發(fā)布時(shí)間：2018-06-01 23:14

  本文選題：妊娠 + 肝功能異常　； 參考：《吉林大學(xué)》2014年碩士論文

【摘要】：目的：本文旨在討論妊娠合并肝功能異常的病因分布、特點(diǎn)，病因相關(guān)性對(duì)比研究和各病因?qū)δ笅腩A(yù)后影響，以及妊娠合并慢性乙型肝炎患者肝損害臨床類型，孕期與肝損害程度、HBV DNA滴度的相關(guān)性等。 方法：回顧性分析吉林大學(xué)第一醫(yī)院2000年9月~2014年2月收治的299例妊娠合并肝功能異常的孕婦，并收集患者入院24小時(shí)的肝功能指標(biāo)、孕周孕齡、生育史、HBV DNA水平、孕婦及胎兒預(yù)后等資料。同時(shí)隨機(jī)選擇同期健康且無合并癥的孕婦200例作為正常對(duì)照組,80例HBV攜帶者作為無癥狀妊娠組。計(jì)量資料觀察指標(biāo)以平均值±標(biāo)準(zhǔn)差（x±s）表示，兩組計(jì)量資料采用t檢驗(yàn)，兩組計(jì)數(shù)資料比較采用χ2檢驗(yàn)，以P0.05示差異有明顯性，P0.01示差異顯著性。全部數(shù)據(jù)資料采用SPSS20.0統(tǒng)計(jì)軟件進(jìn)行分析。 結(jié)果： 1.299例妊娠合并肝功能異�；颊撸酝砥谌焉�(占75.2%)為主。其中符合診斷標(biāo)準(zhǔn)的初產(chǎn)婦與經(jīng)產(chǎn)婦181例患者中，以初產(chǎn)婦為主，共112例（占61.8%）。 2.299例妊娠合并肝功能異常的患者中，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綜合征11例（占3.7%）；原因不明21例（占7.1%）；另外，PIH合并HELLP綜合征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綜合征及PIH1例（占0.3%）。其中妊娠合并病毒性肝炎可出現(xiàn)在任何孕期，但以晚期妊娠為主；妊娠合并PIH、ICP、AFLP患者均集中于中、晚期妊娠，尤以晚期妊娠顯著；HG患者只發(fā)生于妊娠早、中期；妊娠合并AIH、WD、肝硬化及不同病因相重疊均罕見。另外，妊娠早期和晚期發(fā)生肝功能異常最常見病因均為病毒性肝炎，妊娠中期為PIH。如除外病毒性肝炎因素，僅分析妊娠期特有的病因妊娠早期則以HG為主，妊娠中期、晚期以PIH為主。 3.以每3孕周為一組，共14組，結(jié)果顯示孕16-18W及34-36W為發(fā)生肝功能異常的兩個(gè)高峰期。分別有21例（占7.1%）、75例（占25.1%）患者。其中孕16-18W與34-36W病因均以病毒性肝炎為首，分別為8例（占38.1%）和28例（占37.3%）。如排除病毒性肝炎因素，僅分析妊娠合并肝功能異常特有病因時(shí)，16-18W最主要病因?yàn)镠G，6例（占28.6%）；34-36W最主要病因?yàn)镻IH，23例（占31.1%）。 4. PIH組初產(chǎn)婦患者多于經(jīng)產(chǎn)婦患者，差異具有明顯統(tǒng)計(jì)學(xué)意義(P0.05）。而CHB、ICP組在生育史上無明顯差異（P0.05）。 5.各病因肝功能指標(biāo)特點(diǎn)，除ICP以TBA升高為主，其他病因均以ALT、AST升高為主，以妊娠合并CHB患者轉(zhuǎn)氨酶升高最明顯。另外CHB、AFLP及ICP部分患者可出現(xiàn)黃疸，病情也相對(duì)較重。妊娠合并肝功能異常最主要的三大病因（CHB、PIH、ICP）ALT、TBIL、TBA、ALB水平進(jìn)行比較時(shí)發(fā)現(xiàn)，妊娠合并CHB患者ALT、TBIL水平均高于其他兩組，，差異顯著（P0.01）,而ICP組TBA水平高于其他兩組，差異顯著（P0.01）。 