上海市产科心脏病监护中心26年妊娠合并心血管疾病死亡病例分析

Analysis of maternal deaths with cardiovascular diseases in Shanghai obstetric heart disease intensive care unit within twenty-six years

目的分析上海市产科心脏病监护中心26年间妊娠合并心血管疾病死亡孕产妇的临床资料。方法收集1993年1月至2018年12月于上海产科心脏病监护中心诊治的、数据完整的孕妇共4112例,回顾性分析其中20例妊娠合并心血管疾病死亡孕产妇的死亡高危因素、心血管并发症、死亡时段、终止妊娠的时机及围产儿结局等。结果(1)死亡孕产妇中,结构异常性心脏病者18例(90%,18/20),妊娠诱发心脏病者2例(10%,2/20),无功能异常性心脏病者。本中心的妊娠合并心血管疾病孕产妇的总体死亡率为0.486%(20/4112)。(2)20例死亡的妊娠合并心血管疾病孕产妇中,未经评估自行妊娠者19例(95%,19/20),心功能Ⅲ~Ⅳ级者14例(70%,14/20),合并肺动脉高压者15例(75%,15/20),既往有心脏病史者的比例较高(60%,12/20);产褥期死亡者17例(85%,17/20),妊娠期死亡者3例(15%,3/20),无分娩期死亡者;心力衰竭死亡者13例(65%,13/20),肺动脉高压危象死亡者4例(20%,4/20),心跳骤停、主动脉夹层和猝死者各1例(5%,1/20)。结论心血管疾病患者应严格掌握妊娠指征,肺动脉高压为妊娠禁忌证,尤其是中重度肺动脉高压心脏病患者不能妊娠。产褥期是危及妊娠合并心血管疾病孕妇的关键期,而心力衰竭为主要死亡原因。应积极预防和治疗心力衰竭,尤其是结构异常性心脏病孕妇,要动态监测其心功能;规范妊娠期保健,及时识别疾病的严重性。

Objective To analyze risk factors,cardiovascular complications,time of death,gestational age of delivery and offspring outcomes in the maternal deaths with cardiovascular diseases(CVD).Methods Totally 4112 cases of pregnant women with CVD in Shanghai obstetric heart disease intensive care unit within 26 years(from January 1993 to December 2018)were collected,and 20 maternal deaths within these cases were analyzed retrospectively.Results(1)Among the 20 deaths,structural heart diseases accounted for 90%(18/20),pregnancy induced heart diseases was 10%(2/20)while there was no dysfunctional heart disease.The mortality of pregnant women with CVD was 0.486%(20/4112).(2)The following risk factors were common in these women,getting pregnant without counselling(95%,19/20),New York Heart Association classⅢorⅣcardiac function(70%,14/20),complicated with pulmonary hypertension(75%,15/20)and prior heart events(60%,12/20).And 85%(17/20)deaths occurred in puerperium,15%(3/20)occurred before labor,while no death occurred during labor.And 65%(13/20)deaths died due to heart failure,20%(4/20)deaths were due to pulmonary hypertension crisis,5%(1/20)died on sudden cardiac arrest,rupture of aortic dissection and sudden death,respectively.Conclusions Women with CVD should get pregnant after strict evaluation.Pulmonary hypertension is one of the most severe contraindications to pregnancy,especially in patients with moderate to severe pulmonary hypertension.The puerperium period is a critical period that threatens the safety of these patients.Since heart failure is the most common cause of death,it is necessary to prevent and treat heart failure and to monitor heart function dynamically,especially in those with structural abnormal heart diseases.Moreover,it is also of importance to standardize antenatal care and to identify the severity of heart diseases in time.