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中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2024, Vol. 20 ›› Issue (03): 312 -321. doi: 10.3877/cma.j.issn.1673-5250.2024.03.010

Original Article

Diagnosis and treatment of acute fatty liver during pregnancy and its pregnancy outcomes

Jing Xue1, Yanan Sun1, Lili Zhu2, Shuhong Li2,†()   

  1. 1. School of Clinical Medicine, Shandong Second Medical University, Weifang 261053, Shandong Province, China
    2. Yantai Yuhuangding Hospital, Yantai 264009, Shandong Province, China
  • Received:2023-10-13 Revised:2024-05-08 Published:2024-06-01
  • Corresponding author: Shuhong Li
  • Supported by:
    Key Laboratory Project of Fertility Control Technology of National Health and Family Planning Commission(2018KF005); Yantai Science and Technology Planning Project(2020YD001)
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Objective

To explore the clinical characteristics and perinatal management of pregnant women with acute fatty liver of pregnancy (AFLP).

Methods

Twenty-six pregnant women with AFLP who were admitted to Yantai Yuhuangding Hospital from January 2013 to January 2023 were selected as research subjects. Among these 26 pregnant women with AFLP, there were 9, 6, 7, 5 and 3 cases with infection, disseminated intravascular coagulation (DIC), acute kidney failure (AKF), multiple organ dysfunction syndrome (MODS), and hematoma, respectively, and they were included in the study groups 1-5 (n=9, 6, 7, 5, 3), and the rest were included in control group 1-5 (n=17, 20, 19, 21, 23). The general clinical data, laboratory examination results, complications, treatment plans and other clinical data of 26 pregnant women with AFLP were retrospectively collected, and were compared by independent-samples t test and Wilcoxon rank sum test between different complication groups and control groups. The procedures followed in this study were in accordance with the regulations of the Ethics Committee of Yantai Yuhuangding Hospital, and was approved by the Ethics Committee (Approval No. 2024-438).

Results

①Among 26 pregnant women with AFLP, the main clinical manifestations were nausea (18 cases, 69.2%), xanthochromia (16 cases, 61.5%), vomiting (12 cases, 46.2%), abdominal discomfort (12 cases, 46.2%), and poor appetite (9 cases, 34.6%). There were 21 cases of primipara (80.8%), 6 cases of twin pregnancy (23.1%) and 25 cases of cesarean section delivery (96.2%). ②The level of serum total bilirubin (TBIL) in study group 1 was significantly higher than that in control group 1, and the difference was statistically significant (Z=-2.29, P=0.022). The prothrombin time (PT), activated partial thromboplastin time (APPT) and D-dimer level in study group 2 were significantly longer and higher than those in control group 2, while fibrinogen (Fib) level in study group 2 was significantly lower than that in control group 2, and all the differences were statistically significant (Z=-2.50, P=0.013; t=4.88, P=0.001; t=2.08, P=0.048; Z=-3.23, P=0.001). The levels of urea and creatinine in study group 3 were significantly higher than those in control group 3, and the differences were statistically significant (Z=-2.46, P=0.014; t=1.78, P=0.001). The levels of urea and creatinine in study group 4 were significantly higher than those in control group 4, and the level of Fib in study group 4 was significantly lower than that in control group 4, and the differences were statistically significant (Z=-2.28, P=0.004; t=4.33, P=0.001; Z=-1.99, P=0.047). PT, APTT, serum TBIL level, plasma transfusion volume and coagulation function recovery time in study group 5 were significantly longer or higher than those in control group 5, and the differences were statistically significant (Z=-1.97, -2.21, -1.97, -2.07, -2.20; P=0.049, 0.027, 0.049, 0.039, 0.028). ③All 26 cases (100.0%) of pregnant women were treated with liver protection and infection prevention. And 23 cases (88.5%) were treated with correction of coagulation therapy, 9 cases (34.6%) were treated with anti-infective therapy, 8 cases (30.8%) were treated with correction of electrolyte therapy, 6 cases (23.1%) were transferred to intensive care unit (ICU), and 2 cases (7.7%) were treated with hemofiltration. Thoracic and abdominal puncture drainage was performed on 2 cases (7.7%), plasma exchange was performed on 2 cases (7.7%), and removal of abdominal wall hematoma was performed on 1 case (3.8%). 26 cases of pregnant women were cured and discharged from hospital after treatment. ④Among the 32 newborns of 26 AFLP pregnant women, 2 cases were intrauterine death, and the other 30 cases of live-born infants were transferred to neonatology department and discharged successfully after treatment.

