麻醉相關(guān)新技術(shù)新業(yè)務(wù)進展妊娠合并心臟病的麻醉風險上海交通大學附屬仁濟醫(yī)院200001張曉怡王珊娟摘要妊娠與分娩引起的心血管功能變化對于妊娠合并心臟病患者妊娠與分娩的風險大大增加隨著兒科心臟病學4CM的馬凡氏綜合征二尖瓣返流二尖瓣狹窄嚴重的左室功能失調(diào)二尖瓣脫垂主動脈瓣狹窄合并心臟病屬高危妊娠是威脅孕產(chǎn)婦生命安全的嚴重疾病在圍生期孕婦死亡原因中占第二位其中心力衰竭的發(fā)生是導致孕產(chǎn)婦死亡的主要原因妊娠期引起心衰的原因有先天性心臟病風濕性心臟病妊高征性心臟病圍生期心肌病心肌炎重度貧血甲亢上感產(chǎn)后過多過快輸液尤其是產(chǎn)后大出血均可成心力衰竭其中尤以風濕性心臟病二尖瓣狹窄為常見先天性心臟病次之其他如妊娠高血壓綜合征等使心室壓力負荷過重亦能引發(fā)心衰二尖瓣狹窄使血液從左心房流至左心室受阻妊娠后由于血容量增加宮縮時回心血量驟增胎兒娩出后大量血液約500ML涌向心臟等因素引起肺循環(huán)血量突然增多左心排血量低于右心造成左心房壓力驟增從而使靜脈及肺部毛細血管壓力增高因此有器質(zhì)性心臟病的孕產(chǎn)婦在妊娠晚期分娩期及產(chǎn)褥期最初3天內(nèi)極易發(fā)生心衰當左房壓力超過血漿滲透壓時大量血清滲出至肺泡及間質(zhì)內(nèi)造成急性肺水腫23正常妊娠的麻醉風險孕婦氧耗比非妊娠婦女增高約20儲氧能力的減少和氧耗的增加使孕婦更容易發(fā)生缺氧1因此麻醉時應(yīng)保障孕婦充足的氧供孕婦腹式呼吸減弱主要以胸式呼吸為主麻醉時應(yīng)注意避免抑制胸式呼吸硬膜外腔阻滯時應(yīng)避免平面過高一般維持在T6以下以免抑制呼吸肌的運動引起嚴重的低血壓和肺通氣障礙由于孕婦妊娠期間孕酮分泌增多可導致孕婦胃排空延遲又由于胎盤分泌的促胃酸激素的水平升高孕婦胃酸的分泌增加胃內(nèi)壓升高食管括約肌壓力降低等都增加了返流誤吸的危險性14幾乎所有的麻醉鎮(zhèn)痛鎮(zhèn)靜藥都能迅速通過胎盤導致胎兒出生后呼吸抑制鎮(zhèn)靜肌張力減退發(fā)紺以及對應(yīng)激的損害如咪唑安定可導致新生兒松軟綜合征異丙酚在麻醉誘導時會使很多產(chǎn)婦發(fā)生低血壓影響胎兒血供異氟烷等吸入性麻醉藥會明顯地抑制宮縮導致胎兒取出后子宮收縮不良增加手術(shù)出血量而分子量小于600DALTON的藥物能夠通過胎盤屏障進入胎兒體內(nèi)分娩前胎兒肝腎功能尚未發(fā)育健全進入胎兒體內(nèi)的肌松藥未能及時代謝剖宮產(chǎn)娩出后可造成新生兒肌張力減低甚至呼吸微弱因此全身麻醉下行剖宮產(chǎn)的病人選擇分子量大于600的肌松藥米庫氯銨阿曲庫銨順阿曲庫銨對娩出的胎兒更安全血管擴張劑ANTONIAPIJUANDOMNECHAANDMICHAELAGATZOULISBPREGNANCYANDHEARTDISEASEREVESPCARDIOL2006599971842WEISSBMHESSOMPULMONARYVASCULARDISEASEANDPREGNANCYCURRENTCONTROVERSIESMANAGEMENTANDPERSPECTIVESEURHEARTJ20002110453ANISHPATELETALCARDIACSURGERYDURINGPREGNANCYTEXHEARTINSTJ2008353307124PARRYAJWESTABYSCARDIOPULMONARYBYPASSDURINGPREGNANCYANNTHORACSURG1996616186595FERRARIETOZZIPVONSEGESSERLKSPONTANEOUSCORONARYARTERYDISSECTIONINAYOUNGWOMANFROMEMERGENCYCORONARYARTERYBYPASSGRAFTINGTOHEARTTRANSPLANTATIONEURJCARDIOTHORACSURG2005282349516MABIEWCFREIRECMSUDDENCHESTPAINANDCARDIACEMERGENCIESINTHEOBSTETRICPATIENTOBSTETGYNECOLCLINNORTHAM199522119377ABBASAELESTERSJCONNOLLYHPREGNANCYANDTHECARDIOVASCULARSYSTEMINTJCARDIOL2005982179898JANICEPIERETTIETALSYSTEMICLUPUSERYTHEMATOSUSPREDICTSINCREASEDLEFTVENTRICULARMASSCIRCULATION20071164194269JENGHSIUHUNGPREGNANCYCOMPLICATEDWITHMATERNALPULMONARYHYPERTENSIONANDPLACENTAACCRETAJCHINMEDASSOC200770610CAMPOSOANDRADEJLBOCANEGRAJAMBROSEJACARVALHOACHARADAKETALPHYSIOLOGICMULTIVALVULARREGURGITATIONDURINGPREGNANCYALONGITUDINALDOPPLERECHOCARDIOGRAPHICINTJCARDIOL1992402657211WRENCOSULLIVANSURVIVALWITHCONGENITALHEARTDISEASEANDNEEDFORFOLLOWUPINADULTLIFEHEART2001854384312KARENKSTOUTANDCATHERINEMOTTOPREGNANCYINWOMENWITHVALVULARHEARTDISEASEHEART20079355255813HAMEEDAKARAALPISTUMMALAPPETALTHEEFFECTOFVALVULARHEARTDISEASEONMATERNALANDFETALOUTCOMEDURINGPREGNANCYJAMCOLLCARDIOL200137893914WARWICKDNGANKEEETALEPHEDRINEFORTHEPREVENTIONOFHYPOTENSIONDURINGSPINALANESTHESIAFORCESAREANDELIVERYANESTHANALG2000901390515ANETTECKRISMERETALTHEEFFICACYOFEPINEPHRINEORVASOPRESSINFORRESUSCITATIONDURINGEPIDURALANESTHESIAANESTHANALG2001937344216SHUSEEVISALYAPUTRAETALSPINALVERSUSEPIDURALANESTHESIAFORCESAREANDELIVERYINSEVEREPREECLAMPSIAAPROSPECTIVERANDOMIZEDMULTICENTERSTUDYANESTHANALG2005101862817MARCVANDEVELDEETALCOMBINEDSPINALEPIDURALANESTHESIAFORCESAREANDELIVERYDOSEDEPENDENTEFFECTSOFHYPERBARICBUPIVACAINEONMATERNALHEMODYNAMICSANESTHANALG20061031879018VEERINGBCOUSINSMCARDIOVASCULARANDPULMONARYEFFECTSOFEPIDURALANESTHESIAANAESTHINTENSIVECARE2000286203519PRAYGJMURPHYANDLESHUTTRECOGNITIONANDMANAGEMENTOFMATERNALCARDIACDISEASEINPREGNANCYBRJANAESTH2004934283920LMONNERYJNANSONANDGCHARLTONP