41例慢性HBV感染危重孕产妇的临床特征分析
DOI: 10.12449/JCH240207
Clinical features of critically ill pregnant and parturient women infected with chronic hepatitis B virus: An analysis of 41 cases
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摘要:
目的 分析慢性HBV感染的危重孕产妇临床特点及其转归,为救治危重孕产妇和防治肝病重症化提供临床经验。 方法 选取2013年3月—2023年3月南京市第二医院重症医学科收治的慢性HBV感染的孕产妇41例,通过医院电子病历系统收集孕产妇的临床资料,总结乙型肝炎孕产妇转入ICU的主要原因、死亡原因、治疗情况等。正态分布的计量资料两组间比较采用成组t检验;非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料两组间比较采用χ2检验。 结果 13例(31.71%)患者未正规产检,8例(19.51%)高病毒载量患者(HBV DNA≥2×105 IU/mL)未接受抗病毒治疗。主要的分娩方式为剖宫产32例(78.05%),婴儿早产23例(56.10%),患者死亡5例(12.20%)。转入ICU的前3位病因分别为肝衰竭、产后大出血和妊娠高血压疾病。肝衰竭主要在孕晚期发病,最多见并发症为肝性脑病(28.57%),最多见合并症为妊娠期肝内胆汁淤积症(21.43%);6例(42.86%)产检规律;13例(92.86%)入院前未接受抗病毒治疗。产后大出血患者平均ICU住院时间为(3.31±1.65) d,其中合并重症肝病者分娩前出现凝血功能异常,治疗48 h仍难以纠正。 结论 慢性HBV感染的孕产妇病情复杂,病死率较高。评估肝脏状态、定期产检和及时行抗病毒治疗对减少慢性HBV孕产妇重症发病、降低病死率尤为重要。 Abstract:Objective To investigate the clinical features and outcomes of critically ill pregnant and parturient women with chronic hepatitis B virus (HBV) infection, and to provide clinical experience for the rescue of critically ill pregnant and parturient women and the prevention and treatment of the severe exacerbation of liver disease. Methods A total of 41 pregnant and parturient women with chronic HBV infection who were admitted to Department of Critical Care Medicine, Nanjing Second Hospital, from March 2013 to March 2023 were enrolled in this study, and their clinical data were collected through the electronic medical record system of hospital to summarize the main causes of transfer to the intensive care unit (ICU), the causes of death, and treatment. The independent-samples t test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test was used for comparison of categorical data between two groups. Results Among the 41 patients, 13 (31.71%) did not receive regular antenatal examination and 8 (19.51%) with a high viral load (HBV DNA ≥2×105 IU/mL) did not receive antiviral therapy. Cesarean section was the main mode of delivery in 32 patients (78.05%); 23 patients (56.10%) had premature delivery, and 5 patients died (12.20%). The top three causes of transfer to the ICU were liver failure, postpartum hemorrhage, and hypertensive disorders of pregnancy. Liver failure mainly occurred in late pregnancy, with hepatic encephalopathy as the most common complication (28.57%) and intrahepatic cholestasis of pregnancy as the most common comorbidity (21.43%); among the 14 patients with liver failure, 6 (42.86%) received regular antenatal examination, and 13 (92.86%) did not receive antiviral therapy before admission. The mean length of ICU stay was 3.31±1.65 days for the patients with postpartum hemorrhage, among whom the patients with severe