妊娠合并心脏病的多学科(分层)管理
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摘要
妊娠合并心脏病是指妊娠妇女既往有心脏病史或妊娠期间新发心脏病,其发病率为0.5%～3.0%,是造成孕产妇死亡的重要原因之一。妊娠合并心脏病一直居于孕产妇死亡原因非产科因素的首位,因此提高妊娠合并心脏病的诊治及管理水平在降低孕产妇病死率、改善母婴结局方面具有重要作用。由于妊娠合并心脏病病因非常复杂,并伴随妊娠导致的血流动力学改变、凝血机制变化、妊娠并发症等会加重原有疾病,妊娠合并心脏病的诊治涉及妇产科、心内科、心外科、麻醉、重症等诸多临床学科的专业领域,各学科之间如何沟通、有效合作是妊娠合并心脏病孕产妇诊治的关键。此外,并非所有心脏病患者的妊娠属于极高危妊娠,分层管理的概念是这类患者最基本的管理理念,基层、社区保健及大多数有妇幼保健单元的机构应在孕前、孕早期进行识别、诊断和风险评估。
The incidence of cardiovascular diseases during pregnancy in women with heart disease,including previous and newly diagnosed ones is from 0.5% to 3.0%,and it is one of the important causes of maternal mortality.Pregnancy complicated with heart diseases has always been the primary non-obstetric factor of maternal mortality,which highlights the importance of improving the diagnosis,treatment and management of pregnancy complicating heart disease in reducing maternal mortality and improving both maternal and infant outcomes.Because of its complex etiology,hemodynamic changes,coagulation mechanism changes,and pregnancy complications,the diagnosis and treatment of pregnancy complicated with heart disease involves gynecology,obstetrics,cardiology,cardiac surgery,anesthesiology and critical care medicine.Therefore,effective communication and cooperation among different disciplines is the key to the diagnosis and treatment of pregnant women with heart disease.In addition,not every pregnant woman complicated with heart disease has extremely high-risk pregnancy.Therefore,stratified management is the most basic management concept.Community-level health care services and most institutions with the department of maternal and child healthcare should identify,diagnose and assess risks before and during early pregnancy.
The incidence of cardiovascular diseases during pregnancy in women with heart disease,including previous and newly diagnosed ones is from 0.5% to 3.0%,and it is one of the important causes of maternal mortality.Pregnancy complicated with heart diseases has always been the primary non-obstetric factor of maternal mortality,which highlights the importance of improving the diagnosis,treatment and management of pregnancy complicating heart disease in reducing maternal mortality and improving both maternal and infant outcomes.Because of its complex etiology,hemodynamic changes,coagulation mechanism changes,and pregnancy complications,the diagnosis and treatment of pregnancy complicated with heart disease involves gynecology,obstetrics,cardiology,cardiac surgery,anesthesiology and critical care medicine.Therefore,effective communication and cooperation among different disciplines is the key to the diagnosis and treatment of pregnant women with heart disease.In addition,not every pregnant woman complicated with heart disease has extremely high-risk pregnancy.Therefore,stratified management is the most basic management concept.Community-level health care services and most institutions with the department of maternal and child healthcare should identify,diagnose and assess risks before and during early pregnancy.
引文
[1]中华医学会妇产科分会产科学组.妊娠合并心脏病的诊治专家共识(2016)[J].中华妇产科杂志,2016,51(6):401-409.DOI:10.3760/cma.j.issn.0529-567x.2016.06.001.
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[7]ELKAYAM U,GOLAND S,PIEPER P G,et al.High-risk cardiac disease in pregnancy:PartⅠ[J].J Am Coll Cardiol,2016,68(4):396-410.DOI:10.1016/j.jacc.2016.05.048.
[8]ZHU J M,MA W G,PETERSS S,et al. Aortic dissection in pregnancy:management strategy and outcomes[J]. Ann Thorac Surg,2017,103(4):1199-1206.DOI:10.1016/j.athoracsur.2016.08.089.
[9]范颖,于新平,李斌.先天性心脏病伴重度肺动脉高压孕产妇12例死因分析[J].心肺血管病杂志,2015,34(1):23-26.DOI:10.3969/j.issn.1007-5062.2015.01.006.FAN Y,YU X P,LI B.Death analysis of 12 pregnant patients withcongenialheartdiseasewithseverepulmonaryarterial hypertension[J].Journal of Cardiovascular and Pulmonary Diseases,2015,34(1):23-26.DOI:10.3969/j.issn.1007-5062.2015.01.006.
[10]European Society of Gynecology(ESG),Association for European Paediatric Cardiology(AEPC),German Society for Gender Medicine(DGesGM),et al.ESC Guidelines on the management of cardiovascular diseases during pregnancy:the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology(ESC)[J].Eur Heart J,2011,32(24):3147-3197.DOI:10.1093/eurheartj/ehr218.
