妊娠合并感染性心内膜炎伴赘生物的临床处理及母儿结局

Clinical treatment of infective endocarditis with vegetations in pregnant women and the outcomes of gestation

目的：探讨妊娠合并感染性心内膜炎伴赘生物的临床处理及母儿结局。方法收集2001年1月至2015年10月首都医科大学附属北京安贞医院收治的9例妊娠合并感染性心内膜炎伴赘生物孕妇的临床资料，回顾性分析其临床特点、治疗方案及母儿结局。9例孕妇入院后均由产科、麻醉科、心内科、心外科、体外循环科等多科室会诊，制定个体化治疗方案，并由相关科室协作完成临床治疗。治疗方案包括一般治疗、抗感染治疗、心脏手术及终止妊娠手术的时机及方式。结果（1）临床特点：9例孕妇的年龄为25～36岁；发病孕周为19～36周。临床表现：以发热、咳嗽、咳痰、进行性贫血为主要症状，心力衰竭时患者口唇发绀、不能平卧甚至端坐呼吸；查体可闻及心脏杂音、脾肿大；血培养阳性。基础心脏病类型：先天性心脏病7例，包括主动脉瓣关闭不全2例、二尖瓣关闭不全1例、动脉导管未闭1例、右心室流出道狭窄1例、室间隔缺损2例；风湿性心脏病2例，包括二尖瓣狭窄1例、二尖瓣狭窄人工换瓣后卡瓣1例。心内膜赘生物附着位置：二尖瓣赘生物3例，肺动脉瓣赘生物2例，主动脉瓣赘生物3例，右心室流出道赘生物1例。术前心功能分级：Ⅱ级1例，Ⅲ级3例，Ⅵ级5例。（2）治疗：一般治疗包括吸氧、卧床休息、强心、利尿等。抗感染治疗根据药敏试验，应用联合、足量抗生素治疗。9例孕妇均行基础心脏病的手术治疗及心内膜赘生物清除术；2例孕中期行剖宫取胎术，7例孕晚期行剖宫产术。9例孕妇中，6例心脏手术和终止妊娠手术同时进行，手术时间为孕22～34周；2例在心脏手术前终止妊娠，终止妊娠时间分别为孕33、37周，心脏手术时间分别为产后11、32 d；1例在心脏手术后终止妊娠，心脏手术、终止妊娠时间分别为孕26、37周。（3）母儿结局：7例孕妇抢救成功，2例孕妇死亡，术后心功能分级：Ⅰ级1例，Ⅱ级2例，Ⅲ级4例，Ⅵ级2例。新生儿存活6例，其中足月产儿2例，早产儿4例；死胎或新生儿死亡3例，2例为中期妊娠行剖宫取胎术，1例为极低出生体质量儿，因重度窒息家属放弃治疗死亡。术后随访1～7年，平均（2.0±1.6）年，随访期内存活婴幼儿发育良好。结论妊娠合并感染性心内膜炎伴赘生物虽然风险极高，但由多学科协作制定并实施个体化治疗方案，选择合适的心脏手术和终止妊娠的时机，仍不失为挽救母儿生命的一种方法。

Objective To investigate the clinical treatment of infective endocarditis with vegetations in pregnant women and the outcomes of the gestation. Methods Nine cases of pregnant women diagnosed as infective endocarditis with vegetations in Beijing Anzhen Hospital, Capital Medical University from January 2001 to October 2015 were enrolled in retrospective analysis. Consultations were held by doctors from department of obstetrics, anesthesiology, cardiology, cardial surgery and extracorporeal circulation to decide the individualized treatment plan for the 9 cases of pregnant women after admissions. Clinical treatments including general treatment, anti-infection treatment, cardiac surgery, and termination of pregnancy surgery were completed through collaboration among related departments. The clinical characters,＆amp;nbsp;therapeutic regimens, maternal and neonatal outcomes of the 9 cases were analyzed. Results （1）Clinical characters： the ages of the 9 cases of pregnant women were from 25 to 36 years old. The onset gestational ages were from 19 to 36 weeks. Clinical symptoms： fever, cough, sputum and progressive anemia were the main symptoms. Patients had cyanosis of lips, could not lie on the back or even be orthopnea, when heart failure happened. Heart murmur was audible and splenomegaly was touched in physical examination. Blood cultures were positive. Basic heart disease types： 7 cases of congenital heart diseases included 2 cases of aortic insufficiency, 1 case of mitral insufficiency, 1 case of patent ductus arteriosus, 1 case of right ventricular outflow tract stenosis and 2 cases of ventricular septal defect.Two cases of rheumatic heart diseases included 1 case of mitral stenosis, 1 case of mitral stenosis after artificial disc changed and jammed. According to endocardial vegetations attached position there were 3 cases of mitral valve vegetations, 2 cases of pulmonary valve vegetations, 3 cases of aortic vegetations and 1 case of right ventricular outflow tract neoplasm. Preoperative heart function classification：1 case of levelⅡ, 3 cases of levelⅢ, 5 cases of levelⅣ.（2）Treatments：general treatment included oxygen uptake, rest in bed, cardiac strengthen and diuretic therapy, etc. Combined and adequate antibiotics were applied in anti-infection treatment according to drug sensitive test. Nine cases of pregnant women were all performed surgical treatment of heart diseases and removal of the endocardial vegetations. Caesarean sections were performed for 2 cases in second trimester and for 7 cases in last trimester. Cardiac surgery and caesarean section were operated in 6 cases at the same time among 22-34 weeks of pregnancy. Cardiac surgery were respectively operated in 2 cases 11 days and 32 days after the caesarean section at 33, 37 weeks of pregnancy. While Cardiac surgery was operated （at 26 weeks of pregnancy） before the caesarean section （at 37 weeks of pregnancy） in another 1 case. （3） Maternal and neonatal outcomes：7 cases of pregnant women were rescued successfully, while 2 cases of pregnant women were death. Postoperative heart function classification： 1 case of level Ⅰ, 2 cases of levelⅡ, 4 cases of levelⅢand 2 cases of levelⅥ. Neonatal survivals were 6 cases including 2case of full-term infants, 4 cases of preterm infants. Stillbirth or neonatal death were 3 cases, which included 2 cases performed caesarean section in second trimester and 1 case of very low weight infant who was given up treatment by family because of severe asphyxia. Followed up periods were from 1 to 7 years with an average time of （2.0 ± 1.6） years. Infants and young children grew and developed well during the period of follow up. Conclusions The risk is extremely high of pregnancy with infective endocarditis with vegetations. But there is still a way to save the maternal and neonatal life by using a multidisciplinary collaboration formulation and implementation of individualized treatment plan and selecting the appropriate time for heart surgery and the termination of pregnancy.