liver disease had coagulation disorders before delivery, which were difficult to correct after 48 hours of treatment. Conclusion Pregnant and parturient women with chronic HBV infection tend to have complex conditions and a relatively high mortality rate. For pregnant and parturient women with chronic HBV infection, assessment of liver status, regular antenatal examination, and timely antiviral therapy are of vital importance to reduce severe exacerbation and mortality rate. -
Key words:
- Hepatitis B Virus /
- Pregnant Women /
- Symptoms and Signs
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表 1 不同产检情况患者的基本信息
Table 1. Basic information for patients with different maternity conditions
项目 正规产检组(n=28) 非正规产检组(n=13) 统计值 P值 年龄(岁) 30.8±4.0 30.5±4.7 t=-0.20 0.844 BMI(kg/m2) 22.0±3.0 21.7±2.8 t=-0.35 0.729 外院转入[例(%)] 9(32.1) 8(61.5) χ2=3.16 0.075 孕期监测肝功能[例(%)] 21(75.0) 4(30.8) χ2=7.30 0.007 HBV DNA≥2×105 IU/mL[例(%)] 19(67.9) 2(15.4) χ2=9.78 0.002 HBV DNA(log10 IU/mL) 4.9±1.7 3.8±1.8 t=-1.84 0.075 肝衰竭[例(%)] 6(21.4) 8(61.5) χ2=4.69 0.030 产后大出血[例(%)] 11(39.3) 3(23.1) χ2=0.44 0.506 子痫/子痫前期[例(%)] 8(28.6) 1(7.7) χ2=1.21 0.272 死亡[例(%)] 2(7.1) 3(23.1) χ2=0.88 0.348 表 2 41例转入ICU患者的第一诊断
Table 2. First diagnosis of 41 patients transferred to ICU
病因 例数[例(%)] 死亡[例(%)] 妊娠并发症 17(41.46) 2(4.88) 产后大出血 8(19.51) 1(2.44) HELLP综合征 1(2.44) 子痫 1(2.44) 重度子痫前期 4(9.76) 1(2.44) 慢性高血压合并子痫前期 1(2.44) 子宫破裂 2(4.88) 妊娠合并其他疾病 24(58.54) 3(7.32) 慢加急性肝衰竭 8(19.51) 1(2.44) 慢加亚急性肝衰竭 3(7.32) 急性肝衰竭 2(4.88) 1(2.44) 肝癌 1(2.44) 失代偿期肝硬化 1(2.44) 重型肝炎 2(4.88) 胆汁淤积性肝炎 2(4.88) 心脏病 2(4.88) 急性左心衰竭 1(2.44) 术后呼吸支持 1(2.44) 心肺骤停 1(2.44) 1(2.44) 表 3 14例肝衰竭患者的临床特征
Table 3. Clinical characteristics of 14 patients with liver failure
临床特征 数值 肝衰竭(例) 14 发病孕周(周) 29.27±7.88 住院总时间(d) 28.00±19.58 ICU住院天数(d) 5.5(3.0~8.0) 规律产检[例(%)] 6(42.86) 并发症及合并症[例(%)] 肝性脑病 4(28.57) 感染性休克 1(7.14) 急性肺水肿 1(7.14) 妊娠期肝内胆汁淤积症 3(21.43) 产后出血 2(14.29) 子痫前期重度 1(7.14) 失代偿期肝硬化 1(7.14) 分娩方式[例(%)] 剖宫产 9(64.29) 引产 4(28.57) 母体死亡未分娩 1(7.14) APACHE Ⅱ评分(分) 16(14~23) APACHE Ⅱ评分≥15分[例(%)] 10(71.43) 呼吸支持[例(%)] 6(42.86) 人工肝治疗[例(%)] 6(42.86) 抗感染治疗[例(%)] 12(85.71) HBV DNA[例(%)] <500 IU/mL 2(14.29) 500~200 000 IU/mL 8(57.14) >200 000 IU/mL 4(28.57) 入院前抗病毒治疗[例(%)] 1(7.14) 死亡[例(%)] 3(21.43) 表 4 不同合并症的产后大出血患者各时间点凝血指标比较
Table 4. Comparison of coagulation indexes by time points in patients with postpartum hemorrhage with different comorbidities
