.结论 母鼠HCMV感染可以发生垂直传播,导致子鼠脑、肺、肝脏等易感器官损伤.     

C/EBP α在妊娠期糖尿病大鼠胎肺成熟过程中的作用

目的:探讨CCAAT/增强结合蛋白α(C/EBP α)在妊娠期糖尿病(GDM)大鼠胎肺成熟过程中的作用。方法:将SD孕鼠随机分为妊娠期糖尿病组(GDM组)和对照组。GDM组给予链脲佐菌素行腹腔注射建立GDM模型,每隔一天检测孕鼠的血糖及体重。于孕21天剖宫产取出胎鼠,记录胎鼠体重、数量及胎仔血糖。HE染色观察胎鼠肺组织病理改变,油红O染色检测胎鼠肺组织中脂质的变化情况,透射电镜观察胎鼠肺组织超微结构改变,免疫组化法检测胎鼠肺表面活性物质相关蛋白A(SP-A)和C/EBP α表达情况,RT-PCR法检测SP-A和C/EBP α mRNA表达。Western blot法检测SP-A和C/EBP α蛋白表达。结果:GDM组孕鼠和胎鼠血糖均显著高于对照组,孕鼠体重、胎鼠体重及胎仔量均显著低于对照组,差异均有统计学意义(P均0.000)。GDM组胎鼠肺泡数和肺泡面积均显著低于对照组,肺泡间隔大于对照组,差异均有统计学意义(P0.000)。GDM组胎鼠肺组织中AECⅡ内的板层小体数明显减少,大量糖原颗粒聚集,细胞表面的微绒毛明显减少。油红O染色见胎鼠肺组织中脂滴数明显减少。SP-A和C/EBP α的mRNA和蛋白表达水平显著低于对照组,差异有统计学意义(P均0.05)。结论:GDM胎肺组织中C/EBP α表达降低,抑制了SP-A和脂质生成,阻碍了细胞内糖原转化成脂质。胎肺组织中C/EBP α表达降低可能是GDM胎鼠肺发育延迟的发病机制之一。     

妊娠肝内胆汁淤积症孕妇及其新生儿血清总胆酸水平变化对胎儿心脏功能的影响

目的 探讨妊娠肝内胆汁淤积症(ICP)孕妇及其新生儿脐动脉血(脐血)血清总胆酸(TBA)水平变化对胎儿心脏功能的影响.方法 应用循环酶法测定30例ICP孕妇(ICP组)及30例正常妊娠妇女(对照组)外周静脉血及其新生儿脐血TBA水平,单克隆夹心酶联免疫法测定新生儿脐血心肌肌钙蛋白I(cTnI)水平,用彩色多普勒超声诊断仪测定胎儿左心室Tei指数.结果 (1)TBA:ICP组孕妇血清TBA水平为(36.0±9.6)μmol/L,新生儿脐血TBA水平为(10.1±2.0)μmol/L;分别高于对照组的(3.8±0.9)、(5.5±0.4)μmol/L,差异均有统计学意义(P<0.01),且ICP组孕妇血清TBA水平明显高于其分娩的新生儿脐血TBA水平,两者比较,差异有统计学意义(P<0.01),对照组孕妇血清TBA水平明显低于其分娩的新生儿脐血TBA水平,两者比较,差异也有统计学意义(P<0.01).(2)Tei指数:ICP组胎儿左心室Tei指数为0.58±0.04,明显高于对照组的0.43±0.03,差异有统计学意义(P<0.01).(3)cTnI:ICP组新生儿脐血cTnI水平为(0.92±0.23)μg/L,明显高于对照组的(0.52±0.10)μg/L,差异也有统计学意义(P<0.01).(4)ICP组脐血TBA水平与孕妇血清TBA、脐血cTnI水平及胎儿左心室Tei指数均呈正相关关系(r=0.769、0.635、0.758,P<0.01);脐血cTnI水平与胎儿左心室Tei指数呈正相关关系(r=0.637,P<0.01).结论ICP胎儿存在左心室功能异常及心肌损伤,这种损伤可能与孕妇血TBA水平升高有密切关系;胎儿左心室Tei指数可作为监测ICP胎儿心脏功能及心肌损伤程度的指标.     

