摘要：
目的 观察妊娠急性脂肪肝(AFLP)患者分娩后实验室检查指标的变化趋势和血浆置换(PE)对患者预后以及实验室指标的影响.方法 回顾性分析2009年1月至2017年6月安徽省立医院重症医学科收治的37例AFLP患者的临床资料,试图明确AFLP的自然病程,所有患者均按Swansea标准诊断为AFLP.根据是否进行PE治疗将患者分为PE组(9例)及非PE组(28例).分析PE治疗对患者肝功能和凝血指标的影响.结果 37例AFLP患者最常见的临床症状依次为恶心呕吐(21例,发生率56.8%)、黄疸(21例,发生率56.8%)、上腹部疼痛(14例,发生率37.8%),90%以上的患者有1个以上的症状.37例AFLP患者均有肝功能异常,但严重程度差异很大,天冬氨酸转氨酶(AST)为(271.65±265.90)U/L ;72.9%的患者(27例)血肌酐(SCr)＞140 mmol/L ;72.97%的患者(27例)凝血酶原时间(PT)＞15 s ;所有患者均接受血制品治疗.终止妊娠后肝功能及凝血指标多在分娩后1周内恢复正常:AST于分娩1～2 d迅速下降并持续降低;两组胆固醇均于分娩后3～4 d下降至最低后开始回升;总胆红素(TBil)分娩后基本保持不变;入院时血小板计数(PLT)≥150×109/L的患者于分娩后2 d恢复至约100×109/L,而入院时PLT＜150×109/L的患者于分娩后6 d才缓慢上升至约100×109/L;入院时纤维蛋白原(Fib)＞1.5 g/L的患者在分娩后前2 d轻度下降后逐渐恢复并稳定,而Fib＜1.5 g/L的患者于分娩后第2 d即开始缓慢上升;PT和活化部分凝血活酶时间(APTT)于分娩后5 d基本恢复至正常参考值范围.而PE治疗能显著改善患者的实验室指标AST、TBil、PLT、PT,PE后即刻和PE后2 d均低于PE前〔AST(U/L):197(114,383)、116(65,311)比239(125,430),TBil(μmol/L):109(67,126)、125(103,178)比164(99,198),PLT(×109/L):96.44±33.10、89.89±33.03比126.22±40.83,PT(s):17.82±5.93、18.36±3.19比22.67±8.44,均P＜0.05〕.结论 及时终止妊娠后约1周AFLP患者各项指标基本能恢复正常;PE治疗能改善AFLP患者的肝功能及凝血指标.%Objective To observe the variation tendency of laboratory indexes after delivery in pregnant women with acute fatty liver of pregnancy (AFLP) and the effects of plasma exchange (PE) on the patients prognoses and those parameters. Methods The data of 37 patients with AFLP admitted to the Department of Intensive Care Unit (ICU) of Anhui Provincial Hospital from January 2009 to June 2017 were retrospectively analyzed and the authors tried to clarify the natural course of AFLP; all the selected patients met the Swansea criteria of the AFLP diagnosis. The patients were divided into a PE group (9 cases) and a non-PE group (28 cases) according to whether they were treated with PE or not. At the same time, the effects of PE on liver function and coagulation parameters in the patients were analyzed. Results The most common clinical symptoms of 37 AFLP patients were as follows: nausea and vomiting (21 cases, incidence 56.8%), jaundice (21 cases, 56.8%), upper abdominal pain (14 cases, 37.8%), and more than 90% of patients had more than one symptom. All 37 patients with AFLP had abnormal liver function, their differences in the severity degrees were great, and the level of aspartate aminotransferase (AST) was (271.65±265.90) U/L;the levels of creatinine (SCr) of 72.9% patients (27 cases) were more than 140 mmol/L; the prothrombin times (PT) of 72.97% patients (27 cases) were more than 15 seconds; all patients had received blood product transfusion. Liver function and blood coagulation parameters mostly returned to normal within 1 week after delivery: AST rapidly decreased on the 1 - 2 days after delivery and then continued to decrease; all the cholesterol levels in the two groups decreased to the lowest levels within 3 - 4 days after delivery and then began to rise; the total bilirubin (TBil) levels kept on basically unchanging after delivery; in the patients with levels of platelet counts (PLT) on admission ≥ 150×109/L, on the second day after delivery, their counts returned to approximately 100×109/L, while in patients with PLT 1.5 g/L on admission, the levels slightly decreased 2 days before delivery, then gradually recovered and stabilized after delivery, while the patients with Fib < 1.5 g/L, the levels began to rise slowly on the second day after delivery; prothrombin time (PT) and activated partial thromboplastin time (APTT) were basically return to the normal reference ranges on the fifth day after delivery. The PE therapy could significantly improve the patients' laboratory indexes: the levels of AST, TBil, PLT, PT were significant lower immediately and on the second day after PE compared with those levels before the PE [AST (U/L): 197 (114, 383), 116 (65, 311) vs. 239 (125, 430), TBil (μmol/L):109 (67, 126), 125 (103, 178) vs. 164 (99, 198), PLT (×109/L): 96.44±33.10, 89.89±33.03 vs. 126.22±40.83, PT (s): 17.82±5.93, 18.36±3.19 vs. 22.67±8.44, all P < 0.05]. Conclusion After terminating the delivery in time for about one week, the AFLP patients' various indexes may basically return to normal; PE therapy can improve the patients' liver function and coagulation indexes.
