Pregnancy complicated with viral hepatitis

　　First, etiology

　　Pregnancy and hepatitis are mutually detrimental factors, that is, hepatitis can affect the normal development of pregnancy and produce adverse consequences for mother and child, such as significantly increased incidence of pregnancy-induced hypertension, postpartum hemorrhage, fetal distress, restricted fetal growth and development, preterm birth, stillbirth, and neonatal death; while pregnancy can affect hepatitis, the metabolism during pregnancy is vigorous, and the functions of respiration and excretion of the fetus all need to be completed by the mother; the liver is the main place for the metabolism and inactivation of sex hormones, and the secretion of estrogen and progesterone by the placenta during pregnancy is greatly increased; the heat requirement of pregnant women is 20% higher than that of non-pregnant women, and the demand for iron, calcium, various vitamins, and proteins is greatly increased. If the pregnant woman has malnutrition, the liver function will deteriorate, aggravating the condition; pregnancy-induced hypertension syndrome can cause vasoconstriction of small blood vessels, reducing blood flow to the liver and kidneys, and renal dysfunction can lead to obstruction of excretion of metabolic products, further aggravating liver damage, making massive necrosis of liver cells more likely, and triggering severe hepatitis.

　　Second, pathogenesis

　　1. The impact of viral hepatitis on pregnancy

　　(1) The impact on the mother

　　The occurrence of viral hepatitis during the early stage of pregnancy can exacerbate pregnancy reactions. If it occurs in the late stage of pregnancy, the incidence of pregnancy-induced hypertension disease increases, which may be related to the decreased inactivation ability of aldosterone during liver disease. Due to impaired liver function during childbirth, the synthesis function of coagulation factors is reduced, leading to an increased rate of postpartum hemorrhage. In severe hepatitis, disseminated intravascular coagulation (DIC) often occurs, resulting in systemic bleeding tendency, which directly threatens life.

　　(2) The impact on the fetus

　　Early pregnancy hepatitis can increase the incidence of fetal malformation by about twice. Recent continuous research indicates that viral hepatitis and Down syndrome are closely related in terms of onset. The incidence of miscarriage, preterm birth, stillbirth, neonatal death, and neonatal death in pregnant women with hepatitis is higher than that in non-hepatitis pregnant women. The perinatal mortality rate is significantly increased. When viral hepatitis occurs during pregnancy, neonates can be infected through vertical transmission from mother to child, especially with hepatitis B virus being the most severe.

　　(3) Mother-to-Child Transmission

　　① Hepatitis A

　　Whether HAV can be transmitted through mother-to-child transmission is currently lacking evidence. It is generally believed that HAV is transmitted through fecal-oral route and will not be transmitted to the fetus through the placenta or other routes. In the 1988 Shanghai outbreak of hepatitis A, no newborns born to hepatitis A pregnant women were found to be infected, indicating that the possibility of mother-to-child transmission is very small. In recent years, foreign data have reported that acute hepatitis A in the late pregnancy can cause mother-fetus transmission, which may be the result of the fetus being exposed to contaminated maternal blood or feces during the process of delivery.

　　② Hepatitis B

　　The situation of mother-to-child transmission varies in different regions. In Southeast Asia, mother-to-child transmission is extremely common, with reports showing that 35% to 40% of new cases each year are caused by perinatal transmission, while perinatal transmission is not common in North America and Western Europe. The transmission routes of hepatitis B from mother to child can be divided into the following three aspects:

　　A. Intrauterine Transmission

　　It was previously believed that HBV rarely passed through the placenta, causing intrauterine infection in 5% to 10% of cases. In recent years, more data have shown that the rate of intrauterine infection is 9.1% to 36.7%. Tong et al. used molecular hybridization to detect HBV-DNA in the liver, spleen, pancreas, kidney, and placenta of aborted fetuses, confirming the existence of intrauterine infection. The mechanism by which HBV passes through the placental barrier is not clear, and it is generally believed that it is caused by maternal blood leakage due to damage or altered permeability of the placental barrier.

