中国妊娠期急性脂肪肝临床管理指南(2021)

妊娠期急性脂肪肝（AFLP）是一种罕见但病情危急的产科特有性疾病，致死率高，对母婴安全构成严重威胁。根据对数据库的检索，目前国际上尚未有妊娠期急性脂肪肝相关的临床指南发表，由张卫社教授团队联合杨慧霞教授、陈耀龙教授共同发表的“中国妊娠期急性脂肪肝临床管理指南（2021）”填补了母胎医学领域这一临床指南的空白，选择在《母胎医学杂志（英文）》首发也将进一步在国际母胎医学界输送宝贵的中国规范化诊疗经验，具有里程碑式的意义！

     本指南确定了临床医生最关注的9个临床问题，并对其逐一给出了推荐意见，其中包括：产前AFLP的门诊筛查、诊断、术前风险评估、分娩方式选择、麻醉方式选择、围分娩期并发症、人工肝治疗的指征、预后的评估及治疗期间如何监测等。作者简介与文章摘要如下：

张卫社

（通讯作者）

中南大学湘雅医院 产科主任

杨慧霞（通讯作者）

北京大学第一医院 妇产科主任

《母胎医学杂志（英文）》主编

CSOG MFM Committee Guideline: Clinical Management Guidelines for Acute Fatty Liver of Pregnancy in China (2021)

Author: Li, Ping; Chen, Yaolong; Zhang, Weishe; Yang, Huixia 

Citation: Maternal-Fetal Medicine Committee, Chinese Society of Obstetrics and Gynecology, Chinese Medical Association; Li P, Chen Y, Zhang W, Yang H. CSOG MFM Committee Guideline: Clinical Management Guidelines for Acute Fatty Liver of Pregnancy in China (2021). Maternal Fetal Med 2021;3(4):238-245. doi: 10.1097/FM9.0000000000000121.

Abstract

Acute fatty liver of pregnancy (AFLP) is a rare but critical obstetric-specific disease with a high fatality rate, posing a serious threat to the safety of mothers and infants. These guidelines were specially formulated to standardize AFLP clinical pathways and to improve maternal and infant outcomes. Based on a two-round questionnaire survey, the guideline development team identified the following nine clinical issues that clinicians were most concerned about, and developed recommendations for each of them: prenatal outpatient screening for AFLP, diagnosis, preoperative risk assessment, delivery modes and timing, anesthesia methods, perinatal complications, selecting AFLP patients for artificial liver treatment, prognostic assessment, and monitoring during treatment. The guidelines cover the key issues related to AFLP diagnosis and treatment that concern clinicians.

Clinical question 1: How should the timing and indicators of prenatal outpatient screening for AFLP be determined?

Recommendation 1: Prenatal AFLP screening should be conducted for outpatients at 35–37 weeks of gestation (1C), and routine blood tests, liver function, and coagulation function should be used as first-line outpatient screening indicators (1C). These tests should be immediately performed for pregnant women with gastrointestinal symptoms (such as nausea and vomiting) and suspected AFLP (good clinical practice).

Recommendation 2: Patients with suspected AFLP based on initial screening should undergo re-examination of the above indicators within 24 h to identify AFLP as soon as possible (good clinical practice).

Clinical question 2: How should AFLP be diagnosed?

Recommendation 1: Use the Swansea criteria for diagnosing AFLP (1C).

Recommendation 2: AFLP diagnosis should be mainly based on clinical manifestations, and liver biopsy is unnecessary (2D).

Clinical question 3: How should the preoperative risk of AFLP patients be assessed?

Recommendation 1: Use PTA/INR, TBIL, platelet count, lactic acid, serum creatinine, and disease duration as indicators for preoperative risk assessment (2C).

Recommendation 2: Use prenatal PTA <40% (or INR >1.5), serum TBIL >171 μmol/L, platelet count ≤50 × 10⁹/L, serum creatinine ≥1.5 mg/dL, blood lactic acid ≥5 mmol/L, and disease duration >1 week to determine whether the patient is in the extremely high-risk management population before surgery (2C).

Clinical question 4: How should the mode and timing of delivery in AFLP patients be determined?

Recommendation 1: If vaginal delivery is inevitable, complete vaginal delivery as soon as possible while improving coagulation function and preventing postpartum hemorrhage (2D).

Recommendation 2: For those who cannot deliver vaginally within a short period or those with an unripe cervix, cesarean section be used (1B); as soon as possible (1C).

Clinical question 5: How should the surgical anesthesia method for AFLP patients be selected?

Recommendation 1: Preoperatively establish a multidisciplinary rapid response team (including members of the obstetrics, infectious disease, gastroenterology, anesthesiology, intensive care, neonatology, and blood transfusion departments/units) to formulate surgical anesthesia plans for AFLP patients (2D).

Recommendation 2: Use coagulation function as the main indicator for selecting anesthesia method: patients with INR ≤1.2 should undergo intraspinal anesthesia; single spinal anesthesia and local nerve block should be considered for patients with INR of 1.2<–<1.5; and general anesthesia should be considered for patients with INR ≥1.5 or unstable circulatory function (1D).

Clinical question 6: How should perinatal complications in AFLP patients be managed?

Recommendation 1: Be alert to the occurrence of perinatal complications (common complications include acute renal insufficiency, DIC, and MODS) (2D).

Recommendation 2: Patients with prenatal PTA <40% (or INR ≥1.5) or TBIL >171 μmol/L should be treated as high-risk patients regarding the abovementioned complications (2D).

Clinical question 7: How should AFLP patients be selected for artificial liver treatment?

Recommendation 1: Use artificial liver treatment for patients with severe AFLP (1C).

Clinical question 8: How should the prognosis of AFLP patients be evaluated?

Recommendation 1: Use postoperative PTA, TBIL, platelet count, and serum creatinine as prognostic indicators (2D).

Recommendation 2: If the abovementioned indicators continue to be abnormal after delivery or the patient is not recovering by 1 week after delivery, the patient should be evaluated by a multidisciplinary team, and liver transplantation should be considered if the patient is suitable (1D).

Clinical question 9: How should AFLP patients be monitored during treatment?

Recommendation: Routinely monitoring blood tests include glucose, liver function, kidney function, coagulation function during the treatment period.