6.妊娠肝功能異常組胎兒早產(chǎn)率、宮內(nèi)窘迫率、死胎率及產(chǎn)后出血率均高于對(duì)照組，具有顯著差異（P0.01）。主要病因?qū)υ袐D及胎兒預(yù)后影響中，ICP組胎兒早產(chǎn)率、死胎率較其他組明顯升高，差異具有明顯統(tǒng)計(jì)學(xué)意義（P0.05）,而其他組比較無明顯差異（P0.05）；ICP組胎兒早產(chǎn)率較其他三組明顯升高，差異具有明顯統(tǒng)計(jì)學(xué)意義（P0.05）,且ICP組死胎率較CHB、PIH組明顯升高，差異顯著（P0.01）,而CHB組與PIH組相比無明顯差異（P0.05）；另外，AFLP組死胎率及產(chǎn)后出血率明顯高于其他三組，差異具有顯著統(tǒng)計(jì)學(xué)意義（P0.01）,其他三組無明顯差異（P0.05）。 7.(1)妊娠合并CHB患者輕度肝損害16例（占19.7%），中度肝損害28例（占34.5%），重度肝損害37例（占45.8%）。(2)妊娠早期肝損害分度以輕度為主，較中度、重度肝損害患者明顯增多，差異顯著（P0.01），而中度與重度肝損害患者數(shù)比較無明顯差異（P0.05）；妊娠中期以輕、中度肝損害為主，較重度肝損害患者明顯升高，具有顯著統(tǒng)計(jì)學(xué)意義（P0.01）,而輕度、中度肝損害患者數(shù)比較無明顯差異（P0.05）；妊娠晚期則以中度、重度肝損害為主，較輕度肝損害患者數(shù)明顯升高，差異顯著（P0.01）,但中度與重度組比較時(shí)無明顯差異性（P0.05）。(3)妊娠合并CHB患者肝損害中、重度組胎兒早產(chǎn)率、宮內(nèi)窘迫率、死胎率孕婦產(chǎn)后出血率均較輕度組高，具有明顯統(tǒng)計(jì)學(xué)意義（P0.05）。(4)妊娠晚期、早期與中期HBV DNA滴度比較無明顯差異（P0.05）。 8.(1)妊娠合并CHB患者肝功能損害表現(xiàn)為ALT、AST、TBIL水平明顯升高，ALB水平減低，與正常對(duì)照組和無癥狀妊娠組比較具有明顯統(tǒng)計(jì)學(xué)差異（P0.05）。而正常對(duì)照組與無癥狀妊娠組上述指標(biāo)比較時(shí)，無明顯統(tǒng)計(jì)學(xué)差異（P0.05）。(2)妊娠合并CHB組HBV DNA低滴度和高滴度的患者明顯多于無癥狀妊娠組，均具有明顯統(tǒng)計(jì)學(xué)差異（P0.05，P0.01）。而HBV DNA陰性組兩者比較差異（P0.05）。 結(jié)論： 1.病毒性肝炎、妊高癥、妊娠期肝內(nèi)膽汁淤積癥是引起妊娠期肝功能異常主要病因，且以初產(chǎn)婦晚期妊娠為主。 2.孕16-18W與34-36W是妊娠合并肝功能異常兩個(gè)主要孕期。 3.妊娠合并癥均可不同程度地增加孕婦及胎兒的危險(xiǎn)性。 4.妊娠合并CHB患者，臨床類型以中、重度肝損害為主，HBV DNA滴度與孕期無相關(guān)性。 5. HBV DNA高滴度可作為妊娠期慢性乙型肝炎發(fā)生的預(yù)測(cè)指標(biāo)。
[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 .
【學(xué)位授予單位】：吉林大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R714.255

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本文編號(hào)：1966130