妊娠合并心脏病影响母儿预后的相关因素分析
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摘要
妊娠合并心脏病是中国孕产妇非直接产科死因的第1位,文献报道发展中国家的发病率约0.9%～3.7%,我国的发病率为1.06%。
20世纪80年代以前我国妊娠合并心脏病中最多见的是风湿性心脏病(rheumatic heart disease, RHD);近30年来,随着先天性心脏病(congenital heart disease, CHD)诊断技术的进步和心脏外科手术的发展,CHD患者可以获得早期根治或部分矫正；心脏介入性手术及心脏瓣膜置换术(cardiovalve replacement, CVR)的开展可以使严重瓣膜性心脏病患者有条件接受合理的治疗,使得心脏病术后妊娠女性逐年增多。因此妊娠合并心脏病的类型、临床诊治水平均发生着巨大变化,同时产科医生也面临着很多特殊问题,例如心脏手术后妊娠的最佳时机、妊娠期的抗凝治疗、心脏病孕产妇的妊娠期管理等。
由于妊娠对心血管系统产生巨大的影响,合并心脏病的孕妇则难以耐受这些变化,使原有心脏病病情恶化,对孕妇本身及围生儿的预后产生不良影响。妊娠合并心脏病孕妇,其围生儿易发生自然流产、围生儿死亡、小于胎龄儿、呼吸窘迫综合征、早产及颅内出血等并发症。同时存在产科高危因素的心脏病孕妇与其心脏功能之间的相互作用决定了围生儿的结局。
妊娠合并心脏病属于严重高危妊娠范畴,对于已确诊或手术治疗的心脏病女性在妊娠前及妊娠期的管理需要产科医生与心内科、心胸外科、麻醉科及新生儿科医生的共同协作来完成,因此妊娠合并心脏病的孕产妇大多就诊或转诊于大型综合性医院。
目前国内关于妊娠合并心脏病的母儿预后影响因素分析的报道多为单个医院小样本的研究,或者单个影响因素的分析,缺乏大样本,多个因素分析的全面调查研究,不能全面准确反映我国近年来妊娠合并心脏病对母儿预后影响因素的全面分析。近年我国大型综合性医院妊娠合并心脏病的发病情况及其对母儿预后的影响如何,尚没有多家大型综合性医院的大样本调查分析。
【目的】
本研究旨在通过对广州、深圳、长沙5家三级甲等医院8年来诊断为妊娠合并心脏病患者的临床病例资料进行回顾性研究分析,了解妊娠合并心脏病的发病情况及心脏病的类型分布：分析其影响母儿预后的相关因素,提高对妊娠合并心脏病的认识：探讨有效的对策以减少母儿并发症发生。
【材料和方法】
1、资料收集
回顾性调查2000年～2008年广州市南方医院、珠江医院、广州医学院第三附属医院、深圳市人民医院、长沙市中南大学湘雅二医院5家教学医院收治的所有住院诊断为妊娠合并心脏病的病例共510例,年龄平均(28.513±5.144)岁,初产妇342例,经产168例,双胎16例,其余均为单胎。随机抽出100例(南方医院、珠江医院、广州医学院第三附属医院、深圳市人民医院、中南大学湘雅二医院各20例)同期在院分娩没有妊娠合并症的正常产妇做为对照组。孕期抗凝治疗的心脏病患者及其子代的随访通过电话随访或调查问卷获得。
2、诊断标准
所有心脏病的诊断于妊娠前或此次妊娠中根据病史、体格检查、心电图、超声心动图、动态心电图、胸片、CT等必要的辅助检查,经内科确诊。心功能分级采用1994年纽约心脏病协会制定的心功能分级法。早产、胎儿生长受限等诊断参照乐杰主编的第7版妇产科学。患者子代包括胎儿和新生儿情况的评估均由产科医生和儿科医生共同完成。
3、方法
