妊娠特有肝病诊治进展

妊娠期肝脏存在正常的生理变化。尽管如此,妊娠期仍有3%的孕妇出现肝功能异常。妊娠特有肝病是妊娠期肝功能异常的常见原因,在死亡的妊娠期妇女中,约0%～25%孕妇死于妊娠特有性肝病。提高对妊娠特有肝病的认知度和诊治水平尤为重要。本文回顾了近几年有关妊娠特有肝病的研究文献,总结了部分妊娠特有肝病的诊断和治疗进展,供临床医师参考。     

妊娠特有性肝病

妊娠期肝病分为特有性和非特有性两类,前者包含妊娠并发症引起的肝损害。妊娠特有性肝病母婴病死率较高,而非特有性肝病一般对妊娠本身影响不大。妊娠期间,雌激素、孕酮过多影响肝脏代谢、合成、分泌皤。     

妊娠期肝病的临床特征及研究进展

严重的妊娠期肝病临床罕见。妊娠期肝病最常见的发病原因为肝功能紊乱,总发病率约为3%。妊娠期肝病主要分为妊娠期特有肝病和非妊娠期特有肝病,即妊娠前已经存在的基础性肝病或妊娠期间偶发肝病。对妊娠期已存在的肝脏疾病及合并的肝脏疾病进行鉴别诊断,有助于改善母婴结局。在临床诊断、选择治疗、干预方式时,应优先考虑对母婴的潜在影响。介绍了妊娠期主要肝脏疾病的概况、发病机制、治疗和妊娠结局的最新研究进展,阐述了患基础性肝病的妊娠风险及应对措施,以指导临床诊疗和患者管理。     

妊娠期肝病2137例临床分析

目的 探讨妊娠期肝病的分布,各型肝病的产科预后及与产前医学干预的关系.方法 选择1993-2003年本院孕肝科收治的妊娠期肝病2 137例,统计各项指标的平均数据和构成比.结果 妊娠期合并病毒性肝炎1 503例,占70.3%,其中重症肝炎占4.05%.妊娠期特有肝病634例,其中妊娠胆汁淤积症占49.2%.妊娠期急性脂肪肝占12.3%.孕产妇死亡占0.75%,产后出血占11.7%.围产儿结局:死亡26例占1.34%,窒息17.1%,出生缺陷0.88%,早产儿16.1%,胎儿宫内窘迫13.25%.结论 妊娠期合并肝病中病毒性肝炎占主要地位.特发性肝病中主要有妊娠期肝内胆汁淤积症.最凶险的是妊娠合并重症肝炎和妊娠期急性脂肪肝.两种病毒以上的感染、双胎较易发生重症肝炎.早就诊早治疗是减少不良产科预后的有效方法.     

妊娠期肝病183例分析

分析 18 3例妊娠期肝病的病因、孕期情况及转归 ,探讨如何加强孕期保健及改善妊娠期肝病患者母儿预后的方法。结果 :妊娠各期合并病毒性肝炎 15 6例 ,与妊娠有关的肝病 2 7例 ;孕产妇死亡 2例 ,胎死宫内 4例 ;孕产妇出现肝性脑病、肾功能不全、弥散性血管内凝血、严重感染及产后出血等严重并发症 ,结论 :病毒性肝炎仍是妊娠期肝病的主要病因 ,妊娠急性脂肪肝 (AFL P)、妊娠特发性黄疸与妊高症是危害母婴健康的重要病因。婚前乙肝疫苗接种及注意个人卫生 ,孕期加强肝功能监测有助于减少妊娠期病毒性肝炎的发生 ;孕期将血清胆汁酸列为常规检查有助于早诊断、早治疗 ,减少母婴并发症 ;提高对 AFL P的认识 ,早期诊断 ,立即终止妊娠可改善 AFL P的预后     