　　Wong et al. once proposed diagnostic criteria for intrauterine transmission: a. The presence of anti-HBcIgM in umbilical cord blood or venous blood of infants on the third day after birth indicates recent HBV infection in infants, as IgM cannot cross the placenta; b. The level of HBsAg in venous blood on the third day after birth is higher than that in umbilical cord blood, often indicating the replication of the virus in the infant itself; c. The injection of high-titer hepatitis B immune globulin (HBIG) into infants at birth, as HBsAg can be neutralized by the HBs antibodies from passive immunity, if HBsAg is present in venous blood on the third day, regardless of the level, it means intrauterine infection. However, whether anti-HBeIgM can be used to judge intrauterine HBV infection has not been definitively determined. IgM is the earliest immunoglobulin synthesized during individual development, accounting for 10% of the content in maternal blood. If the fetus has intrauterine infection, the level of IgM in serum significantly increases, so theoretically, the level of IgM in umbilical cord blood can be used as an indicator for diagnosing infection during the fetal stage. It should be noted that although IgM cannot pass through the placenta during normal pregnancy, when maternal blood leaks into the fetal blood circulation, the concentration of IgM can also increase, and often the concentration of IgA also increases simultaneously, both of which rapidly decrease after birth. Some scholars propose that anti-HBcIgM can be used as a marker for neonatal infection and viral replication stimulation of the immune system, but in some newborns with intrauterine infection, anti-HBcIgM was not detected at birth, which may be related to the immature fetal immune system, lack of response, or low response to HBcAg. Therefore, some people believe that using anti-HBcIgM alone to judge intrauterine HBV infection is not very reliable. Since the 1980s, the detection of HBV-DNA has become a sensitive marker for HBV infection, providing a reliable basis for exploring the prevention and treatment of intrauterine HBV infection.

　　Factors affecting intrauterine transmission: a. Pregnant women with acute hepatitis in the late stage of pregnancy are prone to transmit the disease to the fetus. Tong reported that none of the infants born to women with acute HBV infection before 12 weeks of pregnancy had HBsAg positivity. After 28 weeks of pregnancy or during the puerperium with acute HB, 75% of infants have HBsAg positivity. b. Combined with e-antigen positivity, as the e-antigen is small in size and not bound by HBs antibodies, it is easy to pass through the placenta, posing a great risk of intrauterine transmission between mother and child. c. HBsAg is present in amniotic fluid. There are reports that amniocentesis to detect HBsAg in amniotic fluid has a positivity rate of 26%, higher in pregnant women with e-antigen positivity. All infants born to mothers with positive amniotic fluid have HBsAg positivity at the age of 1 month.

　　B. Perinatal transmission

　　According to current data, infection during delivery is the main route of HBV transmission from mother to child, accounting for 40% to 60%. The umbilical cord blood of newborns is negative for HBsAg, but turns positive within 3 months, which is consistent with the incubation period of hepatitis. Since the positivity rate of HBsAg in vaginal secretions is higher than that in amniotic fluid, during delivery, newborns may swallow maternal blood, amniotic fluid, and vaginal secretions containing HBsAg when passing through the birth canal, or maternal blood may leak into the fetal circulation due to uterine contractions causing placental villous vascular rupture during the delivery process. Only 10-8ml of maternal blood entering the fetal circulation can lead to the transmission of hepatitis B.

　　Factors affecting perinatal transmission: a. Pregnant women with e-antigen positivity, according to research, 96% of the vaginal secretions of carriers with e-antigen positivity contain HBsAg, and 90% of the gastric fluids of the newborns delivered by them are positive; b. High rate of umbilical cord blood positivity when the labor lasts more than 9 hours, as the duration of labor is proportional to the blood exchange between mother and child; c. The higher the HBsAg titer, the greater the possibility of transmission between mother and child. When the HBsAg titer is ≤1:128, the positive rate of newborns is 45.5%, while when the titer is ≥1:256, 70% of infants are positive. This is because sufficient amounts of HBsAg are transmitted in微量 blood exchange with high titer. The presence of HBeAg is related to the HBsAg titer, and HBeAg positivity indicates a higher HBsAg titer, hence a higher transmission rate.

