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随着非酒精性脂肪性肝病（NAFLD）的流行，育龄期女性和妊娠期患上NAFLD的比例也在增加。罹患NAFLD会给妊娠期准妈妈和胎儿的健康带来多大的影响？何种治疗措施更为妥当？如何预防NAFLD的发生呢？

 

我国香港中文大学黄丽虹（Grace Wong）教授在第29届亚太肝病学会年会（APASL2020）的 “女性肝病学专题研讨会”中，介绍了脂肪肝与妊娠的治疗和管理方法，并在会后就相关问题接受了《国际肝病》记者提问。现将中英文对照访谈实录分享如下。                                     

 

1、为什么妊娠女性NAFLD非常重要？

 

在包括亚太地区的全世界范围内，非酒精性脂肪性肝病（NAFLD）是一种很常见的慢性肝病，一般成年人群中的患病率约为25%～30%，这就是为什么NAFLD也会在孕妇和育龄期女性中流行的原因。根据文献数据，育龄期女性的NAFLD患病率为10%左右，这意味着NAFLD很常见，并且会引起问题，因为NAFLD与其他代谢风险因素有关，最重要的是与糖尿病有关，使妊娠期糖尿病的风险增加2～4倍，对妊娠和胎儿的转归都有不利影响。

 

在妊娠女性中，NAFLD很常见，并且有重要的预后意义，这就是为什么妊娠女性NAFLD非常重要的原因，我们要提高意识，以便早期诊断和早期干预，有助于改善妊娠转归。

 

<Hepatology Digest>: Could you give an overview of your topic, NAFLD in pregnant women, and why it is important?

 

Dr Wong: NAFLD is a very common chronic liver problem all over the world, including the Asia-Pacific region. The prevalence in the general adult population is around 25-30%. That is why it will also be prevalent amongst pregnant women and women of childbearing age. From the literature, the prevalence in the women of childbearing age is around 10%, which means it is very common, and will cause problems, as it is associated with other metabolic risk factors, most importantly diabetes mellitus. This increases the risk of gestational diabetes 2-4-fold, and that will have a negative impact on pregnancy and fetal outcomes. That is why it is important. It is common, and it has important prognostic implications. This is why we are promoting awareness so diagnoses can be made early on. Early intervention means pregnancy outcomes can be improved.

 

2、NAFLD如此常见，是因为肥胖流行率的增加吗？

 

确实如此，目前，在生活方式方面，亚太地区的饮食已经相当西化，并且年轻人参与运动的时间越来越少，这可以解释为什么越来越多的年轻人患有NAFLD的原因。

 

<Hepatology Digest>: Why is it common? Is it because of the increasing prevalence of obesity?

 

Dr Wong: Definitely. In the Asia-Pacific region, our lifestyle is quite westernized these days in terms of diet, and young adults have less time to exercise, which may explain why we see more young adults with NAFLD.

 

3、母亲患有代谢综合征，对胎儿有什么健康风险？

 

就胎龄而言，胎儿会比较大，意味着胎儿出生时的体重会高于平均水平，NAFLD母亲出生的子女将来具有发生糖尿病的风险，所以，这种风险情况可以传递给下一代，这就是我们倡导女性在妊娠之前就要控制代谢风险因素，降低NAFLD风险的原因。

 

<Hepatology Digest>: You also said there was a health risk, obviously to the mother with metabolic syndrome, but what are the health risks for the fetus?

 

Dr Wong: The fetus will be large for gestational age, meaning birth weight will be higher than average. And in the future, these offspring of women with NAFLD are at risk of developing diabetes, so effectively the condition can be passed on to the next generation. This is why we advocate women controlling the metabolic risk factors prior to pregnancy and reduce the risk of NAFLD.

