妊娠合并主动脉夹层24例临床分析

Clinical analysis of 24 cases of aortic dissection during pregnancy

目的探讨妊娠合并主动脉夹层孕妇的孕期管理及母儿结局。 方法收集2006年1月1日至2016年2月29日在首都医科大学附属北京安贞医院分娩的24例妊娠合并主动脉夹层孕妇的临床资料，回顾性分析其临床特点、治疗方案及母儿结局。 结果（1）临床特点：24例合并主动脉夹层的孕妇，年龄为22~35岁，平均（29±4）岁；发病时间为孕5周~产后1个月；临床表现：主要症状为胸背痛，部分孕妇还出现了游走性或放射性疼痛；主动脉夹层类型：Stanford A型17例，B型7例；主动脉宽度：2.9~10.0 cm，平均（5.6±1.7）cm。实验室检查结果：D-二聚体水平为448~6 421 μg/L，平均（1 097±1 209）μg/L；纤维蛋白降解产物水平为4.1~52.1 mg/L，平均（10.2±9.5）mg/L；白细胞计数为（6.8~36.4）×109/L，平均（29.4±4.2）×109/L；中性粒细胞比值为76.0%~97.6%，平均（84.6±6.3）%。（2）治疗：①19例孕妇行主动脉手术。主动脉手术方式有4种：主动脉根部置换＋全主动脉弓置换＋支架象鼻植入术（Bentall＋Sun＇s术）、主动脉根部置换术（Bentall术）、带膜支架植入术、全胸腹主动脉置换术。19例行主动脉手术的时间为孕5周至产后1个月。手术与终止妊娠的关系：4例孕妇终止妊娠后行主动脉手术；9例孕妇行主动脉手术同时行剖宫取胎术或剖宫产术；6例孕妇主动脉手术后行妇产科手术。②5例孕妇未行主动脉手术，其中2例Stanford A型和1例B型孕妇来院后未及手术即死亡，2例B型孕妇行保守治疗。24例孕妇终止妊娠的时间为孕6~37周，平均孕（26±10）周。（3）母儿结局：24例孕妇中20例抢救成功（83%，20/24），4例死亡（17%，4/24）。新生儿存活10例，其中足月儿4例，早产儿6例，新生儿出生体质量为1 080~3 800 g，平均（2 302±764）g；其中极低出生体质量儿3例，低出生体质量儿1例，新生儿窒息3例。新生儿随访0.5~10.0年，平均（1.4±1.7）年，随访期内婴幼儿发育良好。 结论妊娠合并主动脉夹层发病凶险，通过早期识别，应做到初诊及时准确，评估后血管外科及时进行干预，以保障母儿安全。

ObjectiveTo investigate the management and perinatal outcome of aortic dissection during pregnancy. Methods24 pregnant women with aortic dissection who delivered in Beijing Anzhen Hospital Affiliated to Capital Medical University from January 1st, 2006 to February 29th, 2016 were recruited. The clinical data, the management and the perinatal outcome were analyzed retrospectively. Results（1） Clinical features： The average age of the patients was （29±4） years old. The clinical symptoms occurred from 5 gestational weeks to 1 month after delivery. The major symptoms were chest pain, and some complained migratory or radiating pains. There were 17 Stanford type A cases and 7 type B cases. The aortic widths were 2.9-10.0 cm, with the average of （5.6±1.7） cm. D-dimer level was 448-6 421 μg/L, with the average of （1 097±1 209） μg/L, and the fibrin degradation products were 4.1-52.1 mg/L, with the average of （10.2±9.5） mg/L.The white blood cell ranged （6.8-36.4）×109/L, with the average of （29.4±4.2）×109/L; and the neutrophil rate was 76.0%-97.6%, with the average of （84.6±6.3） %. （2） The treatment： ①19 patients underwent aorta surgeries. The surgeries included aortic root replacement with total aortic arch replacement plus stented elephant trunk implantation （Bentall＋Sun＇s surgery）, aortic root replacement （Bentall surgery）, stent implantation, thoracic and abdominal aorta replacement. The aortic operation time of the 19 patients were 5 gestational weeks to 1 month after delivery. The relation between aortic operation and the termination of pregnancy： 4 patients underwent aorta surgery after termination of pregnancy, 9 patients had cesarean section and aorta surgery at the same time, 6 patients underwent aorta surgery before cesarean section. ② 5 patients did not receive arota surgery, 2 patients of type A dissection and 1 patient of type B dissection died before the surgery; 2 cases of type B dissection underwent conservative treatment. The termination time of pregnancy was 6-37 gestational weeks, with the average of （26±10） weeks. （3）Maternal and fetal outcomes： 20 patients survived after treatment （83%, 20/24） and 4 patients died （17%, 4/24）. 10 cases were live births, including 4 full-term infants and 6 preterm premature infants. The birth weight of the neonates was 1 080-3 800 g, with the average of （2 302±764） g. Three of them were very low birth weight infants and 1 was low birth weight infant; 3 neonates had mild asphyxia. The neonates were followed up for 0.5 to 10 years, with the average time of （1.4±1.7） years. So far the infants＇ development was good. ConclusionsPregnancy with aortic dissection is pernicious. Early identification, prompt diagnosis and prompt interventing of the vascular surgery are necessary to the safety of mother and fetus.