　　C. Postpartum transmission

　　It is mainly through mother-to-child contact that the virus infects newborns, mainly related to contact with the mother's saliva and breastfeeding. Lee's study found that the rate of HBsAg-positive milk virus carriage in mothers was 70%, considering breastfeeding as one of the routes of mother-to-child transmission, but subsequent epidemiological surveys failed to confirm this. Most scholars believe that the rate of HBV-DNA positivity in the colostrum of those with three positive hepatitis B tests in the blood and HBeAg plus anti-HBC is 100%, and breastfeeding is not recommended. However, the issue of breastfeeding for HBsAg-positive mothers, especially those who are double-positive, has not reached a consensus.

　　About 1/3 of HBsAg carriers in China come from mother-to-child transmission, and 2/3 come from horizontal transmission in childhood. The T cell function of infants has not fully developed, and they are immunologically tolerant to HBsAg, which is easy to become a chronic carrier state, and it is easy to develop liver cirrhosis and primary liver cancer later.

　　③ Hepatitis C

　　Based on the research data of HCV, most people believe that HCV can be vertically transmitted between mother and child. In the late stage of pregnancy, if a woman has HC, 2/3 of the cases will be transmitted from mother to child, among which 1/3 will later develop into chronic liver disease, and these children have no other clinical manifestations except for increased transaminases. In addition, pregnant women who are intravenous drug users and HIV carriers are risk factors for perinatal transmission of HCV. However, some authors believe that the concentration of HCV in the blood is very low, and its vertical transmission rarely occurs. More research is needed on the mother-to-child transmission of HCV.

　　HDV vertical transmission from mother to child is relatively rare, mainly seen in pregnant women with HBeAg positivity. HEV mother-to-child transmission has not been reported in China; Khuroo studied the neonates of 8 pregnant women with HE in 1995, and found that HEV-RNA was detected in the blood samples of 5 neonates at birth, and IgG anti-HVE was positive, among whom 1 had jaundice and elevated ALT at birth.

　　2. The impact of pregnancy on viral hepatitis

      The metabolic rate is high during pregnancy, and a large amount of nutrients is consumed; the fetus relies on the mother's liver to complete its metabolism and detoxification; in addition, the large amount of sex hormones produced by endocrine changes during pregnancy, such as estrogen, need to be metabolized and inactivated in the liver. The fatigue, bleeding, surgery, and anesthesia during delivery all increase the burden on the liver, so it is easy to be infected with viral hepatitis during pregnancy, or to exacerbate existing liver disease. When pregnant women have hepatitis, the condition is more severe than that of non-pregnant women, and the later the pregnancy, the more likely it is to develop severe hepatitis. However, in the past 20 years, Western and European literature emphasizes that pregnancy does not increase the incidence of hepatitis, and the severity of hepatitis is also not related to pregnancy itself. However, data from developing countries still believe that the prognosis of hepatitis during pregnancy is poor, especially in the late stages of pregnancy, if accompanied by acute hepatitis, the risk of severe hepatitis and mortality is much higher than that of non-pregnant hepatitis patients. If pregnant women have hepatitis E in the late stage of pregnancy, the mortality rate can reach 10% to 20%.

　　1. The onset of viral hepatitis in early pregnancy can exacerbate pregnancy reactions, and the incidence of abortion and fetal malformation can be about twice as high.

　　2. The incidence of pregnancy-induced hypertension can increase in late pregnancy with viral hepatitis, which may be related to the decreased inactivation ability of the liver for aldosterone. It can increase the incidence of postpartum hemorrhage due to the decreased synthesis function of coagulation factors. If it is severe hepatitis, it often complicates with DIC, presenting with systemic hemorrhagic tendency, directly threatening the safety of both mother and child.

　　3. Mother-to-child vertical transmission of liver viruses.

　　One, pregnancy complicated with hepatitis A

　　The symptoms are the same as those in non-pregnant individuals, with an acute onset. In addition to gastrointestinal symptoms and jaundice, a positive anti-HAV-IgM in serological tests can confirm the diagnosis.

　　Two, pregnancy complicated with hepatitis B

　　1. Symptoms such as nausea, vomiting, and fatigue, jaundice, etc., with an acute onset, and an elevated serum ALT level.

　　2. Serological detection indicators:

　　HBV surface antigen (HBsAg): It is the most commonly used indicator for HBV infection. Before the serum ALT level rises during the incubation period of infection, HBsAg can be positive. When HBsAg is of high titer, the e antigen (HBeAg) is also positive at the same time. Clinically, using only HBsAg as an infection indicator is insufficient; it should be combined with clinical manifestations and other indicators for judgment.

