妊娠合并心脏病患者剖宫产的麻醉管理回顾性分析

Anesthetic management in cesarean section in women with heart disease: analysis of 96 cases

目的总结妊娠合并心脏病孕产妇剖宫产的麻醉管理经验,分析不同麻醉方式和心脏病类型对孕产妇和新生儿预后的影响。方法筛选我院在2015年1月至2017年12月期间诊断为妊娠合并心脏病并择期行剖宫产术的孕产妇96例,年龄(27. 4±4. 9)岁,孕(37. 30±2. 45)周,BMI:26. 20±3. 31。依据麻醉方式分为:硬膜外麻醉组(n=63)、蛛网膜下腔阻滞组(n=21)和全身麻醉组(n=12);依据心脏病类型分为:先天性心脏病组(n=33)、先天性心脏病术后组(n=31)、瓣膜置换术后组(n=21)、围产期心肌病组(n=4)和肺动脉高压组(n=7)。统计分析不同麻醉方式对合并心脏病孕产妇和新生儿预后的影响,以及不同心脏病类型孕产妇及其新生儿的预后。结果 (1)蛛网膜下腔阻滞后血管活性药物使用率最高,全身麻醉最低(P <0. 05);(2)硬膜外麻醉的麻醉至手术开台时间较其他两组长(P <0. 05),不同麻醉方式术中输液量、新生儿Apgar评分和产妇术后ICU停留时间均无统计学差异(P> 0. 05);(3)以心脏病类型分组中:术中输液量和出血量无统计学差异(P> 0. 05),围产期心肌病组和肺动脉高压组新生儿Apgar评分较其他组低(P <0. 05),产妇术后ICU停留时间较其他组长(P <0. 05)。结论 (1)蛛网膜下腔阻滞后低血压发生率高,但经血管活性药物治疗后,不影响产妇及新生儿的预后;(2)全身麻醉虽有潜在气管插管困难和反流误吸的风险,但其循环稳定、麻醉至手术开台时间短,并不增加孕产妇心脏病并发症的发生率和降低新生儿Apgar评分;(3)合并围产期心肌病和肺动脉高压孕产妇围术期易发生心衰和肺动脉高压危象。

Objective To review our experience with anesthetic management in cesarean section in women with different heart diseases and analyze how different anesthesia management and heart diseases affect pregnancy and neonatal outcomes. Methods We retrospectively collected the data from 96 pregnant women with heart disease （mean age 27.4±4.9 years, at 37.30±2.45 weeks’ gestation with a mean body mass index of 26.20±3.31） undergoing elective cesarean section in our hospital between January, 2015 and December, 2017. Cesarean section was performed under epidural anesthesia （n=63）, spinal anesthesia （n=21）, or general anesthesia （n=12）. The women were found to have congenital heart disease （n=33）, a history of surgery for congenital heart disease （n=31）, a history of valve replacement （n=21）, perioperative cardiomyopathy （n=4）, or pulmonary hypertension （n=7）. The pregnancy and neonatal outcomes were compared across different anesthesia management and different heart diseases. Results ①The rate of use of vasoactive drugs was the highest with spinal anesthesia and the lowest with general anesthesia （P〈0.05）. ②The onset time of anesthesia was significantly longer with epidural anesthesia than with spinal anesthesia and general anesthesia （P〈0.05）. The volume of intraoperative fluid infusion, neonatal Apgar scores and the length of postoperative ICU stay did not differ significantly among the women receiving different anesthesia management （P〉0.05）. ③The volume of intraoperative fluid infusion and bleeding were similar among the women with different heart diseases （P〉0.05）, but in women with perioperative cardiomyopathy and pulmonary hypertension, the neonatal Apgar scores were significantly lower （P〈0.05） and postoperative ICU stay was significantly longer （P〈0.05） than those in women with other types of heart diseases. Conclusion ①Hypotension is a common complication after spinal anesthesia for cesarean section but does not significantly affect the pregnancy or neonatal outcomes. ②General anesthesia, though with the risks of difficult airway and aspiration of gastric contents, can achieve stable circulation and more rapid onset of anesthesia and does not increase the complications of pregnancy or reduce neonatal Apgar scores. ③Pregnant women with perioperative cardiomyopathy and pulmonary hypertension are at high risks of perioperative heart failure and pulmonary hypertension crisis.