孕鼠血清高胆酸水平对胎鼠大脑组织形态的影响

目的 探讨孕鼠血清高胆酸水平对胎鼠大脑组织形态的影响.方法将30只清洁级成年SD孕鼠随机分为A、B、C 3组,每组10只.在妊娠第13～20天,A组孕鼠每天1次腹腔注射纯胆酸5.5 mg·kg-1·d-1(高胆酸);B组孕鼠每天1次腹腔注射纯胆酸1.4 mg·kg-1·d-1(低胆酸);C组同步注射等量生理盐水.妊娠第21天剖腹取胎,测定胎鼠体重及记录死亡率.测定孕鼠和胎鼠血清总胆酸水平,采用酶联免疫吸附试验测定血神经元特异烯醇化酶(NSE)水平.同时,胎鼠断头取脑,采用光镜和电镜观察胎鼠大脑组织的病理改变.结果 (1)3组孕鼠及胎鼠血清胆酸水平分别为:A组(22.3±8.1)μmol/L,(28.8±8.1)μmol/L;B组(9.8±3.6)μmol/L,(9.3±3.5)μmol/L;C组(3.6±1.8)μmol/L,(4.0±1.2)μmol/L.3组间相互比较,差异有统计学意义(P＜0.01).孕鼠血清总胆酸水平与胎鼠血清总胆酸水平呈正相关关系(r=0.875,P＜0.01).(2)胎鼠死亡率在A、B、C组中分别是30.1%,16.9%和7.1%,3组间相互比较,差异有统计学意义(P＜0.05).(3)A、B、C组胎鼠血清NSE水平分别为(31.9±13.1),(13.9±5.9)和(9.3±3.9)ng/L,A组明显高于B组及C组(P＜0.01);B组与C组比较,差异无统计学意义(P＞0.05).胎鼠血清NSE水平与总胆酸水平呈正相关(r=0.758,P＜0.01).(4)胎鼠大脑皮层组织光镜下病理改变:A、B组胎鼠均表现为不同程度的大脑皮层组织层次紊乱,神经元变性坏死,密度降低,胞核固缩深染.胎鼠神经元变性面积积分在A、B、C组中分别是(1.4±0.6),(1.5±0.7)和(0.7±0.3),A组和B组明显高于C组(P＜0.01);A组与B组比较,差异无统计学意义(P＞0.05).胎鼠神经元变性面积积分与胎鼠血清NSE水平的r为0.282(P＞0.05).胎鼠神经元坏死面积积分在A、B、C组中分别是(1.8±0.7),(0.9±0.4)和(0.6±0.3),A组明显高于B组和C组(P＜0.05);B组与C组比较,差异无统计学意义(P＞0.05).胎鼠神经元坏死面积积分与胎鼠血清NSE水平呈正相关关系(r=0.798,P＜0.01).(5)胎鼠神经细胞透射电镜下病理改变:A、B组胎鼠均表现为不同程度的神经细胞核膜双层结构模糊,核固缩及核仁消失,染色质浓缩;内质网和线粒体数目减少,残留线粒体肿胀破坏,嵴空化消失.胎鼠神经细胞内线粒体数密度(Nv)在A、B、C组中分别是(21.9±9.0),(45.5±13.1)和(36.1±12.1)μm-3.A组明显低于B组和C组(P＜0.01);B组与C组比较,差异无统计学意义(P＞0.05).胎鼠神经细胞内线粒体平均体积((V))在A、B、C组中分别是(7.0±1.8),(5.7±1.6)和(3.2±1.2)×10-4μm3.A组和B组明显高于C组(P＜0.01);A组与B组比较,差异无统计学意义(P＞0.05).结论 孕鼠血清中胆酸可使胎鼠脑组织出现明显的病理改变,低水平胆酸主要导致神经细胞变性和线粒体体积增大,而高水平胆酸主要导致神经细胞坏死和线粒体数目减少.胎鼠血清NSE水平与总胆酸水平呈正相关关系.     

熊脱氧胆酸对抗乙炔雌二醇诱发孕大鼠肝内胆汁淤积的作用机制

目的:研究熊脱氧胆酸(ursodeoxycholicacid,UDCA)对雌激素诱发孕鼠肝内胆汁淤积肝脏胆盐输出泵(bilesaltexportpump,BSEP)及肝脏法尼醇受体(farnesoidXreceptor,FXR)表达的影响,探讨UDCA治疗妊娠期肝内胆汁淤积症(intrahepatischolesta-sisofpregnancy,ICP)的作用机制。方法:随机将孕15d的大鼠40只分成4组,1,2-丙二醇(propyleneGlycol,PG)组,17-α-乙炔雌二醇(ethinylestradiol,EE)组,UDCA组和UDCA+EE组。用药前,用药后5d测血浆中谷丙转氨酶(ALT),谷草转氨酶(AST),碱性磷酸酶(ALP),总胆酸(TBA)。同时观察肝脏形态学变化及胎鼠生长发育情况;应用免疫组化法分析肝脏BSEP及FXR的表达。结果:用药后EE组的孕鼠ALT、AST、ALP、TBA比用药前显著升高(P<0·05),PG组无明显变化(P>0·05),UDCA组,UDCA+EE组ALT,AST,ALP无明显变化(P>0·05),但TBA明显升高(P<0·05)。EE组孕鼠肝脏出现肝内胆汁淤积表现,其余3组肝脏形态结构正常。EE组胎仔身长,尾长,体重,死胎数,活胎数,孕天数与其余3组比较有显著差异(P<0·05)。EE组BSEP表达降低,FXR表达升高,与PG组,UDCA组,UDCA+EE组差异均有显著性(P<0·05)。结论:UDCA对雌激素诱发孕鼠肝内胆汁淤积肝脏具有保护作用,能改善胎仔预后,可能是通过恢复肝脏BSEP的表达促进胆汁分泌,而不是通过影响FXR表达调节胆汁酸的合成。     

