CAJ | 학술논문

目的探讨妊娠期肝内胆汁淤积症(ICP)孕妇发生胎儿死亡的临床特点、实验室指标及胎儿监护手段.方法对1999年1月至2010年12月浙江大学医学院附属妇产科医院收治的发生死胎的21例ICP孕妇的临床资料进行回顾性分析.结果 (1)21例ICP孕妇的平均年龄(30.2±4.6)岁,其中＞35岁者4例;经产妇6例,1例2年前因ICP发生死胎而引产1次;20例单胎妊娠,1例双胎妊娠.(2)21例ICP孕妇的死胎均发生在孕晚期,胎儿死亡的孕周为29～41周,平均(33.8±4.2)周.12例发生在孕29～37周,9例发生在孕37周后.9例为门诊B超检查时确诊胎死宫内;9例因诊断ICP入院治疗期间发生胎心消失;2例临产后胎心消失;1例胎心监护提示V型减速,拟行急诊刮宫产术于麻醉期间胎心消失.在所有ICP孕妇中围产儿死亡率为0.148%(21/14 184).(3)21例ICP孕妇均有皮肤瘙痒,其中11例有全身皮肤瘙痒.10例在发生死胎前自觉胎动减少或消失.21例ICP孕妇血清甘胆酸水平均升高,其中21.49～64.48 μmol/L 11例,t≥64.48 μmol/L 10例.血清总胆汁酸水平升高16例(另5例未检查),最高达270μmoL/L.血清丙氨酸氨基转移酶和天冬氨酸氨基转移酶水平升高14例,总胆红素＞21μmol/L 7例,直接胆红素升高12例.21例ICP孕妇中,重度15例,轻度6例.(4)9例孕妇门诊即确诊宫内死胎未做胎心监护,其余12例住院检查结果为:胎心监护结果可疑2例,无应激试验(NST)提示胎心轻度V型减速1例,B超提示脐动脉舒张期血流缺如3例,胎儿生物物理指标评分低值1例.(5)21例ICP孕妇均经阴道分娩.6例为自然宫缩娩出死胎,其余15例予米非司酮配合依沙吖啶羊膜腔注射或缩宫素引产,14例在48 h内成功娩出死胎,仅1例追加地诺前列酮栓后引产成功.所有死胎外观无异常,脐带长度均在正常范围,有4例脐带绕颈或绕体.胎盘胎膜外观无异常,18例羊水Ⅲ度胎粪污染,2例合并羊水过少.10例行死胎及胎盘病理检查,其中1例合并多发畸形,其余死胎病理检查未见明显异常,10例胎盘病理检查均有绒毛膜周围或底蜕膜、大血管周围的纤维蛋白沉积,同时伴有钙化、退行性变、红色梗死及局灶性合体细胞结节增多.结论 ICP孕妇发生死胎的孕周常在孕晚期,时间常在正常宫缩后,ICP重度可能是发生死胎的关键因素;尚无有效的胎儿监护指标可预测死胎的发生.因此,应综合评估病情,加强胎儿监护,适时终止妊娠. 目的探討妊娠期肝內膽汁淤積癥(ICP)孕婦髮生胎兒死亡的臨床特點、實驗室指標及胎兒鑑護手段.方法對1999年1月至2010年12月浙江大學醫學院附屬婦產科醫院收治的髮生死胎的21例ICP孕婦的臨床資料進行迴顧性分析.結果 (1)21例ICP孕婦的平均年齡(30.2±4.6)歲,其中＞35歲者4例;經產婦6例,1例2年前因ICP髮生死胎而引產1次;20例單胎妊娠,1例雙胎妊娠.(2)21例ICP孕婦的死胎均髮生在孕晚期,胎兒死亡的孕週為29～41週,平均(33.8±4.2)週.12例髮生在孕29～37週,9例髮生在孕37週後.9例為門診B超檢查時確診胎死宮內;9例因診斷ICP入院治療期間髮生胎心消失;2例臨產後胎心消失;1例胎心鑑護提示V型減速,擬行急診颳宮產術于痳醉期間胎心消失.在所有ICP孕婦中圍產兒死亡率為0.148%(21/14 184).(3)21例ICP孕婦均有皮膚瘙癢,其中11例有全身皮膚瘙癢.10例在髮生死胎前自覺胎動減少或消失.21例ICP孕婦血清甘膽痠水平均升高,其中21.49～64.48 μmol/L 11例,t≥64.48 μmol/L 10例.血清總膽汁痠水平升高16例(另5例未檢查),最高達270μmoL/L.