Pregnancy with liver cirrhosis
Introduction
Introduction to pregnancy complicated with cirrhosis Cirrhosis of cirrhosis is a diffuse, progressive liver damage caused by various factors, extensive degeneration and necrosis of hepatocytes, destruction of reticular protein structure, regeneration of hepatocyte nodules, and formation of massive connective tissue hyperplasia. The fibers are separated to form pseudohepatic lobules, and the liver shrinks and hardens. Clinical manifestations of liver damage and portal hypertension are the main manifestations, early symptoms are not obvious, late gastrointestinal bleeding, hepatic encephalopathy, secondary infections and other serious complications, endangering the lives of mothers and children, previously reported pregnant women with cirrhosis of pregnancy The mortality rate is high, and patients with cirrhosis have not been advocated for continued pregnancy in the past. In recent years, the progress of cirrhosis treatment and the enhancement of perinatal monitoring, pregnancy with cirrhosis can have a better prognosis. basic knowledge The proportion of illness: 0.001% Susceptible population: pregnant women. Mode of infection: non-infectious Complications: anemia, pregnancy-induced hypertension, postpartum hemorrhage
Cause
Pregnancy with cirrhosis
(1) Causes of the disease
Common diseases of liver cirrhosis are due to viral hepatitis, chronic alcoholism, schistosomiasis, drug-induced poisoning or chemical poisons, cholestasis, genetic metabolic defects, etc., European and American countries are mainly caused by alcoholic poisoning, accounting for about 65%, and Compared with men, women are more likely to cause alcoholic cirrhosis, causing women with irreversible cirrhosis to have less daily minimum alcohol consumption and short duration. Viral hepatitis is the main cause of cirrhosis in China, type B, C and D viruses. Hepatitis is closely related to cirrhosis. After the 1970s, cirrhosis of schistosomiasis has been rare. Cardiac, biliary, autoimmune, and congenital metabolic cirrhosis are rare in China.
(two) pathogenesis
1. The effect of cirrhosis on pregnancy and childbirth Viral hepatitis, chronic alcoholism, schistosomiasis, drugs or chemical poisoning are common causes of cirrhosis, compensatory cirrhosis, pregnancy outcomes are good, decompensated cirrhosis can cause Metabolic disorders have adverse effects on pregnancy and fetus. The literature reports that the rate of abortion in patients with cirrhosis is 8% to 13.7%, the premature rate is 15% to 20%, and the perinatal mortality is 17.9% to 18.2%. Pregnancy increased, and no reports of congenital cirrhosis were reported in surviving infants, but the incidence of low birth weight and fetal distress increased.
Pregnancy with cirrhosis increases the incidence of pregnancy-induced hypertension syndrome, which is reported to be 81.8% in the literature. It may increase the activity of renin-angiotensin-aldosterone system in patients with cirrhosis, hypoproteinemia, estrogen metabolism disorder and deficiency. Oxygen-related, can further worsen the disease, cirrhosis with ascites, low protein, uterine muscle fiber edema, etc., easy to cause uterine contraction after labor, stagnation of labor, due to coagulation mechanism, clotting factor deficiency can cause postpartum hemorrhage, and cirrhosis patients Anemia, low protein, etc., reduce the body's immunity, prone to post-production infection, maternal cirrhosis, death causes mainly gastrointestinal bleeding, postpartum hemorrhage and hepatic encephalopathy, the literature reported that the maternal mortality rate can reach 10.34%.
2. The effect of pregnancy on cirrhosis Whether pregnancy has an effect on cirrhosis, scholars disagree, some scholars believe that pregnancy has no adverse effects on cirrhosis, liver compensatory function is good, can be normal pregnancy delivery, but most views It is believed that pregnancy increases the burden on the liver, and it is more likely to produce ascites, which worsens the condition of cirrhosis. In addition, patients with cirrhosis are often accompanied by esophageal or gastric varices, increased blood volume during pregnancy, excessive filling of the portal system, and increased uterus in the uterus. Increased internal pressure can increase the expansion of esophageal veins, and the second stage of labor during the delivery period, such as forced breath holding, can cause esophageal and gastric varices to rupture, causing major bleeding and life-threatening.
Prevention
Pregnancy with cirrhosis prevention
Precautions for pregnancy with cirrhosis are mainly for the prevention, early diagnosis and treatment of primary diseases.