通过对妊娠合并心脏病患者的病例收集和分析,了解妊娠合并心脏病的发病情况、心脏病的类型分布及母儿合并症的发生情况；了解妊娠期行心脏手术的安全性；比较孕期不同心功能级别、不同类型心脏病的孕产妇死亡率、并发症发生率及其围生儿转归；比较已手术和未手术的RHD及CHD对孕产妇及围生儿转归的影响；探讨孕期抗凝剂的使用与母儿预后的关系。
4、统计学处理
应用统计软件SPSS12.0进行统计分析；在Excel2003进行制表和绘图；计量数据描述使用平均数和标准差表示,应用方差分析与t检验等方法进行统计分析；频数资料描述采用百分比(%)表示,使用卡方检验(或连续性较正卡方检验)；P<0.05表示差异有显著性。
【结果】
1、妊娠合并心脏病的发病情况及类型分布妊娠合并心脏病孕产妇占住院孕产妇总数的0.57%,RHD居首位占37.84%,CHD病次之占25.68%,心律失常第三位占20.21%。
2、孕产妇结局
2.1妊娠合并心脏病孕产妇合并症及孕产妇死亡情况妊娠合并心脏病孕产妇的内科合并症为心力衰竭(25.09%)、心律失常(8.57%)、肺动脉高压(6.94%)；产科并发症是早产(20.61%)、子痫前期(14.9%)；合并感染为11.02%。9例孕产妇死亡,死亡率1.76%,其中4例CHD(2例艾森曼格综合征),3例RHD,妊娠期高血压疾病性心脏病和围产期心肌病(peripartum cardiomyopathy, PPCM)各1例。
2.2不同心功能分级的孕产妇预后比较心功能Ⅰ、Ⅱ级均无孕产妇死亡；心功能Ⅳ级与心功能Ⅲ级孕产妇死亡率(x2=5.360,P=0.021)比较有显著性差异,P<0.05;心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级与对照组心衰发生率(x2=79.902,P=0.000)比较有显著性差异,P<0.05。
2.3不同心脏病类型的孕产妇预后比较妊娠合并CHD、RHD、心律失常及妊娠期高血压疾病性心脏病之间的并发症发生率(x2=59.539,P=0.000)比较有显著性差异,P<0.05;发生心衰的心脏病中妊娠期高血压疾病性心脏病占比例最高为59例,占46.09%。其次为RHD52例,占40.63%；其中96.72%妊娠期高血压疾病性心脏病发生心力衰竭,80%PPCM发生心力衰竭；RHD发生心力衰竭比例为26.94%。妊娠合并CHD、RHD、妊娠期高血压疾病性心脏病及PPCM之间的孕产妇死亡率(x2=2.400,P=0.494)比较无显著性差异,P>0.05。
2.4心脏手术与未手术的孕产妇预后比较
2.4.1 CHD手术组与未手术组孕产妇预后比较两组孕期心功能(x2=1.108,P=0.293)比较无显著性差异,P>0.05；两组心脏并发症发生率(x2=0.523,P=0.470)、产科并发症发生率(x2=0.026,P=0.871)比较无显著性差异,P>0.05；两组孕产妇死亡率(x2=0.000,P=0.100)、分娩方式(x2=0.506,P=0.477)比较无显著性差异,P>0.05。
2.4.2 RHD手术组与未手术组孕产妇预后比较两组心功能Ⅰ-Ⅱ级与心功能Ⅲ-Ⅳ级(x2=8.532,P=0.003)、心脏并发症发生率(x2=26.155,P=0.000)、产科并发症发生率(x2=4.442,P=0.035)比较有显著性差异,P<0.05。两组孕产妇死亡率(x2=0.000,P=1.000)比较无显著性差异,P>0.05。
3、围生儿结局
3.1围生儿并发症及死亡情况围生儿常见的并发症是早产儿(17.34%)、胎儿生长受限(fetal growth restriction, FGR) (10.00%)、新生儿窒息(7.14%),新生儿畸形(1.43%)；围生儿死亡率是1.43%。
