妊娠合并肝功能异常299例临床分析

发布时间：2018-06-01 23:14

本文选题：妊娠 + 肝功能异常　；参考：《吉林大学》2014年硕士论文

【摘要】：目的：本文旨在讨论妊娠合并肝功能异常的病因分布、特点，病因相关性对比研究和各病因对母婴预后影响，以及妊娠合并慢性乙型肝炎患者肝损害临床类型，孕期与肝损害程度、HBV DNA滴度的相关性等。方法：回顾性分析吉林大学第一医院2000年9月~2014年2月收治的299例妊娠合并肝功能异常的孕妇，并收集患者入院24小时的肝功能指标、孕周孕龄、生育史、HBV DNA水平、孕妇及胎儿预后等资料。同时随机选择同期健康且无合并症的孕妇200例作为正常对照组,80例HBV携带者作为无症状妊娠组。计量资料观察指标以平均值±标准差（x±s）表示，两组计量资料采用t检验，两组计数资料比较采用χ2检验，以P0.05示差异有明显性，P0.01示差异显著性。全部数据资料采用SPSS20.0统计软件进行分析。结果： 1.299例妊娠合并肝功能异常患者，以晚期妊娠(占75.2%)为主。其中符合诊断标准的初产妇与经产妇181例患者中，以初产妇为主，共112例（占61.8%）。 2.299例妊娠合并肝功能异常的患者中，妊娠合并病毒性肝炎91例（占30.4%），其中：CHB81例，甲型肝炎2例，丙型肝炎7例，戊型肝炎1例；妊娠合并肝硬化4例（占1.3%）：其中乙型肝炎后肝硬化2例，丙型肝炎后肝硬化1例，不明原因肝硬化1例；AIH、WD各1例（占0.3%）；PIH77例（占25.8%）；ICP48例（占16.1%）；HG15例（占5.0%）；AFLP13例（占4.3%）；HELLP综合征11例（占3.7%）；原因不明21例（占7.1%）；另外，PIH合并HELLP综合征11例(占3.7%）；CHB合并ICP2例(占0.8%）；CHB合并PIH3例（占1.0%）；CHB合并HELLP综合征及PIH1例（占0.3%）。其中妊娠合并病毒性肝炎可出现在任何孕期，但以晚期妊娠为主；妊娠合并PIH、ICP、AFLP患者均集中于中、晚期妊娠，尤以晚期妊娠显著；HG患者只发生于妊娠早、中期；妊娠合并AIH、WD、肝硬化及不同病因相重叠均罕见。另外，妊娠早期和晚期发生肝功能异常最常见病因均为病毒性肝炎，妊娠中期为PIH。如除外病毒性肝炎因素，仅分析妊娠期特有的病因妊娠早期则以HG为主，妊娠中期、晚期以PIH为主。 3.以每3孕周为一组，共14组，结果显示孕16-18W及34-36W为发生肝功能异常的两个高峰期。分别有21例（占7.1%）、75例（占25.1%）患者。其中孕16-18W与34-36W病因均以病毒性肝炎为首，分别为8例（占38.1%）和28例（占37.3%）。如排除病毒性肝炎因素，仅分析妊娠合并肝功能异常特有病因时，16-18W最主要病因为HG，6例（占28.6%）；34-36W最主要病因为PIH，23例（占31.1%）。 4. PIH组初产妇患者多于经产妇患者，差异具有明显统计学意义(P0.05）。而CHB、ICP组在生育史上无明显差异（P0.05）。 5.各病因肝功能指标特点，除ICP以TBA升高为主，其他病因均以ALT、AST升高为主，以妊娠合并CHB患者转氨酶升高最明显。另外CHB、AFLP及ICP部分患者可出现黄疸，病情也相对较重。妊娠合并肝功能异常最主要的三大病因（CHB、PIH、ICP）ALT、TBIL、TBA、ALB水平进行比较时发现，妊娠合并CHB患者ALT、TBIL水平均高于其他两组，差异显著（P0.01）,而ICP组TBA水平高于其他两组，差异显著（P0.01）。 