妊娠期肝内胆汁淤积症患者血清中白细胞介素18、12及肿瘤坏死因子α的水平变化及其临床意义

目的 探讨白细胞介素(IL)18、IL-12及肿瘤坏死因子α(TNF-α)在妊娠期肝内胆汁淤积症(ICP)患者肝功能异常中的作用.方法 选择2010年4-9月在重庆医科大学附属第一医院就诊的62例ICP患者为ICP组,其中重度患者32例,轻度患者30例;同期就诊的30例健康孕妇为对照组,另选同期在重庆医科大学附属第一医院感染科住院的30例乙型肝炎妇女为肝炎组.采用ELISA 法测定IL-18、IL-12及TNF-α水平.检测血清丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)水平.同时观察ICP组及对照组的围产儿结局.结果 (1)肝炎组血清中IL-18、IL-12、TNF-α水平分别为(256±51)、(122±96)、(207±3)ng/L,ALT、AST水平分别为(363±174)、(359±237)U/L;ICP组IL-18、IL-12、TNF-α水平分别为(72±32)、(42±28)、(48±14)ng/L,ALT、AST水平分别为(201±128)、(132±87)U/L;对照组IL-18、IL-12、TNF-α水平分别为(43±13)、(10±3)、(33±9)ng/L,ALT、AST水平分别为(13±4)、(15±3)U/L.肝炎组血清中IL-18、IL-12、TNF-α及ALT、AST 水平显著高于ICP组和对照组,差异均有统计学意义(P＜0.05);ICP组也显著高于对照组,差异均有统计学意义(P＜0.05).(2)ICP组重度患者血清中IL-18、IL-12、TNF-α水平分别为(81±32)、(50±25)、(50±14)ng/L,ALT、AST水平分别为(269±111)、(181±73)U/L;轻度患者IL-18、IL-12、TNF-α水平分别为(48±18)、(17±4)、(40±10)ng/L,ALT、AST水平分别为(87±46)、(50±21)U/L,ICP组重度患者血清中IL-18、IL-12、TNF-α及AST、ALT水平显著高于轻度患者和对照组,差异均有统计学意义(P＜0.05);轻度患者血清中AST和ALT水平显著高于对照组,差异有统计学意义(P＜0.05).(3)ICP组重度患者的早产儿发生率(50%,16/32)及羊水胎粪污染率(31%,10/32)显著高于轻度患者[分别为7%(2/30)及3%(1/30)]和对照组[分别为3%(1/30)及3%(1/30)],差异均有统计学意义(P＜0.05);重度患者新生儿1分钟Apgar评分≤7分的例数(2例)与轻度患者(1例)和对照组(1例)比较,差异无统计学意义(P＞0.05).结论 IL-18、IL-12和TNF-α可能参与ICP患者肝细胞损害的过程,其水平升高有助于临床诊断ICP患者的肝细胞损害.

Abstract：

Objective To investigate the effect of Interleukin(IL)-18,IL-12 and tumor necrosis factor-α(TNF-α)in hepatic injury in intrahepatic cholestasis of pregnancy(ICP).Methods Sixty-two cases of ICP patients(ICP group),30 cases of normal pregnant women(control group)and 30 cases of hepatitis B(HBV) women (hepatitis group) were recruited. Serum IL-18, IL-12 and TNF-α were examined by ELISA. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were examined by automatic biochemical analysis instrument. Results ( 1 ) In hepatitis group, serum concentrations of IL-18,IL-12 and TNF-α were (256±51 ) ng/L, ( 122±96) ng/L and (207±3) ng/L; serum levels of ALT and AST were(363±174) U/L and (359 ±237) U/L, respectively. In ICP group, serum concentrations of IL18, IL-12 and TNF-α were (72±32) ng/L, (42 ±28) ng/L and (48±14) ng/L; serum levels of ALT and AST were (201 ±128) U/L and ( 132±87) U/L, respectively. While in control group, serum concentrations of IL-18, IL-12 and TNF-α were (43 ± 13) ng/L, ( 10±3) ng/L and (33±9) ng/L; serum levels of ALT and AST were (13 ~ 4) U/L and (15 ± 3) U/L, respectively. Serum IL-18, IL-12, TNF-α, ALT and AST levels in hepatitis group were significantly higher than those in ICP group and control group ( P ＜0. 05 ).Serum IL-18, IL-12, TNF-α, ALT and AST levels in ICP group were significantly higher than those in control group(P ＜ 0. 05 ). (2) In severe ICP subgroup, serum concentrations of IL-18, IL-12 and TNF-α were (81 ±32) ng/L, (50 ±25) ng/L and(50 ± 14) ng/L; serum levels of ALT and AST were (269 ± 111 ) U/L and (181±73) U/L In mild ICP subgroup, serum concentrations of IL-18, IL-12 and TNF-α were (48 ±18 ) ng/L, (17 ± 4 ) ng/L and (40 ± 10 ) ng/L; serum levels of ALT and AST were (87±46) U/L and (50 ±21 ) U/L, respectively. Serum IL-18, IL-12, TNF-α, ALT and AST levels in severe ICP subgroup were significantly higher than those in mild ICP subgroup and control group (P ＜ 0. 05). And serum ALT and AST levels in mild ICP subgroup were significantly higher than those in control group(P ＜0. 05). (3) There were 16 cases with preterm birth (50%, 16/32 ) and 10 cases with meconium-stained amniotic fluid( 31%, 10/32 ) in severe ICP subgroup, significantly higher than those in mild ICP subgroup ( P＜ 0. 05 ), which contained 2 preterm births ( 7%, 2/30) and 1 meconium-stained amniotic fluid (3%, 1/30). While in control group, the numbers were 1(3%, 1/30)and 1(3%, 1/30),respectively. As for the cases of neonates whose 1 minute Apgar score were not more than 7, there were 2 cases, 1 case and 1 case in severe ICP subgroup, mild ICP subgroup and control group, respectively,which showed no significant difference(P＞ 0. 05). Conclusion Serum IL-18, IL-12 and TNF-α may be involved in the process of hepatic injury of ICP.     