Conclusions

The clinical manifestations of AFLP pregnant women are mostly gastrointestinal symptoms. Early diagnosis of AFLP, early termination of pregnancy and management by multi-disciplinary team (MDT) in obstetrics are the key to rescue AFLP.

Key words: Fatty liver, Acute fatty liver of pregnancy, Pregnancy complications, Pregnancy outcome, Peripartum period, Pregnant and postpartum women
表1 本研究26例AFLP孕产妇及其分娩的32例新生儿临床资料比较[例数(%)]
临床资料 发生率 临床资料 发生率
AFLP孕产妇临床表现   分娩方式  
恶心 18(69.2) 经阴道分娩 1(3.8)
皮肤黄染 16(61.5) 剖宫产术分娩 25(96.2)
呕吐 12(46.2) 新生儿性别  
腹部不适 12(46.2) 男 21(65.6)
纳差 9(34.6) 女 11(34.4)
口渴 5(19.2) 是否为早产儿  
乏力 4(15.4) 是 20(62.5)
尿频/多 2(7.7) 否 12(37.5)
是否为初产妇   胎儿宫内窒息  
是 21(80.8) 轻度 5(15.6)
否 5(19.2) 重度 3(9.4)
是否为单胎妊娠   无 24(75.0)
是 20(76.9) 新生儿死亡 2(6.2)
否 6(23.1)    
表2 研究组1与对照组1 AFLP孕产妇实验室检查结果比较
组别 例数 WBC[×109/L，M(Q1，Q3)] AST[IU/L，M(Q1，Q3)] ALT[IU/L，M(Q1，Q3)] TBIL[μmol/L，M(Q1，Q3)] ALB(g/L，±s)
研究组1 9 13.6(10.2，16.4) 177.0(124.0，180.0) 186.0(142.5，317.5) 97.5(75.0，145.9) 22.3±4.3
对照组1 17 11.0(9.0，12.5) 172.0(113.5，231.0) 223.0(162.5，287.5) 47.4(35.8，100.6) 24.6±4.1
统计量   Z＝－1.83 Z＝－0.30 Z＝－0.59 Z＝－2.29 t＝－1.32
P值   0.067 0.767 0.553 0.022 0.189
表3 研究组2与对照组2 AFLP孕产妇实验室检查结果比较
组别 例数 BPC(×109/L，±s) PT[s，M(Q1，Q3)] APTT(s，±s) Fib[g/L，M(Q1，Q3)] D-二聚体(mg/L，±s)
研究组2 6 155.0±84.6 19.0(16.0，22.8) 59.0±9.8 0.5(0.3，0.7) 28.3±13.4
对照组2 20 170.4±85.1 13.9(13.5，15.1) 42.2±6.6 1.4(1.0，1.9) 17.4±10.6
统计量   t＝－0.39 Z＝－2.50 t＝4.88 Z＝－3.23 t＝2.08
P值   0.700 0.013 0.001 0.001 0.048
组别 例数 AST[IU/L，M(Q1，Q3)] ALT[IU/L，M(Q1，Q3)] TBIL[μmol/L，M(Q1，Q3)] ALB(g/L，±s)
研究组2 6 164.0(101.5，228.7) 170.0(130.0，289.2) 115.3(51.5，152.2) 21.8±4.9
对照组2 20 174.0(115.0，247.7) 214.5(151.2，330.7) 68.1(44.2，103.9) 24.4±4.0
统计量   Z＝－0.52 Z＝－0.73 Z＝－1.22 t＝－1.30
P值   0.605 0.465 0.224 0.205
表4 研究组3与对照组3 AFLP孕产妇实验室检查结果比较
组别 例数 尿素[mmol/L，M(Q1，Q3)] 肌酐(μmol/L，±s) 尿酸(μmol/L，±s) AST[IU/L，M(Q1，Q3)] ALT[IU/L，M(Q1，Q3)] TBIL[μmol/L, M(Q1，Q3)]