 

4、孕妇存在哪些因素时，应该怀疑患有NAFLD？

 

首先是体重，如果孕妇体重超重，是重要的风险因素，我们还要筛查诸如血压、空腹血糖和血脂等常见的代谢风险因素。从本质上，这些因素是代谢综合征的诊断标准，如果孕妇存在三种或以上代谢风险因素，则存在代谢综合征，也是发生糖尿病和NAFLD的重要风险因素。

 

<Hepatology Digest>: What factors do you look for that raise suspicion of the presence of NAFLD in a pregnant woman?

 

Dr Wong: The first thing would be body weight. If the woman is overweight, then that would be a key risk factor. We would also do screening for common metabolic risk factors like blood pressure, fasting glucose, and lipid profile. Essentially, these are the diagnostic criteria for metabolic syndrome. If they have three or more of those, then metabolic syndrome exists, which is a strong risk factor for diabetes.

 

5、如果一名准妈妈被诊断为妊娠期糖尿病，是否自动进行NAFLD的检查？

 

这是个好主意。目前的局限性是需要进一步检查，才能确定NAFLD的诊断。妊娠期糖尿病的检测通常是由产科医生完成，一般情况下，这个过程就会停止，除非患者的妊娠期糖尿病非常严重，才会被转介给内分泌科医生或普通内科医生，只有这种情况下，才可能要求进行超声检查，或者进行其他无创性评估，诸如脂肪肝指数和有助于诊断NAFLD的其他血液参数。

 

<Hepatology Digest>: If a mother-to-be is diagnosed to have gestational diabetes, then is it automatic to test for NAFLD?

 

Dr Wong: That would be a good idea. The current limitation would be the need for further testing to establish a diagnosis of NAFLD, but testing for gestational diabetes is usually done by the obstetrician, so normally the process stops there unless the gestational diabetes is severe. Then the patient would be referred to an endocrinologist or general internalist, and only then might ultrasound testing be requested, or other non-invasive assessments, such as fatty liver index and other blood-based parameters that help in the diagnosis of NAFLD.

 

6、一旦确诊，是整体治疗新陈代谢，还是仅仅关注肝脏疾病？

 

因为NAFLD只是代谢综合征的许多表现之一，所以，要对患者的代谢风险因素进行更全面的管理，如果所有这些代谢风险因素都得到控制，NAFLD就会改善，其他代谢问题也会改善。在怀孕期间开始药物治疗是不太可取的，所以，主要方法是控制饮食，正如我在演讲中提到的，这涉及到控制热量以及宏量营养素等特定成分的摄入。

 

<Hepatology Digest>: Once a diagnosis is established, do you treat the overall metabolism, or do you focus strictly on the hepatology?

 

Dr Wong: It is a more general management of the metabolic risk factors, because NAFLD is just one of the many manifestations of the metabolic syndrome. If all those metabolic risk factors are controlled, NAFLD would improve, as would other metabolic problems. The main approach would be dietary control, as initiating drug therapy in pregnancy is less desirable. As I mentioned in my talk, this involves controlling the calorie intake, as well as specific components of the macronutrients.

 

7、对严重代谢综合征采取什么治疗措施？

 

大多数时候，血糖控制较差，需要应用胰岛素，虽然胰岛素对改善肝脏病理并无益处，但是，控制血糖仍然是最重要的组分，如果血糖控制改善，至少在短期和中期，肝脏状况不会明显恶化。从长期来看，胰岛素并不是控制血糖的最好方法，也不能改善NAFLD，所以，在分娩后，我们会将胰岛素换为对肝脏更加有益的其他口服降糖药物。

 

<Hepatology Digest>: Where there is severe metabolic syndrome present, what measures are taken then?

 

Dr Wong: Most of the time, that would be poor glycemic control, so insulin would be needed. However, insulin would not be a beneficial addition to liver pathology, but glycemia remains the most important component to control. If glycemia control improves, at least in the short- and mid-term, the liver condition would not deteriorate significantly. In the long-term, insulin would not be the best glycemic therapy or to improve NAFLD, so after delivery, we would switch from insulin to other oral medications, which will be more liver-friendly.