妊娠肝内胆汁淤积症患者胎儿缺氧的影响因素

目的　探讨妊娠肝内胆汁淤积症 (ICP)患者胎儿缺氧机理及其相关因素。方法　分别测定ICP患者 (30例 ,ICP组 )及正常妊娠妇女 (30例 ,对照组 )新生儿脐动脉血胆汁酸总量 (TBA)、次黄嘌呤 (HX)、内皮素 (ET)及有核红细胞 (NRBC)计数。结果　 (1)ICP组缺氧者 (10例 )脐血HX水平为(18.6 8± 15 .73) μmol/L ,明显高于ICP组无缺氧者 (2 0例 ) [(6 .87± 2 .82 ) μmol/L ]及对照组 [(6 .81±2 .83) μmol/L](P <0 .0 1) ;但NRBC[(4 .2 0± 2 .49)个 / 10 0白细胞 ,(3.40± 2 .2 6 )个 / 10 0白细胞 ,(3.5 0± 1.74)个 / 10 0白细胞 ]及ET水平 [(72 .44± 12 .2 3)ng/L ,(70 .16± 2 6 .6 1)ng/L ,(6 7.2 7± 43.5 6 )ng/L],各组相似 (P >0 .0 5 )。 (2 )ICP组缺氧者脐血TBA为 (2 3.77± 11.82 ) μmol/L ,明显高于ICP组无缺氧者 (14.86± 5 .46 ) μmol/L ,ICP组无缺氧者脐血TBA又高于对照组 [(9.2 8± 4.39) μmol/L](P <0 .0 1) ;且ICP组脐血TBA与HX水平呈正相关 (r=0 .6 89,P <0 .0 1) ;ICP组羊水胎粪污染率明显高于对照组 (5 3.3% ,13.3% ;P <0 .0 1) ,ICP组羊水胎粪污染者脐血TBA[(2 1.44± 9.92 ) μmol/L],明显高于羊水清亮者 [(13.6 9± 5 .74) μmol/L],差异有显著性 (P <0 .0 5 )。 结论　ICP时 ,     

1340例妊娠期肝内胆汁淤积症的回顾性分析

目的 回顾分析1340例妊娠期肝内胆汁淤积症(intrahepatic eholestasis of pregnancy,ICP)患者的临床资料,探讨ICP分型对诊断和处理的临床意义. 方法 对我院2000年1月至2007年12月的8年中收治的1340例ICP患者病例资料进行回顾性分析.比较不同ICP分型患者的临床表现、生化结果、分娩方式、围产儿结局等指标. 结果 ICP患者占同期产科住院孕妇总数的8.58 oA(1340/15 625),院内分娩孕妇的早产发生率为11.72 %(124/1058).新生儿窒息率为2.07%(23/1110),围产儿死亡率为1.08%(12/1110).75.97%(1018/1340)的ICP孕妇以皮肤瘙痒为主要症状,轻、重型ICP患者皮肤瘙痒症状出现的比例差异无统计学意义[74.89%(522/697)和77.14%(496/643),X~2=0.94,P>±.05].ICP患者有、无皮肤瘙痒时的围产儿死亡率(1.02%和1.46%)、新生儿窒息率(2.30%和1.82%)和早产发生率(11.61%和12.04%)差异均无统计学意义(P均>0.05).甘胆酸(glycocholic,acid,CG)≥64.43/μmol/L与CG＜64.43μmol/L、AST和(或)ALT≥250U/L与AST和ALT均<250U/L、TBA>40/μmol/L与TBA<40μmol/L的患者比较,前者的围产儿死亡率、新生儿窒息率和早产的发生率均低于后者(P均d0.05).轻型ICP患者平均分娩孕周晚于重型ICP患者[(38.3±1.9)周和(36.1±1.7)周,P<0.05],而剖宫产率(73.73%和97.33%)、早产率(6.13%和18.28%)、新生儿窒息率(1.05%和3.49%)和围产儿死亡率(0.18%和2.26%)均低于重型ICP患者(P均<0.05). 结论 ICP分型对终止妊娠时问、分娩方式选择有指导意义,重型ICP宜剖宫产,轻型ICP可在密切监护下阴道试产.     