研究组3 7 8.2(7.7，12.7) 234.5±75.8 562.0±184.0 228.0(177.0，248.0) 176.0(148.0，287.0) 97.5(61.9，133.2)
对照组3 19 5.6(3.7，7.6) 127.6±52.3 445.8±86.5 141.0(113.0，231.0) 223.0(161.0，296.0) 57.8(43.8，107.1)
统计量   Z＝－2.46 t＝1.78 t＝1.61 Z＝－1.16 Z＝－0.72 Z＝－1.01
P值   0.014 0.001 0.152 0.247 0.470 0.312
表5 研究组4与对照组4 AFLP孕产妇实验室检查结果比较
组别 例数 WBC[×109/L，M(Q1，Q3)] BPC(×109/L，±s) PT[s，M(Q1，Q3)] APTT(s，±s) Fib(g/L，M(Q1，Q3)] D-二聚体[mg/L，M(Q1，Q3)] 尿素[mmol/L，M(Q1，Q3)]
研究组4 5 11.1(10.6，14.9) 118.4±73.1 17.8(13.9，23.1) 55.5±16.5 0.4(0.3，1.4) 28.8(17.2，44.，0) 10.2(7.9，13.2)
对照组4 21 11.4(8.9，13.6) 178.4±83.2 14.3(13.5，17.2) 43.8±7.0 1.3(0.8，1.6) 15.7(11.3，22.3) 5.6(3.6，7.6)
统计量   Z＝－0.59 t＝－1.48 Z＝－1.50 t＝－1.55 Z＝－1.99 Z＝－1.85 Z＝－2.28
P值   0.558 0.153 0.134 0.190 0.047 0.064 0.004
组别 例数 肌酐(μmol/L，±s) 尿酸(μmol/L，±s) 血氨[μmol/L，M(Q1，Q3)] AST[IU/L，M(Q1，Q3)] ALT[IU/L，M(Q1，Q3)] TBIL[μmol/L，M(Q1，Q3)] ALB[g/L，M(Q1，Q3)]
研究组4 5 256.8±79.9 562.0±211.0 32.0(20.5，60.7) 187.0(104.0，229.5) 176.0(96.0，236.5) 97.5(53.5，141.6) 20.6(16.8，24.3)
对照组4 21 132.5±52.1 456.9±96.0 39.5(24.7，58.5) 166.0(117.0，247.5) 223.0(154.5，322.0) 61.9(44.6，110.1) 24.7(21.3，27.5)
统计量   t＝4.33 t＝1.09 Z＝－0.02 Z＝－0.52 Z＝－1.07 Z＝－0.75 Z＝－1.79
P值   0.001 0.333 0.808 0.603 0.283 0.454 0.074
表6 研究组5与对照组5 AFLP孕产妇实验室检查结果比较[M(Q1，Q3)]
组别 例数 BPC(×109/L) PT(s) APTT(s) Fib(g/L) D-二聚体(mg/L) AST(IU/L) ALT(IU/L)
研究组5 3 203.0a 22.5a 56.2a 0.4a 10.8a 113a 137a
对照组5 23 145.0(93.0，238.0) 14.0(13.6，17.7) 44.3(37.8，47.5) 1.2(0.7，1.6) 19.4(12.2，26.0) 177.0(125.0，247.0) 206.0(164.0，296.0)
Z值   －0.28 －1.97 －2.21 －1.49 －0.76 －1.49 －1.16
P值   0.779 0.049 0.027 0.138 0.446 0.137 0.244
组别 例数 TBIL(μmol/L) ALB(g/L) 冷沉淀输注量(U) 红细胞悬液输注量(U) 血浆输注量(mL) 血小板输注量(U) 凝血恢复正常时间(s)
研究组5 3 133.2a 21.2a 26a 8.5a 2 240a 1a 6a
对照组5 23 61.9(43.8，107.1) 23.8(20.8，27.4) 18(10，25) 5.0(3.0，14.7) 600(350，1 400) 2(1，3) 4(1，5)
Z值   －1.97 －0.68 －1.76 －0.30 －2.07 －0.94 －2.20
P值   0.049 0.500 0.080 0.760 0.039 0.350 0.028
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