　　HBV surface antibody (anti-HBs): It is a protective antibody. After a period of time during acute HBV infection, the appearance of anti-HBs indicates that the body has acquired immunity.

　　HBV e antigen (HBeAg): It is a degradation product of HBcAg. During acute infection, the appearance of HBeAg is slightly later than HBsAg, and the subtypes e1, e2 of the e antigen more reflect the replication activity of HBV.

　　HBV e antibody (anti-HBe): Generally, when HBeAg disappears from the blood and anti-HBe appears, it indicates a reduction in viral replication, decreased transmissibility, and a tendency for the disease to stabilize gradually.

　　Core antibody (anti-HBc): During acute infection, anti-HBc-IgM can be detected 2 to 4 weeks after the appearance of HBsAg, before the onset of clinical symptoms, so anti-HBc-IgM is more common in the early stage of infection or during the active phase of chronic infection.

　　HBV DNA (HBV-DNA): A positive HBV-DNA is a direct evidence of HBV replication and a transmissibility indicator. HBV-DNA is balanced with HBeAg and DNA polymerase. In blood samples with HBeAg positivity, 86% to 100% can detect HBV-DNA.

　　Based on clinical symptoms, signs, liver function tests, and serological indicators, the diagnosis of hepatitis B in pregnancy can be quickly clarified.

　　3. When applying serological diagnosis for HBV intrauterine infection, attention should be paid to the following three criteria:

　　(1) A positive HBsAg in neonatal umbilical cord serum can serve as a reference indicator.

　　(2) A positive HBcAb-IgM in neonatal umbilical cord serum can confirm intrauterine infection.

　　(3) If conditions permit the measurement of umbilical cord serum for HBV DNA, a positive result can further confirm the diagnosis, but this indicator is not yet widely applicable in China.

　　Three, pregnancy complicated with severe hepatitis

　　Diagnosis criteria: sudden onset, obvious toxic symptoms, and severe jaundice.

　　1. Within 1 week, the serum bilirubin level is ≥171 μmol/L (10 mg/dL) or increases by ≥17.1 μmol/L (1 mg/dL) per day.

　　2. The prothrombin time is significantly prolonged, up to 0.5 to 1 times or even longer than the normal value.

　　3. There is varying degrees of hepatic coma, and severe cases may present with liver odor.

　　4. Abdominal fluid may appear, or the liver dullness border may shrink.

　　Firstly, strengthen health education and perinatal care

　　Patients in the acute stage should be isolated and treated. Special attention should be paid to preventing iatrogenic transmission and hospital-acquired infections. The beds, delivery rooms, delivery beds, and equipment for HBsAg-positive individuals should be strictly separated in the delivery room; pregnant women in hepatitis endemic areas should enhance nutrition and increase their resistance to prevent the occurrence of hepatitis. Pregnant women who have recently been exposed to hepatitis A should be given human blood gamma globulin. Women with hepatitis should wait for half a year after the recovery from hepatitis, or preferably 2 years later to become pregnant. Strict disinfection and isolation procedures should be implemented during delivery for HBsAg and HBeAg-positive pregnant women to shorten the delivery process, prevent fetal distress, aspiration of amniotic fluid, and laceration of the birth canal. Strengthen health education on dietary hygiene, pay attention to the disinfection of tableware, and pay special attention to hygiene for raw cold dishes. Hepatitis A is a benign self-limiting disease, and the hepatitis A virus is transmitted through fecal contamination and oral infection, especially for shellfish such as scallops, which should be paid more attention to.

　　Secondly, immunization prevention

　　1. Hepatitis A

　　Inactivated vaccine can be used for vaccination of children or adults over 1 year old, and if human blood gamma globulin has been injected, it should be injected again after 8 weeks.

　　2. Hepatitis B

　　Immunoglobulin (HBIG) is a highly effective anti-HBV immunoglobulin that can provide passive immunity to mothers or newborns and is an effective measure for preventing hepatitis B infection. HBIG can be injected intramuscularly into HBsAg-positive pregnant women 3 months before delivery, which can significantly reduce intrauterine infection of their newborns, and follow-up shows no adverse reactions. The best time for newborn injection is within 24 hours after birth, generally not exceeding 48 hours. More injections can lead to better effects, and it can be injected once a month, for a total of 2 to 3 times, with a dose of 0.5 mL/kg each time, or 1 to 2 mL each time. In case of accidental exposure, an emergency injection is required, usually 1 to 2 mL. The last injection should be started at the same time as the hepatitis B vaccine.

