妊娠合并心脏病课件-妇产科课件

AffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心脏病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕妇36岁，孕3产0孕28周，心悸胸闷1周入院。患者既往有先天性心脏病史，曾中孕引产2次，后放环，此次带环受孕。查体：皮肤粘膜无明显紫绀，心率110次/分，呼吸25次/分，两肺未闻及湿性啰音。腹围84cm，宫高23cm，胎心率130次/分AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalitiesAffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities一、妊娠期心脏血管方面的变化1、妊娠期血容量增加（32~34周高峰），心排出量增加，心率加快，心脏负担妊娠晚期子宫增大、膈肌上升心脏向上向左移位大血管扭曲心脏负担AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities第一产程：宫缩，回心血量第二产程：宫缩;骨骼肌及腹壁肌收缩，周围循环阻力；加腹压使内脏血涌向心脏。第三产程：血液动力学急剧变化：胎盘循环停止回心血量增加；腹腔内压骤减血液向内脏灌注回心血量减少。2、分娩期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities3、产褥期子宫缩复使血液进入体循环孕期组织间液体回到体循环回心血量增加，心脏负担加重，尤其是产后3天内。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心脏病最危险的三个时期妊娠32-34周分娩期产后3日内AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二、心脏病对妊娠影响心脏病不影响受孕，但可引起流产、早产、死胎、胎儿发育迟缓、胎窘。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities三、妊娠合并心脏病的种类先天性心脏病发达国家最常见心脏病类型（70-80%）发展中国家少见（10-20%）风湿性心脏病发展中国家常见（50-90%），发达国家少见（15%）心肌病罕见但严重高血压时有发生（6-8%）较严重AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities先天性心脏病

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities按照分流方式分类左向右分流型先天性心脏病房间隔缺损室间隔缺损动脉导管未闭右向左分流型先天性心脏病法洛四联症艾森曼格综合症无分流型先天性心脏病肺动脉口狭窄主动脉缩窄Marfan综合症AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并风湿性心脏病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并风湿性心脏病二尖瓣狭窄：最常见二尖瓣关闭不全主动脉瓣狭窄及关闭不全AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二尖瓣狭窄血容量↑左房血流量增加→左室受阻引起左心房压力升高→肺充血→严重肺水肿AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠高血压性心脏病孕前无心血管疾病史本次妊娠出现妊娠高血压疾病晚孕、产时或产后10天内以心肌损坏为特征心衰征候群(以左心衰为主的全心衰)产后病因消除,病情会逐渐缓解AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities围生期心肌病指妊娠后半期以前无任何心脏疾病，在妊娠最后3个月至产后5个月内发生的扩张型心肌病病因不明，心脏苍白，心室扩大。与病毒感染、营养不良、贫血、妊高症等有关，积极治疗心衰，心脏明显扩大者预后差AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities四、诊断1、妊娠合并心脏病的诊断：病史体征心脏扩大：叩诊和x线心脏杂音：舒张期或粗糙收缩期严重心律不齐心电图提示心肌损害注意：与妊娠本身症状及体征的鉴别AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities2、心脏病心功能分级主观功能量据患者生活能力状况分Ⅰ级：一般体力活动不受限Ⅱ级：一般体力活动有心慌、疲劳感，休息后好转Ⅲ级：一般体力活动明显受限，轻微活动亦受限，休息后好转Ⅳ级：休息时仍有不适AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities客观手段分级法A级：无心血管的客观依据B级：客观检查表明属于轻度心血管疾患C级：属于中度心血管疾患D级：属于重度心血管疾患诊断时两种分级法并列使用AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨询十分必要可以妊娠：心脏病变较轻，心功能Ⅰ-Ⅱ级，既往无心衰病史AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨询不宜妊娠：心功能Ⅲ-Ⅳ级有心衰病史严重的心律失常右向左分流型先心肺动脉高压、主动脉狭窄其它AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities六、常见并发症心力衰竭心内膜炎缺氧紫绀静脉栓塞和肺栓塞AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities识别早期心力衰竭

轻微活动即胸闷心悸气短夜间因胸闷而坐位呼吸

窗口呼吸新鲜空气休息HR≥110bpmR≥20/min持续性肺底少量湿罗音咳嗽后不消失AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities八、防治妊娠合并心脏病主要死亡原因是心衰，因此应做到孕前咨询、孕期加强监护。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities1.妊娠期（1）不宜妊娠者：终止妊娠孕12周前：人工流产（有心衰者应纠正心衰后终止妊娠）。孕12周后：严密观察下继续妊娠。（2）可以妊娠者：加强产检,预防心衰。孕20周前每2周产检1次，20周后每周产检1次；并提前2周住院待产。

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（3）心力衰竭的预防避免劳累和情绪激动饮食：高蛋白、高维生素等，适当低盐预防及治疗心衰的诱因关于预防性应用洋地黄的问题AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（4）心衰的处理强心利尿血管扩张剂必要时终止妊娠其他AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（1）分娩方式的选择阴道分娩:心功能Ⅰ-Ⅱ级剖宫产:心功能Ⅲ-Ⅳ级（2）阴道分娩的处理

1）第一产程

2）第二产程

3）第三产程2.分娩期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities1）第一产程镇静:适当应用安定、度冷丁必要时强心：西地兰抗菌素:临产即开始应用,直至产后1周.AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities避免使用腹压尽量缩短第二产程：会阴切开、产钳、胎吸2）第二产程AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities3）第三产程镇静腹部放沙袋不常规使用宫缩剂，严禁使用麦角新硷！AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities休息预防感染预防心衰哺乳问题：心功能Ⅲ-Ⅳ级者不宜哺乳3、产褥期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities初孕妇，36岁，有风湿性心脏病病史，现妊娠10周，轻微活动后即感胸闷、气急、心悸，近十天来半夜胸闷需坐起。检查：心率112次/分，呼吸22次/分，双肺底可闻及细的湿罗音，双下肢浮肿（+）。处理是：A.立即终止妊娠B.积极控制心衰，继续妊娠C.控制心衰后终止妊娠D.利尿、应用抗生素，控制心衰后根据情况决定是否继续妊娠AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities作业妊娠期早期心衰的诊断依据心脏病孕妇如何选择分娩方式？如阴道分娩应如何处理？

