妊娠合并心脏病伴肺动脉高压患者的妊娠结局

Perinatal management and pregnancy outcome in pregnant women with pulmonary hypertension complicating cardiac disease

目的探讨妊娠合并心脏病伴肺动脉高压患者的妊娠结局。方法收集1996年1月至2004年8月间,我院产科收治的61例妊娠合并心脏病伴肺动脉高压患者的临床资料(其中先天性心脏病36例,风湿性心脏病21例,心律失常1例,原发性肺动脉高压性心脏病2例,系统性红斑狼疮性心脏病1例),根据肺动脉压力情况分为轻度组32例[30～49mmHg(1mmHg=0.133kPa)],中度组23例(50～79mmHg),重度组6例(≥80mmHg),分析各组心脏病种类、心功能级别、终止妊娠孕周和方式以及母儿结局。结果(1)轻度组心功能Ⅰ～Ⅱ级者23例,中度组心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级的发病例数分别为9、5、5、4例,重度组心功能Ⅲ～Ⅳ级者5例。(2)风湿性心脏病患者中,中、重度肺动脉高压者11例,占52%(11/21);发生严重心功能衰竭者9例,占43%(9/21),先天性心脏病患者中,以轻、中度肺动脉高压者为主(97%,35/36),且以心功能Ⅰ～Ⅱ级者为主(81%,29/36)。(3)轻度组足月妊娠24例,新生儿平均体重为2744g;中度组足月分娩11例,早产8例,医源性流产4例;重度组足月分娩1例,早产3例,医源性流产2例。各组围产儿疾病发生率比较,差异无统计学意义(P>0.05)。(4)妊娠合并心脏病伴肺动脉高压者的分娩方式以剖宫产分娩为主,占79%(48/61)。(5)孕产妇死亡率为2%(1/61),医源性胎儿丢失率为13%(8/61例)。结论随着肺动脉压力的升高,孕妇心功能衰竭的发生率随之增加,围产儿疾病发生率和胎儿丢失率也明显增加;妊娠合并风湿性心脏病患者中、重度肺动脉高压的发生率高于先天性心脏病患者;手术终止妊娠是比较安全的分娩方式。

Objective To evaluate the pregnancy outcome of women with pulmonary hypertension complicating cardiac disease. Methods Clinical data of 61 cases of pregnant women with pulmonary hypertension from Jan 1996 to Aug 2004 were analyzed and they were divided into three groups ： 32 cases of slight group [pulmonary hypertension from 30 mm Hg （ 1 mm Hg =0. 133 kPa） to 49 mm Hg], 23 cases of moderate group （pulmonary hypertension from 50 mm Hg to 79 mm Hg ） and 6 cases of severe group （pulmonary hypertension equal to or higher than 80 mm Hg）. The types of heart disease, cardiac functional status（New York heart association, NYHA）, gestational weeks of pregnancy termination, mode of delivery and outcomes of infants were compared between the groups. Results （ 1 ） The occurrence rate of NYHA class Ⅲ-Ⅳ was 5/6 in severe group. The rate of NYHA class Ⅰ -Ⅱ was 72% （23/32） in slight group. （2） The rate of moderate and severe pulmonary hypertension was 53% （11/21） and of NYHA class Ⅳ 43% （9/21） in rheumatic heart disease. The rate of slight pulmonary hypertension was 97% （35/36） and NYHA class Ⅰ -Ⅱ 81% （29/36） in congenital heart disease. （3） The rate of term delivery was 75 % （24/32） and the birth weight was 2744 g on average in slight group. The rate of term delivery was 48% （ 11/23 ）, preterm labor 35% （8/23）,abortion 17% （4/23） in moderate group. The rate of term delivery was 1/6, preterm labor occurred in 3 cases, and abortion in 2 cases in severe group. The rates of neonatal complications between the three groups had no significant difference. （4） Caesarean section rate was 79% （48/61） among all patients. （5） Overall maternal mortality was 2% （1/61）. Conclusions The rate of heart failure increases gradually with the severity of pulmonary hypertension. The severity of pulmonary hypertension in rheumatic heart disease is higher than in congenital heart disease. The rate of maternal mortality and fetal loss increases in pregnant women with pulmonary hypertension complicating cardiac disease. Perinatal morbidity is higher than normal. Cesarean section is more suitable for those women.