S-腺苷甲硫氨酸联合还原型谷胱甘肽治疗妊娠期肝内胆汁淤积症

【摘 要】 目的：探讨S-腺苷甲硫氨酸（S-adenosylmethionine,SAM）联合还原型谷胱甘肽治疗妊娠期肝内胆汁淤积症（intrahepatic cholestasis of pregnancy,ICP）的临床效果。方法：选取本院2012年1月-2015年6月收治的117例ICP患者采用SPSS 16.0软件生成随机数字表后分为联合组58例和对照组59例,2组患者均采用SAM+常规治疗,联合组加用还原型谷胱甘肽治疗,2组患者的疗程均为4周,对比2组的治疗效果。结果：治疗前联合组和对照组的血总胆汁酸（TBA）、谷丙转氨酶（ALT）、谷草转氨酶（AST）水平及瘙痒程度评分差异无统计学意义（P＞0.05）;治疗后2组患者的血TBA、ALT、AST水平及瘙痒程度评分均较本组治疗前显著降低（P＜0.05）;治疗后,联合组患者的血TBA、ALT、AST水平及瘙痒程度评分低于对照组患者,差异有统计学意义（P＜0.05）;2组分娩孕周、胎儿窘迫、Apgar评分及新生儿体质量比较,差异无统计学意义（均P＞0.05）;联合组剖宫产率显著低于对照组,差异有统计学意义（P＜0.05）。结论：还原型谷胱甘肽联合SAM治疗ICP较单用SAM具有更加显著的临床效果。     

妊娠期肝内胆汁淤积症胎儿胆汁酸水平与肺表面活性物质的相关性研究

目的 探讨妊娠期肝内胆汁淤积症(ICP)胎儿总胆汁酸水平与胎儿肺表面活性物质(PS)的关系.方法 选择2008年4月至2010年2月在中南大学湘雅二医院住院行剖宫产分娩的ICP孕妇55例(ICP组),记录ICP组孕妇的新生儿出生至产后7 d的一般情况,凡符合胎儿窘迫、新生儿窒息、新生儿呼吸窘迫综合征其中1项者为病理围产儿,无上述情况为正常围产儿.另选同期健康孕妇23例为对照组.采用循环酶法测定两组孕妇血、脐血及羊水中总胆汁酸水平;ELISA法测定两组胎儿脐血肺表面活性蛋白A(SP-A)水平;高效液相色谱法测定两组羊水中磷脂酰胆碱(PC)、磷脂酰肌醇(PI)、溶血卵磷脂(LPC)、神经鞘磷脂(SM)的含量.结果 (1)ICP组孕妇血、脐血及羊水中总胆汁酸水平分别为(30.1±7.9)、(9.3±3.3)及(4.4 ±1.5)mmol/L,明显高于对照组的(4.8±2.2)、(4.9±0.9)及(1.4±1.1)mmol/L,两组分别比较,差异均有统计学意义(P＜0.05).(2)ICP 组胎儿脐血SP-A水平为(29.5±6.4)μg/L,明显高于对照组的(22.6±7.4)μg/L,两组比较,差异均有统计学意义(P＜0.05).(3)ICP组中病理围产儿20例,健康围产儿35例,病理围产儿脐血总胆汁酸及SP-A水平分别为(10.9±2.2)mmol/L及(37.0±5.9)μg/L,健康围产儿分别为(8.0±2.8)mmol/L及(26.7±4.8)μg/L,两者比较,差异有统计学意义(P＜0.05).(4)脐血总胆汁酸水平分别与孕妇血、羊水总胆汁酸水平呈正相关(r1=0.706,r2=0.763,P＜0.05);脐血SP-A水平与脐血总胆汁酸水平呈正相关(r3=0.494,P＜0.05).(5)ICP组羊水中PC及PI的含量分别为(65.4±7.2)及(3.8±0.6)mg/L,均明显低于对照组的(69.7±3.7)及(4.3±0.7)mg/L,两组比较,差异有统计学意义(P＜0.05);ICP组羊水LPC的含量为(4.8±0.9)mg/L,明显高于对照组的(4.2±0.6)mg/L,两组比较,差异有统计学意义(P＜0.05);ICP组羊水SM的含量为(3.5±0.8)mg/L,与对照组的(4.0±0.5)mg/L比较,差异无统计学意义(P＞0.05).(6)ICP组羊水PC/LPC比值(14.2±3.2)明显低于对照组(16.9±2.5),差异有统计学意义(P＜0.05).(7)脐血总胆汁酸水平与羊水PC、PI的含量均呈负相关(r1=-0.561,r2=-0.407,P＜0.05);与LPC含量无相关性(r3=0.260,P＞0.05).结论 ICP孕妇的胎儿脐血及羊水中总胆汁酸水平均明显高于健康孕妇,其胎儿PS的改变与胎儿体内高总胆汁酸水平有关.