组别 例数 Hb (g/L) PLT(×109/L) PT(s) INR APTT(s) Fib (g/L) 分娩前 非重症肝病组 8 93.7±25.9 177.5(168.0~233.0) 12.0±1.1 1.1±0.1 28.9±5.2 3.4±0.8 重症肝病组 5 96.9±23.6 128.0(75.0~136.0) 19.7±9.2 1.7±0.8 53.6±39.7 1.9±1.3 统计值 t=-0.224 Z=-2.199 t=-2.429 t=-2.216 t=-1.780 t=2.652 P值 0.827 0.030 0.033 0.049 0.103 0.023 转入ICU时 非重症肝病组 8 76.3±29.5 95.4±46.3 12.9±1.4 1.2±0.1 37.3±11.6 1.9±1.2 重症肝病组 5 63.6±16.7 91.4±40.4 17.5±4.1 1.5±0.3 52.5±22.3 1.6±0.7 统计值 t=0.893 t=0.163 t=-2.968 t=-2.714 t=-1.644 t=0.570 P值 0.389 0.873 0.013 0.020 0.128 0.579 治疗48 h后 非重症肝病组 9 89.0(72.0~92.0) 122.3±37.4 12.1±1.4 1.1±0.1 33.1±7.1 3.7±0.9 重症肝病组 5 91.0(89.0~91.0) 86.0±35.4 19.3±8.5 1.7±0.7 40.3±10.8 2.0±1.8 统计值 Z=0.537 t=1.774 t=-2.555 t=-2.554 t=-1.450 t=2.318 P值 0.606 0.101 0.025 0.025 0.175 0.039 注:入院时及转入ICU时各有1例患者凝血功能差,超出检测结果范围,未纳入分析。APTT,活化部分凝血活酶时间;Fib,纤维蛋白原。 表 5 死亡孕产妇病例资料
Table 5. Information on maternal death cases
患者 年龄 (岁) 转入ICU 分娩方式 转入ICU时 APACHE Ⅱ评分(分) 死亡风险系数(%) 死亡诊断 病例1 36 产前 未分娩 15 42.50 慢加急性肝衰竭,肝性脑病Ⅱ期,肺部感染,感染性休克 病例2 31 产前 剖宫产 23 38.50 慢加急性肝衰竭,肝性脑病Ⅲ期 病例3 25 产后 剖宫产 70 98.00 产后大出血,急性肺水肿,乙型肝炎肝硬化,慢性肝衰竭,肺部感染,腹部感染 病例4 33 产后 剖宫产 9 8.34 HELLP综合征,脑室出血,多脏器功能衰竭 病例5 35 产前 未分娩 47 98.11 心功能不全、心跳呼吸骤停,先兆早产,上呼吸道感染 注:死亡风险系数,基于APACHE Ⅱ评分系统的病死率预测。 -
[1] ZHAO BJ, YANG YY, CONG L. Data analysis on 232 cases of critically ill pregnant women cured by combination of the department of obstetrics and ICU[J]. Acta Univ Med Anhui, 2017, 52( 9): 1375- 1379. DOI: 10.19405/j.cnki.issn1000-1492.2017.09.026.赵保静, 杨媛媛, 丛林. 产科联合ICU救治232例危重孕产妇的资料分析[J]. 安徽医科大学学报, 2017, 52( 9): 1375- 1379. DOI: 10.19405/j.cnki.issn1000-1492.2017.09.026. [2] YUE JX, HUANG QQ, REN ZF, et al. Analysis of treatment for 360 critically ill pregnant and parturient women in intensive care unit[J]. Chin Crit Care Med, 2022, 34( 8): 853- 857. DOI: 10.3760/cma.j.cn121430-20211122-01758.岳锦熙, 黄青青, 任宗芳, 等. 360例危重孕产妇ICU救治分析[J]. 中华危重病急救医学, 2022, 34( 8): 853- 857. DOI: 10.3760/cma.j.cn121430-20211122-01758. [3] LIU Y, WANG DF, WANG Y, et al. Analysis of treatment with 167 critically ill pregnant women in intensive care unit[J]. Chin Crit Care Med, 2018, 30( 10): 964- 967. DOI: 10.3760/cma.j.issn.2095-4352.2018.10.012.刘颖, 王迪芬, 汪颖, 等. 167例ICU危重症孕产妇救治分析[J]. 中华危重病急救医学, 2018, 30( 10): 964- 967. DOI: 10.3760/cma.j.issn.2095-4352.2018.10.012. [4] CUI FQ, WOODRING J, CHAN PL, et al. Considerations of antiviral treatment to interrupt mother-to-child transmission of hepatitis B virus in China[J]. Int J Epidemiol, 2018, 47( 5): 1529- 1537. DOI: 10.1093/ije/dyy077. [5] TAN J, LIU X, MAO X, et al. HBsAg positivity during pregnancy and adverse maternal outcomes: A retrospective cohort analysis[J]. J Viral Hepat, 2016, 23( 10): 812- 819. DOI: 10.1111/jvh.12545. [6] PENG SX, WAN ZH, LIN XF, et al. Maternal hepatitis B surface antigen carrier status increased the incidence of gestational diabetes mellitus[J]. BMC Infect Dis, 2019, 19( 1): 147. DOI: 10.1186/s12879-019-3749-1. [7] SAY L, SOUZA JP, PATTINSON RC. Maternal near miss: Towards a standard tool for monitoring quality of maternal health care[J]. Best Pract Res Clin Obstet Gynaecol, 2009, 23( 3): 287- 296. DOI: 10.1016/j.bpobgyn.2009.01.007. [8] XIE X, KONG BH, DUAN T. Obstetrics and gynecology[M]. 