Complication
Pregnancy complicated with cirrhosis complications Complications, anemia, pregnancy-induced hypertension, postpartum hemorrhage
Complications of pregnant women include anemia, pregnancy-induced hypertension, postpartum hemorrhage, postpartum infection, etc. The incidence of complications in pregnant women with cirrhosis is higher than 40%, because the renin-angiotensin-aldosterone system undergoes liver metabolism. Increased activity of the system during cirrhosis, plus anemia, hypoproteinemia, etc., the incidence of pregnancy-induced hypertension increases, due to clotting factor deficiency and uterine weakness in patients with cirrhosis, the incidence of postpartum hemorrhage increases, cirrhosis The patient's resistance is reduced, as well as hypoproteinemia, anemia, and fatigue during birth, and the incidence of postpartum infections increases.
Symptom
Pregnancy with cirrhosis symptoms Common symptoms Upper abdominal pain Ascites bloating Nasal bleeding Appetite loss Skinny spider Huangqi nausea hardening
1. History has a history of hepatitis or schistosomiasis, chronic alcoholism, malnutrition and other medical history, most people have been diagnosed with cirrhosis in the internal medicine before conception.
2. Clinical manifestations
(1) Liver function compensation period: mild symptoms, may have fatigue, loss of appetite, abdominal distension, etc. These symptoms often appear when tired, relieved after rest, signs are not obvious, the liver is often swollen, some patients have spleen Large, spider mites and liver palms can appear.
(2) Decompensation of liver function: loss of appetite is a common symptom, sometimes accompanied by nausea, vomiting, weight loss, fatigue, abdominal pain or bloating, gums, nosebleeds or hematemesis and black feces, physical examination can find complexion Black, thin and withered, skin mucosa with purple spots or bleeding points, abdominal wall venous engorgement, ascites, moderate hardness of the liver, smooth surface, liver in the late stage of the patient shrink, hard, surface nodules, splenomegaly.
Examine
Pregnancy with cirrhosis
1. Anemia with varying degrees of blood routine, accompanied by decreased white blood cells and platelets in hypersplenism.
2. There is no change in the regular compensation period of urine. When there is jaundice, the urinary biliary and bilirubin increase. When there is liver and kidney syndrome, there are protein, cast and hematuria.
3. Liver function is normal during liver compensatory period; liver function is abnormal in decompensated period, transaminase is increased, cholesterol is lowered, bile acid and chenodeoxycholic acid are imbalanced, serum albumin is decreased, globulin is elevated, and white ball ratio is imbalanced. At the time of jaundice, serum total bilirubin and direct bilirubin were elevated; late coagulation dysfunction.
4. Immunological examination 1 Cellular immunity is reduced, and CD3, CD4 and CD8 cells are decreased in most patients. 2 The humoral immunity increased, and the concentrations of IgG and IgA increased. Generally, IgG was elevated. 3 Non-specific autoantibodies can sometimes occur. 4 The disease is due to viral hepatitis, and the hepatitis virus antigen and antibody are positive.
Other auxiliary inspections:
1. B early visible liver enlargement, liver parenchyma, echo enhancement, thickening, late liver shrinkage, surface nodular, uneven, often accompanied by ascites.
2. Esophageal sputum meal X examination of esophageal varices can be seen in the worm-like or sacral filling defects, longitudinal mucosal folds widened; gastric varices can be seen in chrysanthemum-like filling defects.
3. CT and MRI early liver enlargement, the proportion of late liver is imbalanced, the liver surface is irregular; the spleen is enlarged, ascites.
4. Endoscopy can directly see the varicose veins, to understand the degree and location of the varicose veins, if there is bleeding visible bleeding points, and to stop bleeding.
5. Liver biopsy Liver biopsy not only has the value of diagnosis, but also the type of liver cirrhosis, the degree of hepatocyte damage and connective tissue formation, which helps to determine treatment and prognosis.
Diagnosis
Diagnosis and differentiation of pregnancy complicated with liver cirrhosis
The onset and course of cirrhosis are generally slow, the condition is concealed, and the incubation period is longer, 3 to 5 years or longer. Many patients do not go to the hospital until the liver function is incomplete. Therefore, it is very important to diagnose liver cirrhosis early. The diagnosis depends mainly on medical history, clinical manifestations and auxiliary examinations; liver biopsy is performed only when the diagnosis is not clear.
Hepatomegaly should be differentiated from chronic hepatitis, primary liver cancer, clonorchiasis, and ascites should be differentiated from tuberculous peritonitis, constrictive pericarditis, dystrophic edema, chronic nephritis, etc. Liver cirrhosis should be differentiated from intrahepatic or extrahepatic obstruction. In addition, complications should be differentiated from peptic ulcer bleeding, uremia, and diabetic ketoacidosis.
