妊娠合并重度肺动脉高压患者施行不同麻醉方式剖宫产的效果观察

Observation on the effect of different anesthesia on cesarean section in pregnant women with severe pulmonary arterial hypertension

目的分析妊娠合并重度肺动脉高压(PAH)患者施行不同麻醉方式剖宫产的临床效果。方法回顾性分析于2014年8月至2016年2月济南军区总医院急诊收入行剖宫产术的40例妊娠合并重度PAH患者,根据患者术前的不同麻醉方式将所有患者分为两组,椎管内麻醉组23例(其中施行腰麻-硬膜外联合麻醉的患者为联合组13例,施行连续硬膜外麻醉的患者为硬膜外组10例)、全身麻醉组17例。对比分析两组患者年龄、体重、孕产史、孕周、孕期合并症、心脏病史、心功能等一般资料及妊娠结局和术后住院情况。结果两组患者年龄、体重、孕产史、孕周、孕期合并症(心律失常、低氧血症、低蛋白血症、肺部感染)、心脏病史、心功能等一般资料比较差异无统计学意义(t/χ~2值为0.006~0.774,均P>0.05)。全身麻醉组的ICU入住时间、术后机械通气时间和术后总住院时间明显高于椎管内麻醉组(t值分别为-3.474、-3.752、-3.636,均P<0.05)。联合麻醉组患者死于术后肺动脉高压危象1例(7.69%),硬膜外组患者无死亡病例。联合麻醉组患者有12例妊娠满28周,3例发生新生儿窒息(23.08%),新生儿死亡1例(7.69%),死因为急性呼吸窘迫综合征;硬膜外组患者中有9例妊娠满28周,2例发生新生儿窒息(20.00%),新生儿死亡1例(10.00%),死因为急性呼吸窘迫综合征。全身麻醉组患者15例妊娠满28周,4例发生新生儿窒息(23.53%),新生儿死亡1例(5.88%),死因为急性呼吸窘迫综合征。两组患者的产妇死亡率、新生儿窒息率、新生儿死亡率比较差异无统计学意义(χ~2值分别为0.758、0.018、0.112,均P>0.05)。结论妊娠合并重度PAH患者施行椎管内麻醉的ICU入住时间、术后机械通气时间和术后总住院时间明显短于施行全身麻醉的患者,患者无椎管内麻醉禁忌症的情况下,应优先选择椎管内麻醉。

Objective To investigate the clinical effects of different anesthesia on cesarean section in pregnant women with severe pulmonary arterial hypertension（PAH）. Methods Totally 40 pregnant women with severe PAH performing cesarean section in Jinan Military General Hospital during August 2014 to February 2016 were analyzed retrospectively. They were divided into two groups according to different anesthesia methods. Totally 23 cases were treated with spinal anesthesia,including 13 cases in combined anesthesia group treated with combined spinal epidural anesthesia,and 10 cases in epidural anesthesia group treated with continuous epidural anesthesia.General anesthesia was used in 17 patients. Age,weight,pregnancy history,gestational age,pregnancy complications,heart disease history,heart function and other general information,outcome of pregnancy and hospitalizations after surgery were compared and analyzed between two groups. Results There was no significant difference in age, weight, gestational age, pregnancy history, pregnancy complications（arrhythmia, hypoxemia, hypoproteinemia, pulmonary infection）, heart disease, heart function and other general information between two groups（t/χ~2value ranged 0. 006-0. 774,all P〈0. 05）. The ICU admission time,postoperative mechanical ventilation time and total postoperative hospitalization of patients in the general anesthesia group were significantly higher than those in the spinal anesthesia group（t value was-3. 474,-3. 752 and-3. 636,respectively,all P〈0. 05）. One patient（7. 69%） in the combined anesthesia group died from postoperative pulmonary hypertension crisis,while there was no death in the epidural group. In the combined anesthesia group,there were 12 cases pregnant for at least 28 weeks,3 newborns suffered neonatal asphyxia（23. 08%）,and 1newborn died,suffering acute respiratory distress syndrome（7. 69%）. In the epidural anesthesia group,there were 9 cases pregnant for at least 28 weeks,2 newborns suffered neonatal asphyxia（20. 00%）,and 1 newborn died,suffering acute respiratory distress syndrome（10. 00%）. In the general anesthesia group,there were 15 cases pregnant for at least 28 weeks,4 newborns suffered neonatal asphyxia（23. 53%）,and 1 newborn died,suffering acute respiratory distress syndrome（5. 88%）. There was no significant difference in maternal mortality,neonatal asphyxia rate and neonatal mortality between two groups（χ~2value was 0. 758,0. 018 and 0. 112,respectively,all P〈0. 05）. Conclusion ICU admission time,postoperative mechanical ventilation time and total hospitalization after surgery of the pregnant women with severe PAH who treated with cesarean section with spinal anesthesia are significantly shorter than those of the patients treated with general anesthesia. The spinal anesthesia should be prior in patients without spinal anesthesia contraindications.