血清丙氨痠氨基轉移酶和天鼕氨痠氨基轉移酶水平升高14例,總膽紅素＞21μmol/L 7例,直接膽紅素升高12例.21例ICP孕婦中,重度15例,輕度6例.(4)9例孕婦門診即確診宮內死胎未做胎心鑑護,其餘12例住院檢查結果為:胎心鑑護結果可疑2例,無應激試驗(NST)提示胎心輕度V型減速1例,B超提示臍動脈舒張期血流缺如3例,胎兒生物物理指標評分低值1例.(5)21例ICP孕婦均經陰道分娩.6例為自然宮縮娩齣死胎,其餘15例予米非司酮配閤依沙吖啶羊膜腔註射或縮宮素引產,14例在48 h內成功娩齣死胎,僅1例追加地諾前列酮栓後引產成功.所有死胎外觀無異常,臍帶長度均在正常範圍,有4例臍帶繞頸或繞體.胎盤胎膜外觀無異常,18例羊水Ⅲ度胎糞汙染,2例閤併羊水過少.10例行死胎及胎盤病理檢查,其中1例閤併多髮畸形,其餘死胎病理檢查未見明顯異常,10例胎盤病理檢查均有絨毛膜週圍或底蛻膜、大血管週圍的纖維蛋白沉積,同時伴有鈣化、退行性變、紅色梗死及跼竈性閤體細胞結節增多.結論 ICP孕婦髮生死胎的孕週常在孕晚期,時間常在正常宮縮後,ICP重度可能是髮生死胎的關鍵因素;尚無有效的胎兒鑑護指標可預測死胎的髮生.因此,應綜閤評估病情,加彊胎兒鑑護,適時終止妊娠.
목적 탐토임신기간내담즙어적증(ICP)잉부발생태인사망적림상특점、실험실지표급태인감호수단.방법 대1999년1월지2010년12월절강대학의학원부속부산과의원수치적발생사태적21례ICP잉부적림상자료진행회고성분석.결과 (1)21례ICP잉부적평균년령(30.2±4.6)세,기중＞35세자4례;경산부6례,1례2년전인ICP발생사태이인산1차;20례단태임신,1례쌍태임신.(2)21례ICP잉부적사태균발생재잉만기,태인사망적잉주위29～41주,평균(33.8±4.2)주.12례발생재잉29～37주,9례발생재잉37주후.9례위문진B초검사시학진태사궁내;9례인진단ICP입원치료기간발생태심소실;2례임산후태심소실;1례태심감호제시V형감속,의행급진괄궁산술우마취기간태심소실.재소유ICP잉부중위산인사망솔위0.148%(21/14 184).(3)21례ICP잉부균유피부소양,기중11례유전신피부소양.10례재발생사태전자각태동감소혹소실.21례ICP잉부혈청감담산수평균승고,기중21.49～64.48 μmol/L 11례,t≥64.48 μmol/L 10례.혈청총담즙산수평승고16례(령5례미검사),최고체270μmoL/L.혈청병안산안기전이매화천동안산안기전이매수평승고14례,총담홍소＞21μmol/L 7례,직접담홍소승고12례.21례ICP잉부중,중도15례,경도6례.(4)9례잉부문진즉학진궁내사태미주태심감호,기여12례주원검사결과 위:태심감호결과 가의2례,무응격시험(NST)제시태심경도V형감속1례,B초제시제동맥서장기혈류결여3례,태인생물물리지표평분저치1례.(5)21례ICP잉부균경음도분면.6례위자연궁축면출사태,기여15례여미비사동배합의사아정양막강주사혹축궁소인산,14례재48 h내성공면출사태,부1례추가지낙전렬동전후인산성공.소유사태외관무이상,제대장도균재정상범위,유4례제대요경혹요체.태반태막외관무이상,18례양수Ⅲ도태분오염,2례합병양수과소.10례행사태급태반병리검사,기중1례합병다발기형,기여사태병리검사미견명현이상,10례태반병리검사균유융모막주위혹저세막、대혈관주위적섬유단백침적,동시반유개화、퇴행성변、홍색경사급국조성합체세포결절증다.결론 ICP잉부발생사태적잉주상재잉만기,시간상재정상궁축후,ICP중도가능시발생사태적관건인소;상무유효적태인감호지표가예측사태적발생.인차,응종합평고병정,가강태인감호,괄시종지임신.