Abstract：

Objective To explore the relationship between total bile acid(TBA)concentration and fetal pulmonary surfactant in intrahepatic cholestasis of pregnancy(ICP).Methods Fifry five patients with ICP(ICP group)who received cesarean section from April 2008 to February 2010 in Second Xiangya Hospital,Central South University,were recruited.The general conditions of the neonates within 7 days after birth in ICP group were recorded.Those with fetal distress,neonatal asphyxia,or neonatal respiratory distress syndrome were referred as pathological neonates, others were referred as normal neonates. Over the same period, 23 healthy gravidas were recruited as control group. Enzymatic method was used to detect the TBA concentrations in maternal blood, cord blood and amniotic fluid. ELISA was employed to measure the urfactant protein A (SP-A) concentration in cord blood. High performance liquid chromatography system was used to detect the concentrations of phesphatidylcholine (PC),phosphatidylinositol (PI),lysophosphatidylcholine ( LPC), and sphingomyelin(SM) in amniotic fluid. Results ( 1 ) The concentrations of TBA in maternal blood, cord blood and amniotic fluid were ( 30. 1 ± 7.9 ), (9. 3± 3. 3 ) and (4. 4 ± 1.5 ) mmol/L in ICP group, (4. 8 ± 2. 2), (4. 9 ± 0. 9) and ( 1.4 v 1.1 ) mmol/L in control group, respectively. The differences between the two groups were significant ( P ＜ 0. 05 ). ( 2 ) The SP-A concentration in cord blood in ICP group was ( 29. 5 ± 6. 4 ) μg/L, significantly higher than that in control group, which was ( 22. 6 ± 7. 4 )μg/L ( P＜ 0. 05 ). ( 3 ) There were 20 pathological neonates and 35 normal neonates in ICP group. In pathological neonates, the concentrations of TBA and SP-A in cord blood were (10.9 ± 2.2) mmol/L,(37.0 ± 5.9 ) μg/L, respectively; and were ( 8.0 ± 2. 8 ) mmol/L, ( 26. 7 ± 4. 8 ) μg/L in normal neonates. The differences were significant (P＜ 0. 05 ). (4) There was a positive correlation between TBA concentration in cord blood and in maternal blood ( r1 = 0. 706, P＜0. 05 ). The TBA concentration in cord blood was positively correlated with SP-A concentration as well ( r3 = 0. 494,P ＜ 0. 05 ). (5) The PC and PI concentrations in amniotic fluid were (65.4 ± 7.2) mg/L and ( 3. 8 ± 0. 6 ) mg/L in ICP group, ( 69. 7 ±3.7) mg/L and (4. 3 ± 0. 7 ) mg/L in control group, respectively. The differences were significant (P ＜0. 05 ). The concentration of LPC in amniotic fluid in ICP group was (4. 8 ±0. 9) mg/L, significantly higher than that in control group (P＜0. 05), which was (4. 2 ±0. 6) mg/L. The concentration of SM in amniotic fluid was (3.5±0. 8) mg/L in ICP group, (4. 0 ± 0. 5 ) mg/L in control group, with no significant difference ( P＞0. 05 ). (6) The ratio of PC/LPC in ICP group ( 14. 2± 3. 2 ) was significantly lower than that in control group ( 16. 9 ± 2. 5 ) ( P＜ 0. 05 ). ( 7 ) The TBA concentration in cord blood was negatively correlated with PC and PI concentrations (r1 = -0. 561, r2 = -0. 407, P ＜ 0. 05 ), and had no correlation with LPC concentration (r3 = 0. 260, P＞ 0. 05). Conclusions ( 1 ) The fetal TBA concentrations in both cord blood and amniotic fluid of patients with ICP was higher than those of healthy gravidas, they were also positively correlated with maternal TBA concentration. (2) ICP resulted in the change of fetal pulmonary surfactant and this change was associated with TBA concentrations in both cord blood and amniotic fluid.     