　　There are two types of hepatitis B vaccine: blood vaccine and recombinant DNA vaccine. The latter has better immunogenicity than the blood vaccine. The safety, immunogenicity, protective efficacy, and antibody persistence of the two vaccines are similar. The immunized objects are mainly HBV carriers, susceptible individuals who have been exposed to HBV, and their newborns, with a protection rate of up to 80%. For newborns of mothers with both HBsAg and HBeAg positive, the combined use of HBIG can increase the protection rate to 95%. Those who do not produce antibodies well after the full immunization course can receive a booster immunization once. The development of HCVDNA vaccine is still at the animal experiment stage, but source-safe and reliable human blood gamma globulin can be used for passive immunization of infants with anti-HCV positive mothers before the age of 1. There is no vaccine for hepatitis D and E.

　　1. Peripheral blood count

　　During the acute phase, the white blood cell count is usually slightly low or normal, with a relative increase in lymphocytes. Occasionally, there may be abnormal lymphocytes, but generally not more than 10%. In chronic hepatitis, the white blood cell count is often reduced. In acute severe hepatitis, both the total white blood cell count and the percentage of neutrophils can significantly increase. In some chronic hepatitis patients, platelets may be reduced.

　　2. Liver function tests

　　Serum enzyme determination: There are many types of serum enzymes, mainly to check the enzymes that reflect liver parenchymal damage. According to Chinese experience, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are more sensitive and widely used, although their specificity is not strong. However, if other factors causing elevation can be excluded, especially when the values are very high (more than 10 times the normal value) and the duration is long, it has great diagnostic value for hepatitis. There are two types of AST: one is located in the cytoplasm (ASTs), and the other is ASTm, existing in the mitochondria of liver cells. In severe hepatitis, ASTm increases mainly. Since the half-life of ASTm is shorter than that of ASTs, recovery is earlier. In acute hepatitis, if ASTm continues to rise, there is a possibility of becoming chronic. In chronic hepatitis, if ASTm continues to increase, it should be considered as chronic active hepatitis. Some people believe that the ALT/AST ratio is of certain significance for differential diagnosis. The ratio is 0.56 in viral hepatitis, 1.03 in obstructive jaundice, and 1.15 in normal people. Glutathione S-transferase (GST) increases earliest in severe hepatitis, which is helpful for early diagnosis. Fructose 1,6-bisphosphatase is one of the glycogen synthesis enzymes, and its serum content is significantly increased in all types of chronic hepatitis.

　　Other: The determination of prothrombin time and its activity can be used to determine severe hepatitis. If there is still a significant abnormality after the injection of vitamin K, it often indicates severe damage to liver tissue and poor prognosis. In addition, if cholesterol and cholesterol esters are significantly reduced, it often suggests poor prognosis. Blood ammonia determination is helpful for the diagnosis of hepatic encephalopathy.

　　3. Serological and virological testing

　　4. B-ultrasound diagnosis

　　It has a reference value for judging liver cirrhosis, biliary tract abnormalities, and intrahepatic and extrahepatic space-occupying lesions. Liver biopsy is of great significance in determining diffuse liver lesions and distinguishing clinical types of chronic hepatitis.

   　During the acute phase of pregnancy complicated by viral hepatitis, bed rest is recommended, and a diet rich in nutrition, easy to digest, and light in taste should be consumed. Eating more fruits and vegetables and drinking plenty of water is encouraged. Spicy foods and greasy, heavy flavors should be avoided.

　　One, pregnancy complicated with hepatitis A

　　Currently, there is no specific effective drug for hepatitis A, and generally, the following comprehensive measures are taken:

　　1. Rest and liver protection supportive therapy.

　　Commonly used herbs include Yin Chen decoction, Pseudostellaria decumbens decoction, vitamin C, and complex vitamin B, or intravenous infusion of glucose solution, etc.

　　2. Since the hepatitis A virus does not pass through the placental barrier and does not transmit to the fetus, there is no need for induced abortion or mid-trimester pregnancy induction.