6.妊娠肝功能异常组胎儿早产率、宫内窘迫率、死胎率及产后出血率均高于对照组，具有显著差异（P0.01）。主要病因对孕妇及胎儿预后影响中，，ICP组胎儿早产率、死胎率较其他组明显升高，差异具有明显统计学意义（P0.05）,而其他组比较无明显差异（P0.05）；ICP组胎儿早产率较其他三组明显升高，差异具有明显统计学意义（P0.05）,且ICP组死胎率较CHB、PIH组明显升高，差异显著（P0.01）,而CHB组与PIH组相比无明显差异（P0.05）；另外，AFLP组死胎率及产后出血率明显高于其他三组，差异具有显著统计学意义（P0.01）,其他三组无明显差异（P0.05）。 7.(1)妊娠合并CHB患者轻度肝损害16例（占19.7%），中度肝损害28例（占34.5%），重度肝损害37例（占45.8%）。(2)妊娠早期肝损害分度以轻度为主，较中度、重度肝损害患者明显增多，差异显著（P0.01），而中度与重度肝损害患者数比较无明显差异（P0.05）；妊娠中期以轻、中度肝损害为主，较重度肝损害患者明显升高，具有显著统计学意义（P0.01）,而轻度、中度肝损害患者数比较无明显差异（P0.05）；妊娠晚期则以中度、重度肝损害为主，较轻度肝损害患者数明显升高，差异显著（P0.01）,但中度与重度组比较时无明显差异性（P0.05）。(3)妊娠合并CHB患者肝损害中、重度组胎儿早产率、宫内窘迫率、死胎率孕妇产后出血率均较轻度组高，具有明显统计学意义（P0.05）。(4)妊娠晚期、早期与中期HBV DNA滴度比较无明显差异（P0.05）。 8.(1)妊娠合并CHB患者肝功能损害表现为ALT、AST、TBIL水平明显升高，ALB水平减低，与正常对照组和无症状妊娠组比较具有明显统计学差异（P0.05）。而正常对照组与无症状妊娠组上述指标比较时，无明显统计学差异（P0.05）。(2)妊娠合并CHB组HBV DNA低滴度和高滴度的患者明显多于无症状妊娠组，均具有明显统计学差异（P0.05，P0.01）。而HBV DNA阴性组两者比较差异（P0.05）。结论： 1.病毒性肝炎、妊高症、妊娠期肝内胆汁淤积症是引起妊娠期肝功能异常主要病因，且以初产妇晚期妊娠为主。 2.孕16-18W与34-36W是妊娠合并肝功能异常两个主要孕期。 3.妊娠合并症均可不同程度地增加孕妇及胎儿的危险性。 4.妊娠合并CHB患者，临床类型以中、重度肝损害为主，HBV DNA滴度与孕期无相关性。 5. HBV DNA高滴度可作为妊娠期慢性乙型肝炎发生的预测指标。
[Abstract]:Objective : The purpose of this study was to discuss the etiology , characteristics , etiology and correlation of pregnancy complicated with liver function abnormality , the effect of etiology on mother - to - infant prognosis , and the clinical types of liver injury in pregnant women with chronic hepatitis B , the correlation between pregnancy and liver injury and HBV DNA titer .

