妊娠合并主动脉夹层孕妇11例临床分析

Clinical analysis of 11 cases of pregnancy with aortic dissection

目的探讨妊娠合并主动脉夹层(AD)孕妇的治疗及母儿结局。方法收集2011年1月1日至2022年8月1日空军军医大学第一附属医院收治的11例妊娠合并AD孕妇的临床资料及随访资料,回顾性分析其临床特点、治疗方案及母儿结局。结果(1)临床特点:11例妊娠合并AD孕妇的发病年龄为(30±5)岁,发病孕周为孕(31.4±8.0)周;临床表现:主要症状为突发胸背部疼痛或腰背部疼痛;AD分型:Stanford A型8例,B型3例;主动脉宽度为(42±11)mm。诊断方法:均通过经胸壁超声心动图(TTE)、计算机断层扫描血管造影(CTA)或增强CT检查明确AD的诊断,其中4例CTA检查、4例TTE检查、3例增强CT检查确诊。实验室检查结果:白细胞计数为(15.4±8.7)×10^(9)/L,中性粒细胞计数为(13.5±8.5)×10^(9)/L;中位D-二聚体水平为2.7 mg/L(2.1~9.2 mg/L),中位纤维蛋白降解产物水平为12.0 mg/L(5.4~36.1 mg/L)。(2)治疗:11例妊娠合并AD孕妇均急诊入院,术前心外科、产科、儿科、麻醉科协作制定个体化治疗方案。11例妊娠合并AD孕妇均行主动脉手术,其中6例终止妊娠与主动脉手术同期进行,且均先行剖宫产术再行主动脉手术;4例终止妊娠与主动脉手术分期进行,其中2例剖宫产术后行主动脉手术、2例主动脉手术后行剖宫产术;1例(孕12+6周)主动脉手术后当天自然流产。11例妊娠合并AD孕妇的终止妊娠孕周为孕(32.9±7.4)周。主动脉手术方式:7例行体外循环下升主动脉置换±主动脉瓣置换±冠状动脉移植(或冠状动脉旁路移植)±左右冠状动脉Cabrol分流+全弓置换(或主动脉弓置换)±支架置入术,1例行体外循环下主动脉根部置换术,3例行主动脉腔内隔绝术。(3)母儿结局:11例妊娠合并AD孕妇中,9例(9/11)孕妇存活,2例(2/11)死亡,死亡的2例孕妇发病前均有双下肢缺血表现;9例孕妇分娩后共获新生儿10例(其中1例为双胎),2例分别为孕早期(孕12+6周)主动脉手术后自然流产、孕中期(孕26+3周)剖宫取胎术后胎儿死亡。10例新生儿中,3例为足月儿,7例为早产儿;新生儿出生体重为(2651±784)g;其中6例出现呼吸窘迫综合征。新生儿出生后随访(5.6±3.6)年,随访期内婴幼儿发育良好。结论妊娠合并AD发病凶险,胸背部疼痛为其主要临床表现,尽早识别并选择合适的诊断方法,多学科协作诊治,母儿可获得良好结局。

Objective To investigate the treatment and maternal and fetal outcomes of pregnant women with aortic dissection(AD).Methods The clinical data of 11 pregnant women with AD treated at the First Affiliated Hospital of Air Force Military Medical University from January 1st,2011 to August 1st,2022 were collected,and their clinical characteristics,treatment plans and maternal and fetal outcomes were analyzed retrospectively.Results(1)Clinical characteristics:the age of onset of 11 pregnant women with AD was(30±5)years old,and the week of pregnancy of onset was(31.4±8.0)weeks.Clinical manifestations:the main symptoms were sudden onset of chest and back pain or low back pain.Type of AD:8 cases of Stanford type A,and 3 cases of type B.The aortic width was(42±11)mm.Diagnostic methods:the diagnosis of AD was confirmed by transthoracic echocardiography(TTE),computed tomography angiography(CTA)or enhanced CT examination,among which 4 cases were confirmed by CTA examination,4 cases by TTE examination,and 3 cases by enhanced CT examination.Laboratory results:white blood cell count was(15.4±8.7)×10^(9)/L,neutrophil count was(13.5±8.5)×10^(9)/L,the median D-dimer level was 2.7 mg/L(2.1-9.2 mg/L),and the median fibrin degradation products level was 12.0 mg/L(5.4-36.1 mg/L).(2)Treatments:all 11 patients were admitted to hospital in emergency.Before operation,the departments of cardiac surgery,obstetrics,pediatrics and anesthesiology cooperated to develop individualized treatment plan.Aortic surgery was performed in 11 pregnant women with AD.In 6 of them,pregnancy termination was performed at the same time as aortic surgery,and aortic surgery was performed after cesarean section.Four cases of pregnancy termination and aortic operation were performed by stages,including aortic operation after cesarean section in 2 cases,and cesarean section after aortic operation in 2 cases.One case(12+6 weeks of gestation)had spontaneous abortion on the day after aortic surgery.The gestational age of the 11 patients on pregnancy termination was(32.9±7.4)weeks.Aorta surgical methods:7 patients received under extracorporeal circulation ascending aorta replacement±aortic valve replacement±coronary artery transplantation(or coronary artery bypass transplantation)±left and right coronary Cabrol+total arch replacement(or aortic arch replacement)±stent implantation,1 patient received under extracorporeal circulation aortic root replacement,and 3 patients underwent aortic endoluminal isolation.(3)Maternal and fetal outcomes:among the 11 pregnant women with AD,9(9/11)survived,2(2/11)died with lower limb ischemia before the onset of the disease.A total of 10 newborns were born in 9 pregnant women after delivery(1 of them was twins),and the 2 cases were spontaneous abortion after aortic surgery in the first trimester(12+6 weeks)and fetal death after hysterotomy in the second trimester(26+3 weeks),respectively.Among the 10 surviving neonates,3 were full-term infants and 7 were premature infants.The birth weight of newborn was(2651±784)g.Respiratory distress syndrome was found in 6 cases.The newborns were followed up for(5.6±3.6)years after birth,and the infants developed well during the follow-up period.Conclusions Pregnancy complicated with AD is dangerous,and chest and back pain is the main clinical manifestation of this disease.With early identification and selection of appropriate diagnostic methods,multidisciplinary diagnosis and treatment,mother and children could obtain good outcomes.