妊娠合并心脏病的麻醉风险--综述全文（可编辑）

麻醉相关新技术新业务进展妊娠合并心脏病的麻醉风险上海交通大学附属仁济医院200001张晓怡王珊娟摘要妊娠与分娩引起的心血管功能变化对于妊娠合并心脏病患者妊娠与分娩的风险大大增加随着儿科心脏病学4CM的马凡氏综合征二尖瓣返流二尖瓣狭窄严重的左室功能失调二尖瓣脱垂主动脉瓣狭窄合并心脏病属高危妊娠是威胁孕产妇生命安全的严重疾病在围生期孕妇死亡原因中占第二位其中心力衰竭的发生是导致孕产妇死亡的主要原因妊娠期引起心衰的原因有先天性心脏病风湿性心脏病妊高征性心脏病围生期心肌病心肌炎重度贫血甲亢上感产后过多过快输液尤其是产后大出血均可成心力衰竭其中尤以风湿性心脏病二尖瓣狭窄为常见先天性心脏病次之其他如妊娠高血压综合征等使心室压力负荷过重亦能引发心衰二尖瓣狭窄使血液从左心房流至左心室受阻妊娠后由于血容量增加宫缩时回心血量骤增胎儿娩出后大量血液约500ML涌向心脏等因素引起肺循环血量突然增多左心排血量低于右心造成左心房压力骤增从而使静脉及肺部毛细血管压力增高因此有器质性心脏病的孕产妇在妊娠晚期分娩期及产褥期最初3天内极易发生心衰当左房压力超过血浆渗透压时大量血清渗出至肺泡及间质内造成急性肺水肿23正常妊娠的麻醉风险孕妇氧耗比非妊娠妇女增高约20储氧能力的减少和氧耗的增加使孕妇更容易发生缺氧1因此麻醉时应保障孕妇充足的氧供孕妇腹式呼吸减弱主要以胸式呼吸为主麻醉时应注意避免抑制胸式呼吸硬膜外腔阻滞时应避免平面过高一般维持在T6以下以免抑制呼吸肌的运动引起严重的低血压和肺通气障碍由于孕妇妊娠期间孕酮分泌增多可导致孕妇胃排空延迟又由于胎盘分泌的促胃酸激素的水平升高孕妇胃酸的分泌增加胃内压升高食管括约肌压力降低等都增加了返流误吸的危险性14几乎所有的麻醉镇痛镇静药都能迅速通过胎盘导致胎儿出生后呼吸抑制镇静肌张力减退发绀以及对应激的损害如咪唑安定可导致新生儿松软综合征异丙酚在麻醉诱导时会使很多产妇发生低血压影响胎儿血供异氟烷等吸入性麻醉药会明显地抑制宫缩导致胎儿取出后子宫收缩不良增加手术出血量而分子量小于600DALTON的药物能够通过胎盘屏障进入胎儿体内分娩前胎儿肝肾功能尚未发育健全进入胎儿体内的肌松药未能及时代谢剖宫产娩出后可造成新生儿肌张力减低甚至呼吸微弱因此全身麻醉下行剖宫产的病人选择分子量大于600的肌松药米库氯铵阿曲库铵顺阿曲库铵对娩出的胎儿更安全血管扩张剂ANTONIAPIJUANDOMNECHAANDMICHAELAGATZOULISBPREGNANCYANDHEARTDISEASEREVESPCARDIOL2006599971842WEISSBMHESSOMPULMONARYVASCULARDISEASEANDPREGNANCYCURRENTCONTROVERSIESMANAGEMENTANDPERSPECTIVESEURHEARTJ20002110453ANISHPATELETALCARDIACSURGERYDURINGPREGNANCYTEXHEARTINSTJ2008353307124PARRYAJWESTABYSCARDIOPULMONARYBYPASSDURINGPREGNANCYANNTHORACSURG1996616186595FERRARIETOZZIPVONSEGESSERLKSPONTANEOUSCORONARYARTERYDISSECTIONINAYOUNGWOMANFROMEMERGENCYCORONARYARTERYBYPASSGRAFTINGTOHEARTTRANSPLANTATIONEURJCARDIOTHORACSURG2005282349516MABIEWCFREIRECMSUDDENCHESTPAINANDCARDIACEMERGENCIESINTHEOBSTETRICPATIENTOBSTETGYNECOLCLINNORTHAM199522119377ABBASAELESTERSJCONNOLLYHPREGNANCYANDTHECARDIOVASCULARSYSTEMINTJCARDIOL2005982179898JANICEPIERETTIETALSYSTEMICLUPUSERYTHEMATOSUSPREDICTSINCREASEDLEFTVENTRICULARMASSCIRCULATION20071164194269JENGHSIUHUNGPREGNANCYCOMPLICATEDWITHMATERNALPULMONARYHYPERTENSIONANDPLACENTAACCRETAJCHINMEDASSOC200770610CAMPOSOANDRADEJLBOCANEGRAJAMBROSEJACARVALHOACHARADAKETALPHYSIOLOGICMULTIVALVULARREGURGITATIONDURINGPREGNANCYALONGITUDINALDOPPLERECHOCARDIOGRAPHICINTJCARDIOL1992402657211WRENCOSULLIVANSURVIVALWITHCONGENITALHEARTDISEASEANDNEEDFORFOLLOWUPINADULTLIFEHEART2001854384312KARENKSTOUTANDCATHERINEMOTTOPREGNANCYINWOMENWITHVALVULARHEARTDISEASEHEART20079355255813HAMEEDAKARAALPISTUMMALAPPETALTHEEFFECTOFVALVULARHEARTDISEASEONMATERNALANDFETALOUTCOMEDURINGPREGNANCYJAMCOLLCARDIOL200137893914WARWICKDNGANKEEETALEPHEDRINEFORTHEPREVENTIONOFHYPOTENSIONDURINGSPINALANESTHESIAFORCESAREANDELIVERYANESTHANALG2000901390515ANETTECKRISMERETALTHEEFFICACYOFEPINEPHRINEORVASOPRESSINFORRESUSCITATIONDURINGEPIDURALANESTHESIAANESTHANALG2001937344216SHUSEEVISALYAPUTRAETALSPINALVERSUSEPIDURALANESTHESIAFORCESAREANDELIVERYINSEVEREPREECLAMPSIAAPROSPECTIVERANDOMIZEDMULTICENTERSTUDYANESTHANALG2005101862817MARCVANDEVELDEETALCOMBINEDSPINALEPIDURALANESTHESIAFORCESAREANDELIVERYDOSEDEPENDENTEFFECTSOFHYPERBARICBUPIVACAINEONMATERNALHEMODYNAMICSANESTHANALG20061031879018VEERINGBCOUSINSMCARDIOVASCULARANDPULMONARYEFFECTSOFEPIDURALANESTHESIAANAESTHINTENSIVECARE2000286203519PRAYGJMURPHYANDLESHUTTRECOGNITIONANDMANAGEMENTOFMATERNALCARDIACDISEASEINPREGNANCYBRJANAESTH2004934283920LMONNERYJNANSONANDGCHARLTONP