[11]CANOBBIO M M,WARNES C A,ABOULHOSN J,et al.Management of pregnancy in patients with complex congenital heart disease.A scientific statement for healthcare professionals from the American Heart Association[J].Circulation,2017,135(8):e50-87.DOI:10.1161/CIR.0000000000000458.
[12]REGITZ-ZAGROSEKV,ROOS-HESSELINKJW,BAUERSACHS J,et al.2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy[J].Eur Heart J,2018,39(34):3165-3241.DOI:10.1093/eurheartj/ehy340.
[13]GIBSONP,NAROUSM,FIROZT,etal.Incidenceof myocardial infarction in pregnancy:a systematic review and meta-analysis of population-based studies[J].Eur Heart J Qual Care Clin Outcomes,2017,3(3):198-207.DOI:10.1093/ehjqcco/qcw060.
[14]PIJUAN-DOMENECHA,GALIANL,GOYAM,etal.Cardiac complications during pregnancy are better predicted with the modified who risk score[J].Int J Cardiol,2015(195):149-154.DOI:10.1016/j.ijcard.2015.05.076.
[15]KATRITSIS D G,BORIANI G,COSIO F G,et al.European Heart Rhythm Association(EHRA)consensus document on the management of supraventricular arrhythmias,endorsed by Heart Rhythm Society(HRS),Asia-Pacific Heart Rhythm Society(APHRS),and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia(SOLAECE)[J].Europace,2017,19(3):465-511.DOI:10.1093/europace/euw301.
[16]GREERIA,NELSON-PIERCYC.Low-molecular-weight heparinsforthromboprophylaxisandtreatmentofvenous thromboembolism in pregnancy:a systematic review of safety and efficacy[J].Blood,2005,106(2):401-407.DOI:10.1182/blood-2005-02-0626.
[17]SIU S C,SERMER M,COLMAN J M,et al.Prospective multicenter study of pregnancy outcomes in women with heart disease[J].Circulation,2001,104(5):515-521.
[18]DRENTHEN W,BOERSMA E,BALCI A,et al.Predictors of pregnancy complications in women with congenital heart disease[J].Eur Heart J,2010,31(17):2124-2132.DOI:10.1093/eurheartj/ehq200.
[19]S T E E RPJ, G A T Z O U L I SMA. H e a r td i s e a s ea n d pregnancy[M].Cambridge:Cambridge University Press,2016:39-41.
[20]包照亮,张军,杨冬,等.妊娠合并肺动脉高压死亡患者的临床高危因素特征分析[J].中华妇产科杂志,2014,49(7):495-500.DOI:10.3760/cma.j.issn.0529-567x.2014.07.005.BAO Z L,ZHANG J,YANG D,et al.Analysis of high risk factors for patient death and its clinical characteristics on pregnancy associated with pulmonary arterial hypertension[J].Chinese Journal of Obstetrics and Gynecology,2014,49(7):495-500.DOI:10.3760/cma.j.issn.0529-567x.2014.07.005.
[21]徐晓辉,张军,王慧,等.妊娠合并严重特发性肺动脉高压十例临床分析[J].中华妇产科杂志,2014,49(6):419-423.DOI:10.3760/cma.j.issn.0529-567x.2014.06.005.XUXH,ZHANGJ,WANGH,etal.Severeidiopathic pulmonary arterial hypertension in pregnancy:a review of 10cases[J].Chinese Journal of Obstetrics and Gynecology,2014,49(6):419-423.DOI:10.3760/cma.j.issn.0529-567x.2014.06.005.
[22]ZHAOH,ZHANGH,XUX,etal.Riskfactorsfor perinatal cardiac complications in pregnancy with pulmonary hypertension[J].Pregnancy Hypertens,2018,12:207-213.DOI:10.1016/j.preghy.2017.09.001.
[23]ERBELR,ABOYANSV,BOILEAUC,etal.2014ESC Guidelines on the diagnosis and treatment of aortic diseases:Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult.The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology(ESC)[J].Eur Heart J,2014,35(41):2873-2926.DOI:10.1093/eurheartj/ehu281.
[24]杨璞玉,张军,李燕娜,等.合并主动脉夹层的马凡综合征孕妇的妊娠结局分析[J].中华妇产科杂志,2015,50(5):334-340.DOI:10.3760/cma.j.issn.0529-567x.2015.05.004.YANG P Y,ZHANG J,LI Y N,et al.Maternal and fetal outcomes with aortic dissection in pregnant patients with Marfan syndrome[J]. Chinese Journal of Obstetrics and Gynecology,2015,50(5):334-340.DOI:10.3760/cma.j.issn.0529-567x.2015.05.004.