妊娠肝内胆汁淤积症孕妇胎儿总胆酸水平对胎儿胰腺内分泌功能及胎儿生长发育的影响

目的 探讨妊娠肝内胆汁淤积症(ICP)孕妇的胎儿总胆酸水平与胎儿胰腺内分泌功能变化的关系及其对胎儿生长发育的影响.方法 选择2007年3月至2008年2月在中南大学湘雅二医院妇产科行剖宫产分娩的30例单胎ICP孕妇为ICP组,同期行剖宫产分娩的30例正常单胎孕妇为对照组.采用放射免疫法测定两组新生儿脐动脉血中胰岛素、胰高糖素水平;循环酶法测定总胆酸水平;氧化酶-过氧化物法测定血糖水平.并测量两组新生儿出生体重、身长,计算肥胖指数(PI).结果 (1)ICP组新生儿脐动脉血中胰岛素水平为(9.0±3.3)mU/L、胰岛素/胰高糖素比值为0.048±0.028,分别低于对照组的(10.1±3.7)mU/L及0.050±0.020,差异有统计学意义(P<0.05);ICP组新生儿脐动脉血中总胆酸水平为(10.3±3.8)μmol/L、胰高糖素水平为(235±57)ns/L,分别高于对照组的(4.1±1.3)μmol/L及(205±34)ng/L,差异有统计学意义(P<0.05);ICP组新生儿脐动脉血中血糖水平为(3.4±1.1)mmol/L,对照组为(3.6±1.2)mmol/L,两组比较,差异无统计学意义(P>0.05).(2)ICP组新生儿出生体重及身长分别为(3163±478)g及(46.5±2.3)cm,对照组分别为(3498±393)g及(49.3±1.9)cm,两组分别比较,差异均有统计学意义(P<0.01);ICP组新生儿PI(3.13±0.23)明显高于对照组(2.92±0.29),差异有统计学意义(P<0.01).(3)ICP组新生儿总胆酸水平分别与胰岛素、胰高糖素水平及胰岛素/胰高糖素比值呈直线关系,且随着总胆酸水平的升高,胰岛素水平及胰岛素/胰高糖素比值均降低,胰高糖素水平升高(P<0.01);ICP组新生儿脐动脉血中胰岛素水平及胰岛素/胰高糖素比值分别与出生体重、身长呈正相关,与PI呈负相关(P均<0.01);而胰高糖素水平与出生体重、身长呈负相关,与PI呈正相关(P均<0.01).结论 ICP孕妇的胎儿存在胰岛素分泌不足,胰高糖素分泌增多,胰岛素/胰高糖素比值下降的情况,其变化与脐动脉血总胆酸水平密切相关;胎儿胰腺内分泌功能变化可能影响胎儿的生长发育.     

Predictors of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy with dichorionic diamniotic twin pregnancies

Objective: The aim of our study was to investigate the predictors of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP) with dichorionic diamniotic (DCDA) twin pregnancies.

Methods: This study was a retrospective study of women diagnosed with ICP and DCDA twin pregnancies in Chengdu’s women and children’s central hospital. These patients were subdivided into mild and severe ICP groups according to total bile acid (TBA) level. The clinical characteristics and perinatal outcomes were collected and compared between the two groups. Logistic regression analysis was developed to evaluate predictors of adverse perinatal outcomes.

Results: About 134 cases were included in the study. Eighty-four cases were in the mild ICP group, and the other 50 cases were in the severe ICP group. Level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total bilirubin (TBIL), and direct bilirubin (DBIL) in the severe ICP group were significant higher than those in the mild ICP group. The rate of delivery before 34 gestational weeks, meconium-stained amniotic fluid, and composite adverse neonatal outcome were higher in the severe ICP group than those in the mild ICP group. After adjusting for confounders, ICP onset gestational age (GA)?<30 weeks and AST >200U/l were associated with GA at delivery <34 weeks. ALP >400U/l was an independent risk factor of meconium-stained amniotic fluid. ICP onset GA <30 weeks was an independent risk factor of composite adverse neonatal outcome.

Conclusion: ICP onset GA <30 weeks, TBA >40 µmol/l, AST >200U/l, and ALP >400U/l were associated with composite adverse perinatal outcomes in ICP with DCDA twin pregnancies. For those patients with these characteristics, fetal surveillance and treatment should be enhanced.     

Fetal lung surfactant and development alterations in intrahepatic cholestasis of pregnancy