9th ed. Beijing: People’s Medical Publishing House, 2018.谢幸, 孔北华, 段涛. 妇产科学[M]. 9版. 北京: 人民卫生出版社, 2018. [9] Liver Failure and Artificial Liver Group, Chinese Society of Infectious Diseases, Chinese Medical Association; Severe Liver Disease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Guideline for diagnosis and treatment of liver failure(2018)[J]. J Clin Hepatol, 2019, 35( 1): 38- 44. DOI: 10.3969/j.issn.1001-5256.2019.01.007.中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2018年版)[J]. 临床肝胆病杂志, 2019, 35( 1): 38- 44. DOI: 10.3969/j.issn.1001-5256.2019.01.007. [10] XI JJ, REN HF, ZHANG H, et al. Clinical characteristics of critically ill pregnant women with different admission methods to intensive care unit: Data analysis from 2006 to 2019 in the university hospital[J]. Chin J Crit Care Med, 2021, 33( 10): 1249- 1254. DOI: 10.3760/cma.j.cn121430-20210106-00013.奚晶晶, 任会华, 张华, 等. 不同ICU入院方式危重孕产妇临床特征研究[J]. 中华危重病急救医学, 2021, 33( 10): 1249- 1254. DOI: 10.3760/cma.j.cn121430-20210106-00013. [11] ANANE-FENIN B, AGBENO EK, OSARFO J, et al. A ten-year review of indications and outcomes of obstetric admissions to an intensive care unit in a low-resource country[J]. PLoS One, 2021, 16( 12): e0261974. DOI: 10.1371/journal.pone.0261974. [12] KUMAR R, GUPTA A, SURI T, et al. Determinants of maternal mortality in a critical care unit: A prospective analysis[J]. Lung India, 2022, 39( 1): 44- 50. DOI: 10.4103/lungindia.lungindia_157_21. [13] ZHANG L, YANG SY, YU YF, et al. Prophylactic effect of tenofovir on viral reactivation in immunocompromised pregnant women living with hepatitis B virus[J]. Hepatol Commun, 2022, 6( 9): 2431- 2440. DOI: 10.1002/hep4.1994. [14] ZHANG C, LIANG MY. Antiviral therapy of telbivudine on pregnant outcomes and reduce the neonatal infection rate of hepatitis B patients[J]. Chin J Clin Obstet Gynecol, 2019, 20( 3): 217- 220. DOI: 10.13390/j.issn.1672-1861.2019.03.009.张冲, 梁梅英. 替比夫定对乙肝患者妊娠结局及降低新生儿乙肝感染率的影响[J]. 中国妇产科临床杂志, 2019, 20( 3): 217- 220. DOI: 10.13390/j.issn.1672-1861.2019.03.009. [15] ARATA S, NOZAKI A, TAKIZAWA K, et al. Hepatic failure in pregnancy successfully treated by online hemodiafiltration: Chronic hepatitis B virus infection without viral genome mutation[J]. Hepatol Res, 2013, 43( 12): 1356- 1360. DOI: 10.1111/hepr.12090. [16] BI ZH, WANG LX, LIAN JQ. Definition, prognostic assessment, and advances in the diagnosis and treatment of acute-on-chronic liver failure[J]. J Clin Hepatol, 2022, 38( 7): 1671- 1676. DOI: 10.3969/j.issn.1001-5256.2022.07.041.毕占虎, 王临旭, 连建奇. 慢加急性肝衰竭的定义、预后评估及诊治进展[J]. 