《2023年欧洲肝病学会临床实践指南：妊娠期肝脏疾病管理》摘译

妊娠期肝脏疾病包括妊娠期肝病, 以及在妊娠期间偶然发生的急性和慢性肝脏疾病, 无论是否与妊娠相关, 妊娠期间的肝脏疾病都与孕产妇及胎儿的高发病风险和高死亡风险相关。因此, 欧洲肝病学会邀请相关专家制定临床实践指南, 旨在根据现有的最佳证据, 为肝病学家、胃肠病学家、妇产科医师、全科医师、培训专家, 以及为该患者群体提供护理的医疗保健人员提供妊娠期肝脏疾病管理建议。     

妊娠期肝病

凡妊娠期出现黄疸或肝功能损害者,均可称为妊娠期肝病,可分为二种[1]:(1)妊娠期特有的肝病,分为两种,一种为特发性,主要有妊娠急性脂肪肝(AFLP)、妊娠期肝内胆汁淤积(ICP);另一种为妊娠并发症引起肝损害,如妊娠高血压综合征(PIH)、溶血肝酶升高血小板下降(HELLP)综合征;(2)妊娠     

妊娠期肝病临床研究进展

根据肝损伤与妊娠的关系可将妊娠期肝病分为妊娠期特异性肝病和肝病合并妊娠。妊娠期特异性肝病指的是只发生在妊娠期的肝脏疾病,而肝病合并妊娠指的是既往肝脏疾病基础上合并妊娠。由于妊娠期涉及母亲和胎儿健康的特殊性,妊娠期肝病的诊治对产科和肝病科医生都具有一定挑战性。在妊娠过程中迅速识别诊断及处理相关疾病,对母亲和胎儿预后十分重要。总结评述了妊娠期肝病的流行病学、发病机制、临床表现、诊断治疗、预后等方面研究进展,以期为更多临床医生提供给参考。     

妊娠特有的肝病

妊娠期肝病罕见(<0.1%)。其可分为三类:(1)妊娠特有的肝病;(2)妊娠前已有的肝病;(3)妊娠期新出现的肝病。本综述以第一类为主。妊娠肝内胆汁郁积(ICP)流行病学ICP 似乎有遗传性。其发生率在大多数国家为1/1000～10000次分娩,世界范围内为0.5～1%。在亚洲人及黑人中罕见。     

病毒性肝炎——总论

妊娠期肝病分布特征与产科结局——蒋佩茹等（上海复旦大学附属上海市公共卫生中心妇产科201508）；《上海预防医学》，2006，18（2）：53．55【目的：了解妊娠期肝病的病因、临床类型的分布特征和产科结局。方法：对903例妊娠期肝病中属病毒性肝炎的病因构成及临床类型构成、妊娠期特有肝病类型构成、妊娠期肝病的产后结局进行统计分析。结果：903病例中，妊娠期合并病毒性肝炎672例，占74．4％；妊娠期特有的肝病23l例，占25．6％。妊娠期合并病毒性肝炎的病因以乙型肝炎最多见，占59．2％，乙型肝炎病毒携带状态占18．9％。妊娠期合并病毒性肝炎的临床类型以慢性肝炎最常见，占42．9％。妊娠期特有肝病的类型以妊娠期肝内胆汁淤积症OCP）最多见。急性肝炎围生儿死亡率、新生儿窒息率和早产率分别为2．3％、29．3％和24．8％，慢性肝炎分别为3．1％、17．8％和19．9％。ICP围生儿死亡率、新生儿窒息率和早产率分别为0．00％、l7．8％和20．0％，妊娠期合并重症肝病对产妇病死率的影响不大于非孕妇。结论：妊娠期病毒性肝炎病因以乙型肝炎多见，临床类型以慢性肝炎多见；妊娠期特有肝病以ICP多见。妊娠期肝病对围生儿死亡率、新生儿窒息率和早产率有影响，但妊娠和分娩对妊娠期肝病无显影响。】     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.