妊娠合并重型肝炎73例临床分析

摘要

目的：探讨妊娠合并重型肝炎临床治疗方法，以降低该病母婴围产期病死率。方法对深圳市第三人民医院及深圳市罗湖区妇幼保健院妇产科2007年1月至2012年12月间收治的73例妊娠合并重型肝炎患者的临床资料进行回顾性分析。结果本组73例患者病死率8．22％（6/73）；10例以剖宫产终止妊娠的患者中4例同时行子宫切除术，3例死亡；其余63例均分娩，阴道分娩死亡2例，剖宫产死亡1例；61例围产儿（双胎1例）存活率81．97％（50/61）；本组患者中，早中期妊娠25例，晚期妊娠48例，早中期妊娠死亡1例，晚期妊娠死亡5例；1例为单纯剖宫产终止妊娠，2例为同时行剖宫产和子宫切除术。63例分娩患者经阴道分娩28例，死亡2例，剖宫产35例，死亡1例。与单一感染者比较，合并2种肝炎病毒感染的患者病死率及妊娠结局明显更差；18例 HBV单一感染患者中，剖宫产10例、病死3例及胎儿病死3例，均显著高于其他肝炎患者；15例乙肝合并甲肝患者，剖宫产15例、病死3例及胎儿病死4例均显著高于其他肝炎患者，均差异有统计学意义（P＜0．05）。治疗6个月后，妊娠晚期患者治疗总有效率62．5％（30/48）明显低于妊娠早期患者治疗总有效率88．0％（22/25）（P＜0．05）。治疗前，妊娠晚期合并肝炎患者 RBC-C3bRR（15．52±3．82）％、RNIAP（41．92±7．62）％以及CD4＋T淋巴细胞水平（34．35±10．25）％与妊娠早中期患者RBC-C3bRR（17．91±3．32）％、RNIAP（49．32±10．52）％以及CD4＋T淋巴细胞水平（36．31±7．52）％比较均出现下降；妊娠晚期合并肝炎患者RBC-ICR（15．02±3．52）％、CD8＋T 淋巴细胞水平（33．21±6．71）％与妊娠早中期患者 RBC-ICR（14．12±3．12）％、CD8＋T淋巴细胞水平（30．48±8．32）％比较均出现升高；妊娠晚期患者外周血 GLB（28．74±4．82）g/L、Alb （49．42±10．32）g/L与妊娠早中期患者外周血GLB（28．32±5．68）g/L、Alb（40．23±5．96）g/L比较均出现不同程度的增高。结论妊娠合并重型肝炎病情危重，及时纠正患者低蛋白血症及肝功能障碍，适时终止妊娠可阻止肝脏功能进一步损害，能预防弥散性血管内凝血的发生，对降低母婴围产期病死率有重要的意义。%Objective To investigate the clinical features and treatment of pregnancy with severe hepatitis and reduce perinatal mortality with maternal disease. Methods The clinical data of 73 pregnancy patients with severe hepatitis from 2007 January to 2012 December in our hospital were retrospectively analyzed. Results The mortality rate of these 73 patients was 8.22% (6/73). Ten cases were terminated pregnancy of termination by cesarean section,of which 4 cases underwent hysterectomy,and 3 cases died. Other 63 cases delivered,of which 2 cases died from vaginal delivery,and 1 case died from cesarean section;perinatal survival rate of the rest of 61 cases (1 cases of twins)was 81.97% (50/61). Compared with single pathogen infection,the patients which infected by two different pathogen had higher fatality rate and worse pregnancy outcomes. Cesarean section rate (55. 56% ,10/18 ),the mortality rate (16.67% ,3/18)and fetal mortality (16.67% ,3/18)in patients with hepatitis B infection alone were significantly higher than those of patients with other hepatitis virus infection;Cesarean section rate (1 00% ,1 5/1 5 ),mortality rate (20% , 3/1 5 )and fetal mortality (26 .67% ,4/1 5 )were significantly higher in patients combined with hepatitis A and B infection than those of other patients with other hepatitis virus infection,and the differences were statistically significant (P<0.05),respectively. Late pregnancy patients had a significantly lower rate of efficacy therapy with 62.5% (30/48)than that of early pregnancy patients with 88% (22/25)(P<0.05). Before treatment,expression of RBC-C3bRR (15.52± 3.82)% ,RNIAP (41.92±7.62)% and CD4+T cells (34.35±10.25)% in patients with advanced hepatitis in late pregnancy patients were lower than those of early pregnancy patients with RBC-C3bRR (17.91 ±3.32)% ,(49.32 ±10.52)% RNIAP and CD4+T cells (36.31 ±7.52)% ,respectively. Expression of RBC-ICR (15.02 ±3.52)% and CD8+T cells (33.21 ±6.71 )% in late pregnancy patients more than those in early pregnancy patients with RBC-ICR (14.12±3.12)% and CD8+T cells (30.48±8.32)% ,respectively. Globulin (GLB)(28.74±4.82)g/L and albumin (Alb)(49.42±10.32)g/L from peripheral blood in late pregnancy patients were increased different degrees,when compared with early pregnancy patients with GLB (28.32 ±5.68)g/L and Alb (40.23 ±5.96)g/L. Conclusions Pregnancy patients with severe hepatitis is serious,timely correction of hypoalbuminemia and liver dysfunction is of great significance for preventing hepatic encephalopathy and acute renal failure,and timely termination of pregnancy could stop further damage to liver function,prevent DIC occurrence and reduce maternal perinatal mortality.