临床肝胆病杂志, 2022, 38( 7): 1671- 1676. DOI: 10.3969/j.issn.1001-5256.2022.07.041. [17] LIU JH, YANG JL, DENG HM, et al. Analysis of related factors of 45 cases of death from liver failure during pregnancy[J]. Prog Obstet Gynecol, 2021, 30( 6): 453- 455. DOI: 10.13283/j.cnki.xdfckjz.2021.06.012.刘晶华, 杨杰莲, 邓红梅, 等. 45例妊娠期肝衰竭死亡相关因素分析[J]. 现代妇产科进展, 2021, 30( 6): 453- 455. DOI: 10.13283/j.cnki.xdfckjz.2021.06.012. [18] KUMARASWAMI S, BUTWICK A. Latest advances in postpartum hemorrhage management[J]. Best Pract Res Clin Anaesthesiol, 2022, 36( 1): 123- 134. DOI: 10.1016/j.bpa.2022.02.004. [19] ZHANG XN, YOU RK, WU JH, et al. Investigation on risk factors of postpartum hemorrhage in critically ill pregnant women and analysis of preventive strategies[J]. Matern Child Heath Care China, 2020, 35( 23): 4577- 4580. DOI: 10.19829/j.zgfybj.issn.1001-4411.2020.23.056.章雪娜, 尤荣开, 吴建华, 等. 危重孕产妇产后大出血的危险因素调查和预防策略分析[J]. 中国妇幼保健, 2020, 35( 23): 4577- 4580. DOI: 10.19829/j.zgfybj.issn.1001-4411.2020.23.056. [20] XU SB, CHEN Y. Investigation on risk factors of postpartum hemorrhage and construction of early warning system[J]. Matern Child Heath Care China, 2023, 38( 1): 97- 100. DOI: 10.19829/j.zgfybj.issn.1001-4411.2023.01.026.许顺波, 陈芸. 产妇产后大出血的危险因素调查及早期预警系统构建[J]. 中国妇幼保健, 2023, 38( 1): 97- 100. DOI: 10.19829/j.zgfybj.issn.1001-4411.2023.01.026. [21] XIONG XL, ZHU YX, WEI H, et al. Influence of intrahepatic cholestasis of pregnancy on adverse pregnancy outcomes of HBV-infected pregnant women[J]. J Clin Hepatol, 2022, 38( 8): 1763- 1767. DOI: 10.3969/j.issn.1001-5256.2022.08.009.熊霞鹂, 朱云霞, 魏宏, 等. 妊娠期肝内胆汁淤积症对HBV感染孕妇妊娠不良结局的影响[J]. 临床肝胆病杂志, 2022, 38( 8): 1763- 1767. DOI: 10.3969/j.issn.1001-5256.2022.08.009. [22] WEI H, ZHANG C, MENG J, et al. The clinical features of hepatitis B virus infection and intrahepatic cholestasis in pregnancy[J]. Ginekol Pol, 2022, 93( 5): 389- 395. DOI: 10.5603/GP.a2021.0109. [23] BAO Y, YANG YS, LUO D. Changing characteristic of hemostasis and coagulation in patients with hepatitis B, cirrhosis or liver failure[J]. China J Mod Med, 2016, 26( 8): 56- 59. DOI: 10.3969/j.issn.1005-8982.2016.08.012.包英, 杨元素, 罗丹. 止血与凝血指标在乙肝与肝硬化及肝脏衰竭患者中的改变规律研究[J]. 中国现代医学杂志, 2016, 26( 8): 56- 59. DOI: 10.3969/j.issn.1005-8982.2016.08.012. [24] SHAN KJ, XU WB, WANG Y, et al. Clinical analysis of obstetric patients admitted to ICU in the past decade[J]. Prog Obstet Gynecol, 2019, 28( 10): 754- 760. DOI: 10.13283/j.cnki.xdfckjz.2019.10.007.单可记, 许汪斌, 王英, 等.“二孩政策”对产科重症患者转入ICU的影响[J]. 现代妇产科进展, 2019, 28( 10): 754- 760. DOI: 10.13283/j.cnki.xdfckjz.2019.10.007. [25] QURESHI R, IRFAN AHMED S, RAZA A, et al. Obstetric patients in intensive care unit: Perspective from a teaching hospital in Pakistan[J]. JRSM Open, 2016, 7( 11): 2054270416663569. DOI: 10.1177/2054270416663569.
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