 

8、NAFLD病例应该优先控制血糖？

 

除了上述优先控制血糖之外，还应该控制体重。怀孕期间，容易进食过量，所以，需要密切监测体重增加。通常，我们建议孕妇在怀孕期间的体重增加限制为15 kg～20 kg，体重增加过多，会增加NAFLD的风险。

 

<Hepatology Digest>: So the priority in NAFLD cases is the glycemic control?

 

Dr Wong: And also to control weight gains. It is easy to over-eat in pregnancy, so weight gains need to be monitored closely. Usually, we would advise to limit weight gains during pregnancy between 15-20 kg, as excess weight gains will increase the risk of NAFLD.

 

9、中国人改变生活方式往往非常困难，如果一位妊娠女性在文化上认为自己应该多吃，如何说服她控制饮食？

 

确实如此。我有两个孩子，这也是我自己在怀孕期间的经历。我认为，如果能够提供充分的证据和数据，表明体重增加过多和随之发生的NAFLD对她的子女有害，他们就会有更多的动力来改变生活方式。即使没有体重增加过多，仍然可以获得良好的营养，我们需要的是均衡饮食，可以向他们展示所需的营养成分和比例，因此，即使没有体重增加过多，他们仍然可以吃得健康，并且为婴儿提供恰当的营养。

 

<Hepatology Digest>: Our audience is Chinese physicians. Lifestyle changes are often very difficult for the Chinese. How do you convince a Chinese woman to control her diet at a time when she is culturally thinking she should be eating more?

 

Dr Wong: That is very true. I have had two children and that was also my experience during pregnancy. I think if we provide adequate evidence and data illustrating that excess weight gains and consequent NAFLD are detrimental to her offspring, then they can be more motivated. You can still get good nutrition in the absence of excess weight gains. What is needed is a balanced diet. We can show them the desired components and ratios so they can still eat healthy and provide the correct nutrition for the baby.

 

10、对未能参加本届年会的国内肝病科医生及同道的鼓励首先，我完全理解，在中国大陆、香港以及世界上的许多地方，目前是医务人员非常艰难的时期，医务人员对患者和他们的家人有承诺，要医治患者，无论他们患有新型冠状病毒肺炎还是其他疾病，医务人员的使命是坚守和医治他们的患者，所有的普通内科医生和肝病科医生都在非常努力地工作，他们的付出确实值得赞赏。

 

在未来的几个月里，会有暂时的旅行限制，但是，利用诸如本届年会直播这样的技术，他们仍然可以参与会议，了解新的进展，并且提供反馈。我相信，在几个月的时间内，疫情将会得到控制，期待来自不同国家的医生再次相聚，交流知识和经验。

 

我们都在坚持，在不同层面上，尽我们的最大努力，为当前的疫情形势做出贡献。我们希望疫情能够很快得到控制，我们可以再次相聚，面对面地交流。

 

<Hepatology Digest>: You are one of the few Chinese representatives at this meeting. Most of your mainland Chinese colleagues are unable to attend. If you could share some encouragement for your hepatologist colleagues, what would you say?

 

Dr Wong: Firstly, I fully understand that it is a really tough time for healthcare professionals in China, and indeed many parts of the world now, including Hong Kong. There are a lot of commitments to your patients and their families to care for them, whether that be COVID-19-related or otherwise. Their mission is to stay and care for their patients. All the general physicians and hepatologists are working very hard, and their efforts are really appreciated. There will be travel limitations temporarily over the coming months, but with technology such as the live streaming at this conference, they can still participate, learn what is new and provide feedback. I am sure that in a few months, the situation will be under control, and I look forward to doctors from different countries coming together again to exchange knowledge and experiences. I would say we are all hanging in there and trying our best to contribute at whatever level to the current situation. We hope this will be under control very soon, and we can come together again and meet face-to-face.