[25]LUIS F H P,COOPER H,ARONOW W.Multidisciplinary approach for endocarditis in pregnancy[J].JACC,2017,69(11):2199.
[26]PATEL P A,FERNANDO R J,MACKAY E J,et al.Acute type a aortic dissection in pregnancy-diagnostic and therapeutic challenges in a multidisciplinary setting[J].J Cardiothorac Vasc Anesth,2018,32(4):1991-1997.DOI:10.1053/j.jvca.2018.01.035.
[27]佟朝霞,陈颖.妊娠合并心脏病孕产妇抢救体系的建立[J].中国病案,2013,14(10):74-76.DOI:10.3969/j.issn.1672-2566.2013.10.038.TONG Z X,CHEN Y.Establishment of maternal rescue system of pregnancy complicated by heart disease[J].Chinese Medical Record,2013,14(10):74-76.DOI:10.3969/j.issn.1672-2566.2013.10.038.
[2]熊庆,梁娟.孕产妇病死率及死亡构成的趋势[J].实用妇产科杂志,2010,26(1):1-2.DOI:10.3969/j.issn.1003-6946.2010.01.001.XIONG Q,LIANG J.Trends in maternal mortality and mortality composition[J].JournalofPracticalObstetricsand Gynecology,2010,26(1):1-2.DOI:10.3969/j.issn.1003-6946.2010.01.001.
[3]KHAN K S,WOJDYLA D,SAY L,et al.WHO analysis of causes of maternal death:a systematic review[J].Lancet,2006,367(9516):1066-1074.DOI:10.1016/S0140-6736(06)68397-9.
[4]CANTWELL R,CLUTTON-BROCK T,COOPER G,et al.Saving mothers'lives:reviewing maternal deaths to make motherhood safer:2006—2008.The eighth report of the confidential enquiries into maternal deaths in the United Kingdom[J].BJOG,2011,118 Suppl 1:1-203.DOI:10.1111/j.1471-0528.2010.02847.x.
[5]KNIGHT M,NAIR M,TUFFNELL D,et al.Saving lives,improving mothers'care-surveillance of maternal deaths in the UK2012—2014 and lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity2009—2014[D].Oxford:National Perinatal Epidemiology Unit,University of Oxford,2016.
[6]VAN HAGEN I M,BOERSMA E,JOHNSON M R,et al.Global cardiac risk assessment in the registry of pregnancy and cardiac disease:results of a registry from the European Society of Cardiology[J].Eur J Heart Fail,2016,18(5):523-533.DOI:10.1002/ejhf.501.
[7]ELKAYAM U,GOLAND S,PIEPER P G,et al.High-risk cardiac disease in pregnancy:PartⅠ[J].J Am Coll Cardiol,2016,68(4):396-410.DOI:10.1016/j.jacc.2016.05.048.
[8]ZHU J M,MA W G,PETERSS S,et al. Aortic dissection in pregnancy:management strategy and outcomes[J]. Ann Thorac Surg,2017,103(4):1199-1206.DOI:10.1016/j.athoracsur.2016.08.089.
[9]范颖,于新平,李斌.先天性心脏病伴重度肺动脉高压孕产妇12例死因分析[J].心肺血管病杂志,2015,34(1):23-26.DOI:10.3969/j.issn.1007-5062.2015.01.006.FAN Y,YU X P,LI B.Death analysis of 12 pregnant patients withcongenialheartdiseasewithseverepulmonaryarterial hypertension[J].Journal of Cardiovascular and Pulmonary Diseases,2015,34(1):23-26.DOI:10.3969/j.issn.1007-5062.2015.01.006.
[10]European Society of Gynecology(ESG),Association for European Paediatric Cardiology(AEPC),German Society for Gender Medicine(DGesGM),et al.ESC Guidelines on the management of cardiovascular diseases during pregnancy:the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology(ESC)[J].Eur Heart J,2011,32(24):3147-3197.DOI:10.1093/eurheartj/ehr218.
[11]CANOBBIO M M,WARNES C A,ABOULHOSN J,et al.Management of pregnancy in patients with complex congenital heart disease.A scientific statement for healthcare professionals from the American Heart Association[J].Circulation,2017,135(8):e50-87.DOI:10.1161/CIR.0000000000000458.
[12]REGITZ-ZAGROSEKV,ROOS-HESSELINKJW,BAUERSACHS J,et al.2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy[J].Eur Heart J,2018,39(34):3165-3241.DOI:10.1093/eurheartj/ehy340.
[13]GIBSONP,NAROUSM,FIROZT,etal.Incidenceof myocardial infarction in pregnancy:a systematic review and meta-analysis of population-based studies[J].Eur Heart J Qual Care Clin Outcomes,2017,3(3):198-207.DOI:10.1093/ehjqcco/qcw060.