AIM: To investigate the association between total bile acid (TBA) level during intrahepatic cholestasis of pregnancy (ICP) and fetal lung surfactant alteration. METHODS: We recruited 42 ICP and 32 normal pregnancy women in this study. The maternal blood, fetal blood and amniotic fluid TBA level were detected using a circulating enzymatic method. Umbilical blood pulmonary surfactant protein A (SP-A) was evaluated with enzyme-linked immunosorbent assay. High performance liquid chromatography was used for the determination of phosphatidyl choline (PC), phosphatidyl inositol (PI), lysolecithin (LPC) and sphingomyelin (SM). Amniotic fluid lamellar body was counted with a fully automatic blood cell counter. Fetal lung area and fetal body weight were calculated from data obtained with an iu22 color supersonic diagnostic set. Clinical information of a nonstress test, amniotic fluid properties and neonatal Apgar score, and birth weight were recorded for review. RESULTS: The TBA level in maternal blood, fetal blood and amniotic fluid in the ICP group were significantly higher than that in the control group (maternal blood: 34.11 ± 6.75 mmol/L vs 4.55 ± 1.72 mmol/L, P < 0.05; fetal blood: 11.9 ± 2.23 mmol/L vs 3.52 ± 1.56 mmol/L, P < 0.05; amniotic fluid: 3.89 ± 1.99 mmol/L vs 1.43 ± 1.14 mmol/L, P < 0.05). Amniotic fluid PC and PI in the ICP group were significantly lower than that in the control group (PC: 65.71 ± 7.23 μg/mL vs 69.70 ± 6.68 μg/mL, P < 0.05; PI: 3.87 ± 0.65 μg/mL vs 4.28 ± 0.74 μg/mL, P < 0.05). PC/LPC ratio of the ICP group was lower than that of the control group (14.40 ± 3.14 vs 16.90 ± 2.52, P < 0.05). Amniotic LB in the ICP group was significantly lower than that of the control group ((74.13 ± 4.37) × 10⁹/L vs (103.0 ± 26.82) × 10⁹/L, P < 0.05). Fetal umbilical blood SP-A level in the ICP group was significantly higher than that of the control group (30.26 ± 7.01 ng/mL vs 22.63 ± 7.42 ng/mL, P < 0.05). Fetal lung area/body weight ratio of the ICP group was significantly lower than that of the control group (5.76 ± 0.63 cm²/kg vs 6.89 ± 0.48 cm²/kg, P < 0.05). In the ICP group, umbilical cord blood TBA concentration was positively correlated to the maternal blood TBA concentration (r = 0.746, P < 0.05) and umbilical blood SP-A (r = 0.422, P < 0.05), but it was negatively correlated to the amniotic fluid lamellar corpuscle (r = 0.810, P < 0.05) and fetal lung area/body weight ratio (r = 0.769, P < 0.05). Furthermore, umbilical blood TBA showed a negative correlation to PC, SM and PI (r_pc = 0.536, r_sm = 0.438, r_pi = 0.387 respectively, P < 0.05). The neonatal asphyxia, neonatal respiratory distress syndrome, fetal distress and perinatal death rates in the ICP group are higher than that of the control group. CONCLUSION: ICP has higher TBA in maternal and fetal blood and amniotic fluid. The high concentration of TBA may affect fetal pulmonary surfactant production and fetal lung maturation.     

妊娠肝内胆汁淤积症患者脐带血管病变及血管活性物质的表达与胎儿窘迫发生的关系

目的 探讨妊娠肝内胆汁淤积症(ICP)患者脐带血管病理改变、脐带血管活性物质表达的变化与胎儿窘迫发生的关系.方法 应用HE染色法制片,光镜下观察25例ICP伴有胎儿窘迫(ICP窘迫组)、25例ICP不伴胎儿窘迫(ICP对照组)以及27例正常妊娠妇女(正常妊娠组)新生儿脐带血管病理改变;应用免疫组化辣根过氧化物酶-生物素标记(SABC)法测定内皮型一氧化氮合酶(eNOS)、诱导型一氧化氮合酶(iNOS)及内皮素1(ET-1)蛋白在各组脐静脉内皮细胞中的表达量,以平均吸光度(A)值表示;应用循环酶法测定脐静脉血总胆酸水平并进行相关性分析.结果 (1)脐静脉血总胆酸水平:ICP窘迫组为(19.0±2.3)μmol/L,ICP对照组为(9.0±1.7)μmol/L,正常妊娠组为(4.4±1.5)μmol/L,各组分别比较,差异均有统计学意义(P＜0.05).(2)脐静脉病理改变:ICP患者脐静脉内皮细胞单层扁平结构丧失,细胞向管腔耸立,梭形排列,细胞排列不均甚至脱落.ICP窘迫组患者脐静脉内皮细胞出现此病理改变的发生率(92%,23/25)明显高于ICP对照组(68%,17/25),差异有统计学意义(P＜0.05).(3)脐静脉内皮细胞中eNOS蛋白表达量:ICP窘迫组为0.09±0.06,ICP对照组为0.21±0.08,正常妊娠组为0.47±0.07,各组分别比较,差异均有统计学意义(P＜0.05).脐静脉内皮细胞中iNOS蛋白表达量:ICP窘迫组为0.20±0.04,ICP对照组为0.21±0.05,正常妊娠组为0.26±0.04,两ICP组分别与正常妊娠组比较,差异均有统计学意义(P＜0.01,P＜0.05);而ICP窘迫组与ICP对照组间比较,差异无统计学意义(P＞0.05).(4)脐静脉内皮细胞中ET-1蛋白表达量:ICP窘迫组为0.49±0.08,ICP对照组为0.32±0.07,正常妊娠组为0.14±0.06,两ICP组分别与正常妊娠组比较,差异均有统计学意义(P＜0.01,P＜0.05).(5)脐静脉血总胆酸水平与其病理改变的关系:脐静脉血总胆酸水平升高是脐静脉病理改变的危险因素;且与脐血管内皮细胞eNOS、iNOS的蛋白表达量呈负相关关系(r1=-0.88、r2=-0.45,P＜0.01);与脐血管内皮细胞ET-1蛋白的表达量呈正相关关系(r3=0.79,P＜0.01).结论 ICP患者脐静脉血高胆酸状态可能损伤脐静脉内皮细胞,且与其eNOS、iNOS蛋白表达下调、ET-1蛋白表达上调有关,脐静脉的这些改变可能与ICP患者胎儿窘迫的发生有关.