重症肌无力患者妊娠期临床特点及预后分析  

Clinical characteristics and outcome of pregnant patients with myasthenia gravis

作　　者：陈玉萍[1] 张娟[2] 陈兵[1] 王卫[1] 范敏[3] 陶晓勇[1] Chen Yuping;Zhang Juan;Chen Bing;Wang Wei;Fan Min;Tao Xiaoyong(Department of Neurology,the First Medical Center of PLA General Hospital,Beijing 100853,China;Department of Aspiration and Critical Care,the Eighth Medical Center of PLA General Hospital,Beijing 100091,China;Department of Obstetrics and Gynecology,the Seventh Medical Center of PLA General Hospital,Beijing 100091,China)

机构地区：[1]解放军总医院第一医学中心神经内科学部,北京100853 [2]解放军总医院第八医学中心呼吸与危重症学部,北京100091 [3]解放军总医院第七医学中心妇儿学部,北京100091

出　　处：《中华内科杂志》2021年第2期117-121,共5页Chinese Journal of Internal Medicine

摘　　要：目的探讨重症肌无力(MG)患者妊娠前后肌无力症状的变化及MG对妊娠预后的影响。方法回顾性研究2013年1月至2018年10月28例就诊于解放军总医院第八医学中心MG患者38例次妊娠分娩的临床资料。比较妊娠前与妊娠不同时期MG严重程度评分、血乙酰胆碱受体(AChR)抗体变化及药物的使用情况,并分析妊娠后MG不同转归(改善组、无变化组及恶化组)与MG病程、MG严重程度、重复电刺激(RNS)、胸腺情况的相关性,同时监测妊娠、分娩及新生儿情况。结果(1)MG妊娠时年龄为21~36(27±4)岁。MG病程为0.5~17.2(7.4±5.8)年。Osserman临床分型以ⅡA型为主,占44.1%(15/34),其次为Ⅰ型为29.4%(10/34),ⅡB型占23.5%(8/34),仅1例(2.9%)为Ⅳ型。(2)28例MG患者经38次妊娠,其中3次胎停,1次自然流产,34次活胎。34次活胎妊娠过程中,16例次(47.1%)MG症状改善,10例次(29.4%)MG症状恶化,8例次(23.5%)MG无变化。其中恶化多见于妊娠早期、晚期。(3)比较妊娠后不同MG转归发现,恶化组妊娠前MG病程短于改善组和无变化组,严重程度评分和RNS异常率高于改善组及无变化组[(1.1±0.5)年比(7.1±5.1)年、(9.0±5.4)年;(20.9±6.0)分比(14.8±6.6)分、(13.3±5.0)分;9/10例次比8/16例次、4/8例次];临床分型来看,恶化组患者ⅡB型高于其他两组(6/10例次比1/16例次、1/8例次),差异有统计学意义(P值均<0.01),而血AChR抗体阳性率及胸腺切除在三组中差异无统计学意义。(4)34次活胎妊娠中23次硬膜外麻醉下行剖腹产,11次经阴道分娩,新生儿未发现肢体挛缩,无一过性重症肌无力症状。结论MG患者在病情控制平稳的情况下妊娠是安全的,妊娠前MG病程、严重程度评分及RNS异常可能影响妊娠期MG临床症状,MG病情的加重多见于妊娠早晚期。新生儿一过性肌无力症状并不常见,但须神经科和妇产科医师严密监测。Objective To study the clinical characteristics of pregnant patients with myasthenia gravis(MG)and the influence of MG to pregnancy.Methods A retrospective study was conducted including 28 MG patients with 38 pregnancies admitted to the 8th Medical Center of PLA General Hospital between January 2013 and October 2018.Data were collected including clinical scores of MG,serum level of acetylcholine receptor(AChR)antibodies,abnormal repetitive nerve stimulation(RNS)and history of thymectomy before pregnancy.The course of pregnancy,delivery and neonatal outcome were also analyzed.According the outcome of MG,patients were divided into three groups,i.e.improvement group,stable group and deterioration group.Results(1)The age of MG patients ranged from 21 to 36(27±4)years.The previous course of MG was 0.5-17.2(7.4±5.8)years.Based on Osserman clinical type,typeⅡA was the most common one[44.1%(15/34)],followed with typeⅠ[29.4%(10/34)],typeⅡB[23.5%(8/34)]and typeⅣ(2.9%).(2)There were 38 pregnancies in 28 women whose pregnancy outcomes resulted in one spontaneous abortion,three embryonic arrest and 34 live births.All abortions developed in the first trimester.Among the 34 pregnancies with live births,the symptoms of MG improved in 16 pregnancies(47.1%),whereas those deteriorated in 10 pregnancies(29.4%)during the first or third trimester and remained stable in 8 pregnancies(23.5%).(3)Compared with improvement group and stable group,the deterioration group had shorter duration of MG[(1.1±0.5)years vs.(7.1±5.1)years,(9.0±5.4)years respectively],higher clinical scores(20.9±6.0 vs.14.8±6.6,13.3±5.0)and more frequent abnormal RNS(9/10 vs.8/16,4/8)and typeⅡB(6/10 vs.1/16,1/8)before pregnancy.Positive rate of serum AChR antibody and percentage of thymectomy before pregnancy were comparable between three groups.(4)Spinal anesthesia was performed in 23 pregnancies and 11 cases were vaginal delivery.No transient neonatal MG were found in live-born infants.Conclusions Pregnancy in patients with under-controlled myasthe

关 键 词：重症肌无力 妊娠 乙酰胆碱 新生儿 

分 类 号：R746.1[医药卫生—神经病学与精神病学] R714.2[医药卫生—临床医学]