妊娠合并肺动脉高压产妇的围术期管理

The perioperative management of pregnant women with pulmonary hypertension

肺动脉高压是以肺动脉压力进行性增高,肺部血管壁增厚、硬化导致肺循环阻力增加,最终引起右心衰竭,甚至致使患者死亡的一类疾病,妊娠合并肺动脉高压为妊娠期严重的合并症,虽在孕产妇中并不常见,但其病死率高,严重威胁母婴健康。其机制主要与孕产妇肺小动脉对高心排的失代偿,最终导致右心衰竭有关,且孕期血液高凝状态和体循环阻力的降低使此类患者存在更大风险。因患者人群局限于年轻育龄女性,且妊娠合并肺动脉高压在临床上较为少见。这一特点结合其复杂的病理生理变化,使得妊娠合并肺动脉高压的临床管理困难并且难以规范。目前将任何原因引起的肺动脉高压均列为妊娠禁忌类,严重的肺动脉高压、低氧血症、紫绀、血栓栓塞是孕产妇死亡的主要危险因素。对胎儿的影响包括流产、早产、胎儿生长受限、低出生体重儿、新生儿窒息和新生儿死亡等。了解妊娠合并肺动脉高压的风险及影响预后的因素,规范肺动脉高压孕产妇的围术期管理对改善母婴预后具有重要意义。本文就肺动脉高压的定义、肺动脉高压的分类、妊娠血流动力学改变对肺动脉高压的影响、肺动脉高压对妊娠的影响、肺动脉高压对母婴的影响等多个方面的研究做一综述。

Pulmonary hypertension is a kind of disease with progressive increase of pulmonary artery pressure,thickening and hardening of pulmonary vascular wall,which eventually results in right heart failure and even death.Pregnancy combined with with pulmonary hypertension is a kind of severe complication,which is not common in pregnant women,but its mortality is high,and seriously threatens the maternal and child health.According to literature reports,the mortality rate of pregnant women with pulmonary hypertension is as high as 36%~56%,and its mechanism is mainly related to the decompensation of pulmonary arterioles to high cardiac output,which eventually leads to right heart failure.And high coagulation state of blood and systemic circulatory resistance during pregnancy bring greater risk for the patients.Because the patient population is limited to young women of childbearing age,and pregnancy with pulmonary hypertension is rare in clinical practice,and the clinical management of pregnancy with pulmonary hypertension is difficult and difficult to be standardized.At present,pulmonary hypertension caused by any cause is classified as a contraindication of pregnancy.Severe pulmonary hypertension,hypoxemia,cyanosis and thromboembolism are the main risk factors for maternal death,and its effects on fetus include abortion,premature delivery,fetal growth restriction,low birth weight,neonatal asphyxia and neonatal death.To understand the risk of pregnancy complicated with pulmonary hypertension and the factors affecting prognosis,and to standardize the intraoperative management of pregnant women with pulmonary hypertension is of great significance to improve the prognosis of mother and child.This article reviews the definition of pulmonary hypertension,classification of pulmonary hypertension,the effect of hemodynamic changes in pregnancy on pulmonary hypertension,the effect of pulmonary hypertension on pregnancy,and the effect of pulmonary hypertension on mother and child.