Objective To investigate the clinical features,critical laboratory parameters,and fetal monitoring methods in intrahepatic cholestasis of pregnancy(ICP).Methods A retrospective analysis of 21 cases of ICP suffered with fetal death in Women's hospital.School of Medicine.Zhejiang University from January 1999 to December 2010 were discussed.Results(1)The average age of ICP patients suffered with fetal death were(30.2±4.6)years old.Among them,4 cases were older than 35 years,six cases were multipara.oneo of them suffered stillbirth 2 year before.Twenty cases were singleton pregnancies and 1 cage was twin pregnancy.(2)All 21 cases of fetal death occurred in the third trimester,12 cases occurred before 37 weeks,9 cases after 37 weeks.Nine cases were diagnosed by ultrasound in outpatient clinics,fetal heart beat disappeared in 9 patients after admission because of ICP, two disappeared after labor, one during anesthesia before emergent surgery. Perinatal mortality rate of ICP was 0. 148% (21/14 184), and fetal death occurred from 29 to 41 weeks with an average gestational age of ( 33.8 ± 4. 2 ) weeks, ( 3 ) Puritus occurred in all 21 cases while 11 of them had pruritus all over the body. Ten pregnant women felt the fetal movement decreased or disappeared before diagnosis of fetal death. The glycocholic acid levels increased in all of the 21 cases. Among them, glycocholic acid levels in 11 cases were (21.49 -64. 48) μmol/L, while in 10 cases were ≥64. 48 μmol/L Serum bile acid levels elevated in 16 cases which had been analyzed ( the other 5 cases had not been checked ), and the highest level reached 270 μmol/L Serum alanine aminotransferase and aspartate aminotransferase were increased in 14 cases. Seven cases had their total bilirubin ＞21 μmoL/L, and 12 cases had their direct bilirubin levels significantly elevated. Among the 21 cases of ICP, 15 cases were in severe status, while the other 6 cases were mild. (4) Nine patients had no antepartum surveillance since fetal death were diagnosed before admission. The results of antepartum surveillance were as follows: 2 cases had nonreassuring nonstress test (NST), one had mild "V" type deceleration. Absence of diastolic flow in umbilical artery were found in 3 cases, and low fetal biophysical score was got in one case. ( 5 ) All 21 patients had vaginal delivery. Six of them delivered after natural contraction, and the remaining 14 cases delivered after oral intake of mifepristone and amniotic injection of ethacridine, or oxytocin induced labor within 48 hours, only one case delivered after additional dinoprostone suppositories. The appearance of fetus, placentas and membranes were normal, the lengths of umbilical cord were average. Four cases were found with cords binding the necks or the bodies. Eighteen cases had grade Ⅲ amniotic fluid with meconium-stained, and 2 cases complicated by oligohydramnios. Ten cases had their fetuses and placentas examined by pathologist. Among them, one case had multiple malformations, no more obvious pathological abnormalities were found in other fetuses. Pathologic examination showed that fibrin deposited around chorion and deciduas basalis, large vessels accompanied by calcification, degeneration,hemorrhagic infarction, and increased focal syncytial nodules could be seen in all of the ten placentas. Conclusions Fetal death in pregnant women with ICP of ten occurs after the contractions, Severe ICP may be a key factor that involved in the occurrence of fetal death. Up to now, there is no valid indicators in fetal monitoring, which can predict fetal death. Extensive assessment of the severity and careful antepartum surveillance should be achieved before timely termination of pregnancy.