　　Due to impaired liver function, maternal metabolism and oxygen deficiency may occur, which may lead to preterm labor. Therefore, it is necessary to strengthen self-monitoring of fetal movement counts in the late pregnancy. Those with signs of preterm labor should be hospitalized for treatment as soon as possible, and perform non-stimulus tests (NST) and B-ultrasound for biophysical indicators. During the process of labor, attention should be paid to shortening the second stage of labor, preventing postpartum hemorrhage, and preventing puerperal infection.

　　3. Regarding breastfeeding.

　　Pregnant women who have recovered from hepatitis A after delivery can breastfeed. If in the acute stage, breastfeeding should be prohibited, not only to prevent vertical transmission from mother to child, but also to benefit the mother's recovery.

　　Two, pregnancy complicated with hepatitis B

　　1. General treatment

　　In addition to isolation and bed rest during the acute phase of hepatitis, a light and low-fat diet should be provided, and sufficient calories should be supplied daily. If gastrointestinal symptoms are severe, glucose solution should be administered intravenously.

　　2. Application of liver-protecting drugs

　　A large amount of vitamin C, vitamin K1, and vitamin B1, B6, B12, etc., should be administered daily. Vitamin C is an important substance involved in the oxidation-reduction process of the body, which has the effects of enhancing the body's anti-infection ability, promoting the regeneration of liver cells, and improving liver function; vitamin K1 can promote the synthesis of thromboplastin, fibrinogen, and certain coagulation factors (factor VII, X). Generally, vitamin C 3g, vitamin K1 40mg, and 500ml of 5% or 10% glucose solution are administered intravenously once a day. At the same time, energy mixture is given, such as 250-500ml of 25% glucose solution with 100u of coenzyme A and 3g of vitamin C. At the same time, vitamin E 50mg is injected intramuscularly, which is beneficial for preventing liver cell necrosis. For those with high ALT levels, Qiang Li Ning 80ml and potassium magnesium aspartate 20ml can be added to the glucose solution for intravenous infusion. For those with anemia or hypoproteinemia, appropriate blood transfusion, human serum albumin, or plasma can be given.

　　3. Traditional Chinese medicine treatment

　　The main treatment is to clear heat and promote diuresis, commonly using modified Yin Chen decoction. Formula: Yin Chen 30g, Shan Yao 12-15g, Sheng Huang Qi 15-20g, Huang Qin 12g, Chuan Lian 6g, Fu Ling 15g, Dang Gui 12g, Bai Jiang Cao 12-15g, Chai Hu 9g, Chen Pi 9g. Take one dose daily, which is beneficial for reducing jaundice, improving liver function, and alleviating clinical symptoms.

　　4. Obstetric management of early pregnancy

　　If the HBsAg titer is high and HBeAg is positive with clinical manifestations, an artificial abortion can be performed under active treatment. Because pregnancy and hepatitis B have adverse effects on each other. However, patients in the middle and late stages of pregnancy should prioritize liver protection treatment rather than risking an induced abortion, in order to avoid adverse consequences caused by the induced abortion.

　　5. Delivery and puerperium

　　Attention must be paid to the following three aspects: ①Prevent bleeding; ②Prevent infection: Antibiotics with no adverse effects on the liver and kidneys should be used to prevent infection after delivery; ③Closely monitor clinical symptoms and liver function test results to prevent the progression of the disease.

　　From the perspective of obstetrics, observe whether the fetus has cephalopelvic disproportion, although the labor process is progressing well, the second stage of labor should be appropriately shortened and assisted by forceps to help reduce the physical consumption of the mother and reduce the incidence of neonatal asphyxia. Routine umbilical cord blood detection of liver function and hepatitis serological indicators should be performed after delivery.

　　6. Newborn management

　　In recent years, it is advocated that for infants born to HBsAg-positive pregnant women, a hepatitis B vaccine of 30μg should be injected intradermally within 24 hours, 1 month, and 6 months after birth, which can generally block 90% of the mother-to-child transmission rate. If conditions permit, a human HBs immune globulin (HBIG) can be injected intramuscularly after birth, which is more beneficial to prevent vertical mother-to-child transmission. The effect of the hepatitis B vaccine in China can last for about 5 years, so a booster immunization injection should be given before entering elementary school.

