妊娠合并重度主动脉瓣狭窄患者行剖宫产手术的麻醉管理

Anesthesia Management of Cesarean Section in Pregnant Women with Severe Aortic Stenosis

目的探讨妊娠合并重度主动脉瓣狭窄(aortic stenosis,AS)患者行剖宫产手术的麻醉管理方法。方法回顾性分析2012年1月—2017年9月首都医科大学附属北京安贞医院收治的妊娠合并重度AS行剖宫产手术患者10例的临床资料。结果本组1例AS为风湿性病变所致,余为先天性主动脉瓣二瓣化畸形所致。剖宫产手术均采用硬膜外麻醉,硬膜外给药过程中均预防性应用去甲肾上腺素等血管活性药物维持外周血管阻力,防止血压下降。胎儿娩出后,采用变换体位及延迟胎盘娩出等方法缓解回心血量骤然增加,避免心脏过荷导致心功能恶化;对术前心功能较差及合并中重度主动脉瓣关闭不全者予适量多巴胺静脉泵注,以维护心功能;同时做好行心脏手术的准备。所有患者术中血流动力学稳定,均平稳度过围术期,无不良心血管事件发生,无一例进行同期心脏手术。结论妊娠合并重度AS患者围术期心血管风险极大,硬膜外麻醉适用于此类患者的剖宫产手术,术中预防性应用血管活性药物至关重要。

Objective To investigate anesthesia management of cesarean section in pregnant women with severe aortic stenosis(AS).Methods Clinical data of 10 pregnant women with severe AS who had cesarean section from January 2012 to September 2017 in Beijing Anzhen Hospital,Capital Medical University were retrospectively analyzed.Results The etiology of AS in 9 patients was deformation of congenital bicuspid aortic valve and one patient had rheumatic heart disease.Epidural anesthesia was used for all ten patients.Hypotension should be promptly treated with noradrenaline for maintenance of systemic vascular resistance.After delivery,the goals of hemodynamic management should be to minimize the effect of a sudden increase in preload and preserve cardiac contractility.Patients with cardiac decompensation or those with moderate to severe aortic insufficiency should be treated with dopamine to avoid deterioration of heart function.Cardiac surgery should be prepared as life saving procedures.Patients in our series have been successfully managed with careful titration of an epidural technique to maintain hemodynamic stability.There were no severe cardiovascular complications,and no cardiac surgery was undertaken in the meantime.Conclusion Pregnant women with severe AS are at increased risk of cardiovascular complications during perioperative period of cesarean section,for which epidural anesthesia is a reasonable option.It is of great significance to avoid intraoperative hypotension,which can be treated aggressively with vasopressor agents.