Methods : 299 pregnant women with abnormal liver function were analyzed retrospectively from September 2000 to February 2014 in Jilin University .

Results :

1.299 cases of pregnancy complicated with abnormal liver function were dominated by late pregnancy ( 75.2 % ) . Among the 181 patients who met the criteria of diagnosis , 112 cases ( 61.8 % ) had primary maternal and secondary maternal mortality .

Among 299 cases of pregnancy with abnormal liver function , 91 cases ( 30.4 % ) were pregnant with viral hepatitis , including CHB81 cases , hepatitis A 2 cases , hepatitis C 7 cases and hepatitis E 1 case .
There were 4 cases ( 1.3 % ) of pregnancy complicated with cirrhosis : 1 case of cirrhosis after hepatitis B , 1 case of cirrhosis after hepatitis C and 1 case of unknown cause cirrhosis ;
AIH , WD 1 ( 0.3 % ) ;
PIH77 cases ( 25.8 % ) ;
ICP48 cases ( 16.1 % ) ;
15 cases ( 5.0 % ) ;
AFLP13 ( 4.3 % ) ;
11 cases ( 3.7 % ) of HELLP syndrome ;
The cause was unknown in 21 cases ( 7.1 % ) .
In addition , the PIH combined with HELLP syndrome in 11 cases ( 3.7 % ) ;
There were ICP2 cases ( 0.8 % ) .
There were PIH3 cases ( 1.0 % ) .
The combined HELLP syndrome and PIH1 cases ( 0.3 % ) . Among them , the pregnancy complicated with viral hepatitis could be found in any pregnancy , but in the late stage of pregnancy .
Pregnancy combined with PIH , ICP and AFLP was concentrated in middle and late pregnancy , especially in late pregnancy .
HG patients only occurred in the early and middle stages of pregnancy .
Pregnancy combined with AIH , WD , liver cirrhosis and different etiologies are rare . In addition , the most common causes of abnormal liver function in the early and late stages of pregnancy are viral hepatitis and PIH in the middle of pregnancy .

There were 21 cases ( 7.1 % ) and 28 cases ( 37.3 % ) respectively . Among them , 16 - 18W and 34 - 36W were the first , 8 cases ( 38 . 1 % ) and 28 cases ( 37.3 % ) respectively .
34 - 36 W was the most common cause of PIH , 23 ( 31 . 1 % ) .

4 . There was no significant difference between the PIH group and the pregnant women ( P0.05 ) .

5 . Compared with other two groups , the levels of ALT and TBIL in patients with pregnancy and ICP were higher than those in other two groups ( P0.01 ) , but the levels of ALT and TBIL in patients with pregnancy were higher than those in other two groups ( P0.01 ) .

6 . The preterm birth rate , fetal distress rate , stillbirth rate and postpartum hemorrhage rate in the abnormal group of pregnant liver function were higher than those in the control group .
The premature birth rate of ICP group was significantly higher than that in other three groups ( P0.05 ) , and the death rate of ICP group was significantly higher than that in the group with the PIH group ( P0.01 ) , but there was no significant difference between the two groups ( P0.05 ) .
In addition , the death rate and postpartum hemorrhage rate of AFLP group were significantly higher than that in other three groups ( P0.01 ) . There was no significant difference in other three groups ( P0.05 ) .

7 . ( 1 ) There were 16 cases of mild hepatic impairment ( 19 . 7 % ) , moderate hepatic impairment in 28 ( 34 . 5 % ) , severe hepatic impairment in 37 ( 45.8 % ) .
There was no significant difference in the number of patients with mild and moderate hepatic impairment ( P0.05 ) .
( 4 ) There was no significant difference between the early and medium - term HBV DNA titers ( P0.05 ) . ( 4 ) There was no significant difference between the early and medium - term HBV DNA titers ( P0.05 ) .

8 . ( 1 ) There was a significant difference in the levels of ALT , AST , TBIL and ALB in the patients with pregnancy . The difference between the normal control group and the asymptomatic pregnancy group was significantly higher than that in the normal control group and the asymptomatic pregnancy group ( P0.05 ) . There was a significant difference between HBV DNA negative group and HBV DNA negative group ( P0.05 ) .

Conclusion :

1 . Viral hepatitis , pregnancy - induced hypertension , pregnancy - induced intrahepatic calculosis are the main causes of abnormal liver function during pregnancy , and mainly in the late stage of pregnancy .

2 . Pregnancy 16 - 18W and 34 - 36W are two main stages of pregnancy with abnormal liver function .

3 . Pregnancy complications can increase the risk of pregnant women and fetus in different degrees .

4 . There was no correlation between HBV DNA titer and pregnancy .

5 . The high titer of HBV DNA can be used as a predictor of chronic hepatitis B in pregnancy .
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R714.255

【参考文献】