　　Three, pregnancy complicated with severe hepatitis

　　1. General management: ①Special care should be provided, and blood pressure, respiration, pulse, and fluid intake and output should be recorded correctly; ②A diet of low-fat, low-protein, high-carbohydrate liquid or semi-liquid food should be provided to ensure an energy intake of 6276kJ/d (1500kcal/d), and a large amount of vitamins should be administered.

　　2. Transfusion of 600-800ml of fresh warm blood to increase coagulation factors, and it is necessary to transfuse human albumin or lyophilized plasma to prevent liver cell necrosis and reduce the occurrence of cerebral edema.

　　3. 1mg of glucagon added to 8 units of regular insulin, 10-20ml of 10% potassium chloride added to 500-1000ml of 10% glucose solution, administered intravenously.

　　4. Interferon can be administered at a dose of 3 million units daily for 7 to 14 days, by intramuscular injection, or 1 million units per dose, three times a day, by intramuscular injection.

　　5. 200ml of fetal liver cell suspension, administered intravenously once or every other day, can be used for 3 to 5 times, achieving excellent results. This can also be called fetal liver cell transplantation.

　　6. Intravenous infusion of 800250ml of 14-amino acid or 250ml of complex branched-chain amino acid, once or twice a day, can promote the improvement of liver condition.

　　7. 40ml of 10% aspartate potassium magnesium dissolved in 250ml of 10% glucose solution should be administered intravenously slowly.

　　8. Broad-spectrum antibiotics with minimal impact on liver and kidney function should be administered regardless of the presence of infection signs.

　　Treatment for disseminated intravascular coagulation (DIC):

　　(1) The diagnostic criteria for pregnancy complicated with severe hepatitis and disseminated intravascular coagulation (DIC): ①Platelet count ≤ 50×10^9/L (50,000/mm3); ②Prothrombin time extended more than twice the normal; ③Fibrinogen ≤ 1.25g/L (125mg/dl); ④Positive result in the protamine-para-amine (3P) test or ethanol gel test.

　　(2) Management of DIC: According to the characteristics of obstetrics, heparin can be used when DIC occurs without signs of labor, with an initial dose of 25mg (3125IU) added to 100ml of 5% glucose solution for intravenous infusion (usually completed within 30 minutes), followed by 25mg added to 200ml of 5% glucose solution for intravenous slow infusion. Subsequently, the dose of heparin should be determined based on the results of laboratory tests. If DIC occurs during labor or within 24 hours after delivery, it is advisable to focus on the administration of warm fresh blood, lyophilized plasma, etc., and avoid the use of heparin abruptly. Because at this time, there is a serious lack of coagulation factors, and the natural opening of the uterine blood sinus after delivery itself is prone to bleeding, so improper use of heparin can further exacerbate bleeding.

　　(3) Obstetric management: Emergency treatment must be administered upon admission, and warm fresh blood, human albumin, and lyophilized plasma should be administered first. For patients with hepatic coma, the delivery should be completed as soon as possible after 24 hours of active treatment. According to the 1990 data from the Department of Obstetrics and Gynecology of Shanghai Medical University, among 22 patients with severe hepatitis complicating pregnancy, 9 survived after receiving fresh blood, albumin, plasma, and heparin at appropriate times and in appropriate doses, and undergoing cesarean section or even hysterectomy; 8 survived; 1 died due to DIC after cesarean section. Among the 13 patients who were treated conservatively and awaited vaginal delivery, 2 died without giving birth; another 11 delivered, of whom only 4 survived, including 3 multiparous women with preterm labor and 1 primipara with postpartum hepatic coma who was saved by using fetal liver cell transplantation in the end.

　　The obstetric management principles for such patients are as follows based on the above data:

　　a. Multiparous women with preterm labor can deliver vaginally under the above active treatment conditions.

　　b. For primiparas who are full-term or near full-term, cesarean section should be performed under local anesthesia within 1 to 2 days of the above active treatment. However, analgesics such as pethidine (Duret) should be avoided after surgery to prevent exacerbation of liver burden and the progression of the disease, or even death.

　　c. Postoperative supportive therapy and broad-spectrum antibiotics should be administered to prevent infection.