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalitiesAffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities

本课结束！Thanks!AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心脏病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕妇36岁，孕3产0孕28周，心悸胸闷1周入院。患者既往有先天性心脏病史，曾中孕引产2次，后放环，此次带环受孕。查体：皮肤粘膜无明显紫绀，心率110次/分，呼吸25次/分，两肺未闻及湿性啰音。腹围84cm，宫高23cm，胎心率130次/分AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalitiesAffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities一、妊娠期心脏血管方面的变化1、妊娠期血容量增加（32~34周高峰），心排出量增加，心率加快，心脏负担妊娠晚期子宫增大、膈肌上升心脏向上向左移位大血管扭曲心脏负担AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities第一产程：宫缩，回心血量第二产程：宫缩;骨骼肌及腹壁肌收缩，周围循环阻力；加腹压使内脏血涌向心脏。第三产程：血液动力学急剧变化：胎盘循环停止回心血量增加；腹腔内压骤减血液向内脏灌注回心血量减少。2、分娩期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities3、产褥期子宫缩复使血液进入体循环孕期组织间液体回到体循环回心血量增加，心脏负担加重，尤其是产后3天内。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心脏病最危险的三个时期妊娠32-34周分娩期产后3日内AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二、心脏病对妊娠影响心脏病不影响受孕，但可引起流产、早产、死胎、胎儿发育迟缓、胎窘。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities三、妊娠合并心脏病的种类先天性心脏病发达国家最常见心脏病类型（70-80%）发展中国家少见（10-20%）风湿性心脏病发展中国家常见（50-90%），发达国家少见（15%）心肌病罕见但严重高血压时有发生（6-8%）较严重AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities先天性心脏病

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities按照分流方式分类左向右分流型先天性心脏病房间隔缺损室间隔缺损动脉导管未闭右向左分流型先天性心脏病法洛四联症艾森曼格综合症无分流型先天性心脏病肺动脉口狭窄主动脉缩窄Marfan综合症AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并风湿性心脏病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并风湿性心脏病二尖瓣狭窄：最常见二尖瓣关闭不全主动脉瓣狭窄及关闭不全AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二尖瓣狭窄血容量↑左房血流量增加→左室受阻引起左心房压力升高→肺充血→严重肺水肿AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠高血压性心脏病孕前无心血管疾病史本次妊娠出现妊娠高血压疾病晚孕、产时或产后10天内以心肌损坏为特征心衰征候群(以左心衰为主的全心衰)产后病因消除,病情会逐渐缓解AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities围生期心肌病指妊娠后半期以前无任何心脏疾病，在妊娠最后3个月至产后5个月内发生的扩张型心肌病病因不明，心脏苍白，心室扩大。与病毒感染、营养不良、贫血、妊高症等有关，积极治疗心衰，心脏明显扩大者预后差AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities四、诊断1、妊娠合并心脏病的诊断：病史体征心脏扩大：叩诊和x线心脏杂音：舒张期或粗糙收缩期严重心律不齐心电图提示心肌损害注意：与妊娠本身症状及体征的鉴别AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities2、心脏病心功能分级主观功能量据患者生活能力状况分Ⅰ级：一般体力活动不受限Ⅱ级：一般体力活动有心慌、疲劳感，休息后好转Ⅲ级：一般体力活动明显受限，轻微活动亦受限，休息后好转Ⅳ级：休息时仍有不适AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities客观手段分级法A级：无心血管的客观依据B级：客观检查表明属于轻度心血管疾患C级：属于中度心血管疾患D级：属于重度心血管疾患诊断时两种分级法并列使用AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨询十分必要可以妊娠：心脏病变较轻，心功能Ⅰ-Ⅱ级，既往无心衰病史AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨询不宜妊娠：心功能Ⅲ-Ⅳ级有心衰病史严重的心律失常右向左分流型先心肺动脉高压、主动脉狭窄其它AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities六、常见并发症心力衰竭心内膜炎缺氧紫绀静脉栓塞和肺栓塞AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities识别早期心力衰竭

轻微活动即胸闷心悸气短夜间因胸闷而坐位呼吸

窗口呼吸新鲜空气休息HR≥110bpmR≥20/min持续性肺底少量湿罗音咳嗽后不消失AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities八、防治妊娠合并心脏病主要死亡原因是心衰，因此应做到孕前咨询、孕期加强监护。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities1.妊娠期（1）不宜妊娠者：终止妊娠孕12周前：人工流产（有心衰者应纠正心衰后终止妊娠）。孕12周后：严密观察下继续妊娠。（2）可以妊娠者：加强产检,预防心衰。孕20周前每2周产检1次，20周后每周产检1次；并提前2周住院待产。

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（3）心力衰竭的预防避免劳累和情绪激动饮食：高蛋白、高维生素等，适当低盐预防及治疗心衰的诱因关于预防性应用洋地黄的问题AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（4）心衰的处理强心利尿血管扩张剂必要时终止妊娠其他AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（1）分娩方式的选择阴道分娩:心功能Ⅰ-Ⅱ级剖宫产:心功能Ⅲ-Ⅳ级（2）阴道分娩的处理

1）第一产程

2）第二产程

3）第三产程2.分娩期AffiliatedHospitalofYouJianAffiliatedHospital