[14]PIJUAN-DOMENECHA,GALIANL,GOYAM,etal.Cardiac complications during pregnancy are better predicted with the modified who risk score[J].Int J Cardiol,2015(195):149-154.DOI:10.1016/j.ijcard.2015.05.076.
[15]KATRITSIS D G,BORIANI G,COSIO F G,et al.European Heart Rhythm Association(EHRA)consensus document on the management of supraventricular arrhythmias,endorsed by Heart Rhythm Society(HRS),Asia-Pacific Heart Rhythm Society(APHRS),and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia(SOLAECE)[J].Europace,2017,19(3):465-511.DOI:10.1093/europace/euw301.
[16]GREERIA,NELSON-PIERCYC.Low-molecular-weight heparinsforthromboprophylaxisandtreatmentofvenous thromboembolism in pregnancy:a systematic review of safety and efficacy[J].Blood,2005,106(2):401-407.DOI:10.1182/blood-2005-02-0626.
[17]SIU S C,SERMER M,COLMAN J M,et al.Prospective multicenter study of pregnancy outcomes in women with heart disease[J].Circulation,2001,104(5):515-521.
[18]DRENTHEN W,BOERSMA E,BALCI A,et al.Predictors of pregnancy complications in women with congenital heart disease[J].Eur Heart J,2010,31(17):2124-2132.DOI:10.1093/eurheartj/ehq200.
[19]S T E E RPJ, G A T Z O U L I SMA. H e a r td i s e a s ea n d pregnancy[M].Cambridge:Cambridge University Press,2016:39-41.
[20]包照亮,张军,杨冬,等.妊娠合并肺动脉高压死亡患者的临床高危因素特征分析[J].中华妇产科杂志,2014,49(7):495-500.DOI:10.3760/cma.j.issn.0529-567x.2014.07.005.BAO Z L,ZHANG J,YANG D,et al.Analysis of high risk factors for patient death and its clinical characteristics on pregnancy associated with pulmonary arterial hypertension[J].Chinese Journal of Obstetrics and Gynecology,2014,49(7):495-500.DOI:10.3760/cma.j.issn.0529-567x.2014.07.005.
[21]徐晓辉,张军,王慧,等.妊娠合并严重特发性肺动脉高压十例临床分析[J].中华妇产科杂志,2014,49(6):419-423.DOI:10.3760/cma.j.issn.0529-567x.2014.06.005.XUXH,ZHANGJ,WANGH,etal.Severeidiopathic pulmonary arterial hypertension in pregnancy:a review of 10cases[J].Chinese Journal of Obstetrics and Gynecology,2014,49(6):419-423.DOI:10.3760/cma.j.issn.0529-567x.2014.06.005.
[22]ZHAOH,ZHANGH,XUX,etal.Riskfactorsfor perinatal cardiac complications in pregnancy with pulmonary hypertension[J].Pregnancy Hypertens,2018,12:207-213.DOI:10.1016/j.preghy.2017.09.001.
[23]ERBELR,ABOYANSV,BOILEAUC,etal.2014ESC Guidelines on the diagnosis and treatment of aortic diseases:Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult.The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology(ESC)[J].Eur Heart J,2014,35(41):2873-2926.DOI:10.1093/eurheartj/ehu281.
[24]杨璞玉,张军,李燕娜,等.合并主动脉夹层的马凡综合征孕妇的妊娠结局分析[J].中华妇产科杂志,2015,50(5):334-340.DOI:10.3760/cma.j.issn.0529-567x.2015.05.004.YANG P Y,ZHANG J,LI Y N,et al.Maternal and fetal outcomes with aortic dissection in pregnant patients with Marfan syndrome[J]. Chinese Journal of Obstetrics and Gynecology,2015,50(5):334-340.DOI:10.3760/cma.j.issn.0529-567x.2015.05.004.
[25]LUIS F H P,COOPER H,ARONOW W.Multidisciplinary approach for endocarditis in pregnancy[J].JACC,2017,69(11):2199.
[26]PATEL P A,FERNANDO R J,MACKAY E J,et al.Acute type a aortic dissection in pregnancy-diagnostic and therapeutic challenges in a multidisciplinary setting[J].J Cardiothorac Vasc Anesth,2018,32(4):1991-1997.DOI:10.1053/j.jvca.2018.01.035.
[27]佟朝霞,陈颖.妊娠合并心脏病孕产妇抢救体系的建立[J].中国病案,2013,14(10):74-76.DOI:10.3969/j.issn.1672-2566.2013.10.038.TONG Z X,CHEN Y.Establishment of maternal rescue system of pregnancy complicated by heart disease[J].Chinese Medical Record,2013,14(10):74-76.DOI:10.3969/j.issn.1672-2566.2013.10.038.