合并严重心血管疾病孕妇妊娠早中期终止妊娠的方法选择及围术期管理

Method selection and perioperative management of termination of pregnancy during the first and second trimester of pregnancy with severe cardiovascular disease

目的 分析合并严重心血管疾病孕妇在孕早中期终止妊娠的方法及围术期的管理.方法 回顾性分析2016年1月1日至2017年12月30日首都医科大学附属北京安贞医院收治的27例妊娠风险分级为Ⅴ级的妊娠合并严重心血管疾病在孕早中期终止妊娠孕妇的临床资料.结果 （1）27例孕妇的年龄为22～40岁,孕周为6～27周.终止妊娠前的心功能分级：Ⅱ级5例,Ⅲ级15例,Ⅳ级7例.心血管疾病类型：室间隔缺损9例,单纯房间隔缺损3例,单纯动脉导管未闭2例,法洛四联症2例,风湿性瓣膜病1例,心律失常-阵发性房性心动过速2例,心肌病2例,高血压性心脏病2例,原发性肺动脉高压1例,结缔组织病并发肺动脉高压1例,甲状腺功能亢进性心脏病1例,冠心病1例.其中,合并肺动脉高压者21例,合并艾森曼格综合征者5例.（2）终止妊娠的方法和麻醉选择：27例中,早期妊娠者10例,中期妊娠者17例.不插管全身麻醉下负压吸引术8例、钳刮术2例;依沙吖啶羊膜腔内注射引产术1例,剖宫取胎术16例（其中11例剖宫取胎术中采取连续性硬膜外阻滞麻醉,1例采取蛛网膜下腔阻滞联合硬膜外阻滞麻醉,4例蛛网膜下腔阻滞）.（3）终止妊娠的结局：1例孕19周合并重度原发性肺动脉高压者于剖宫取胎术后1d死亡,其余孕妇终止妊娠前后心功能无明显变化,均存活.结论 合并严重心血管疾病的孕妇,强烈建议在孕前由心血管科医师和产科医师进行全面评估.如在妊娠后就诊,应尽快组织多学科联合会诊评估妊娠风险,给予医疗建议.对于妊娠风险分级高者,应把握时机,制定方案后尽早终止妊娠.终止妊娠时如病情允许可采取暂时或永久的避孕措施并指导下一步的治疗方案.

Objective To summarize and analyze the methods of termination of pregnancy in the first and second trimester of pregnancy with severe cardiovascular disease. Methods A retrospective analysis of 27 cases of termination of pregnancy in the first and second trimester of pregnancy in Beijing Anzhen Hospital from January 1, 2016 to December 30, 2017. All of these pregnant women were pregnancy complicated with severe cardiovascular disease in grade Ⅴ pregnancy risk. Results （1）The age of 27 pregnant women was 22-40 years, gestational age was 6-27 weeks; cardiac function grade before induced labor was： 5 cases of grade Ⅱ, 15 cases of grade Ⅲ, 7 cases of gradeⅣ. The cardiovascular diseases included ventricular septal defect in 9 cases, simple atrial septal defect in 3 cases, patent ductus arteriosus in 2 cases, tetralogy of Fallot in 2 cases, rheumatic valvular disease in 1 case, arrhythmia-paroxysmal atrial velocity in 2 cases, cardiomyopathy in 2 cases, hypertensive cardiopathy in 2 cases, primary pulmonary hypertension in 1 case, tissue disease complicated with pulmonary hypertension 1 case, hyperthyroid heart disease in 1 case, coronary heart disease in 1 case. Among them, 21 cases were complicated with pulmonary hypertension, and 5 cases with Eisenmenger syndrome.（2）Methods of termination of pregnancy：in 27 cases, eight cases of vacuum curettage, and 2 cases of forceps curettage under general anesthesia＆nbsp;without intubation;rivanol intraamniotic induction of labor in 1 case;and hysterotomy delivery in 16 cases （11 cases were treated with continuous epidural anesthesia, 1 case was treated with combined spinal and epidural anesthesia, 4 cases were treated with spinal anesthesia）.（3）After termination of pregnancy, one patient with severe primary pulmonary hypertension at 19 weeks of gestation died on the 1st day postoperative. No significant changes in cardiac function were observed in other patients before and after termination of pregnancy, and all of them survived. Conclusions In patients with severe cardiovascular disease, termination of pregnancy after pregnancy may result in maternal death even at the second trimester of pregnancy. It is strongly recommended that such patients undergo pre-pregnancy assessment and fertility counseling. If visiting doctor after pregnancy, we should organize a multidisciplinary consultation as soon as possible to assess the risk of continuing pregnancy and give medical advice. If the risk of pregnancy is high, we should terminate the pregnancy as early as possible, after making a suitable treatment plan. During termination of pregnancy, temporary or permanent contraception may be taken if the condition permits.