3.2不同心功能级别患者的围生儿预后比较心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级组与对照组新生儿体重(x2=86.109,P=0.000)、评分(x2=69.857,P=0.000)、早产儿(x2=71.816,P=0.000)、FGR(x2=53.081,P=0.000)发生率比较有显著性差异,P<0.05；心功能Ⅰ、Ⅱ级组均无围生儿死亡；心功能Ⅲ、Ⅳ级组围生儿死亡率(x2=3.195,P=0.074)比较无显著性差异,P>0.05。
3.3心脏手术与未手术患者的围生儿预后比较
3.3.1 CHD手术组与未手术组围生儿预后比较两组新生儿体重(T=0.514,P=0.608)及评分(T=0.414,P=0.680)比较无显著性差异,P>0.05。两组早产儿(x2=0.004,P=0.949)、新生儿窒息(x2=0.070,P=0.791)、FGR(x2=0.102,P=0.749)发生率比较无显著性差异,P>0.05。
3.3.2 RHD手术组与未手术组围生儿预后比较两组新生儿体重(T=1.601,P=0.111)及评分(T=0.608,P=0.544)比较无显著性差异,P>0.05；未手术组有1例新生儿六指畸形,手术组未见新生儿畸形发生。两组早产儿(x2=5.143,P=0.023)、FGR(x2=4.208,P=0.040)发生率比较有显著性差异,P<0.05；两组新生儿窒息(x2=2.335,P=0.126)比较无显著性差异,P>0.05。
4、心脏病术后的妊娠时间及华法令的使用心脏瓣膜置换术的患者此次妊娠距手术时间为1.5年～16年,平均4.83年；瓣膜扩张术后患者此次妊娠距手术时间为1年～18年,平均6.56年；CHD手术患者此次妊娠距手术时间为1年～25年,平均9.35年。55例行CVR者均使用机械人工瓣膜,均是整个孕期口服华法令抗凝,平均2.764mg／d。63.64%子代远期随访未见华法令相关畸形发生,其中42.85%为母乳喂养。
5、孕期心脏病手术9例孕期心脏手术患者中6例为风湿性瓣膜性心脏病(4例行经皮二尖瓣球囊成形术；2例行二尖瓣置换术)；2例Ⅲ度房室传导阻滞,分娩前安放临时起搏器；1例急性前壁心肌梗塞,剖宫产术3后天行冠状动脉照影。除1例在孕22周行经皮二尖瓣球囊成形术的孕产妇死亡外,其余8位母亲均健康；围生儿1例早产,7例足月,均剖宫产分娩；1例行二尖瓣置换术患者的新生儿出现脑瘫。
【结论】
1、妊娠合并心脏病孕产妇占住院孕产妇总数的0.57%,位于前三位的是RHD、CHD、心律失常。
2、妊娠合并心脏病的孕产妇死亡率是1.76%；常见心脏并发症是心力衰竭和心律失常；常见产科合并症是早产和子痫前期。妊娠合并心脏病的围生儿死亡率是1.43%；常见并发症是早产儿、FGR。
3、围产期心肌病、艾森曼格综合征发病率低,预后差,死亡率高。对于有手术指征的心脏病患者,尤其是RHD尽量在孕前接受手术治疗,可以明显改善母儿结局。
4、心脏瓣膜置换术后整个孕期服用低剂量(＜5mg／d)华法令未见胎儿畸形、产后出血及栓塞性疾病发生；随访3.29年哺乳期服用低剂量华法令是安全的。
5、妊娠期行心脏手术不失为药物治疗无效时的急救方法,其安全性有待大样本循证医学考证。
妊娠合并心脏病属于严重高危妊娠范畴,对于心脏病女性在妊娠前及妊娠期的管理需要产科医生与心内科、心胸外科、麻醉科及新生儿科等医生的协作才能保证妊娠和分娩的顺利进行,因此妊娠合并心脏病的孕妇最好就诊于大型综合性医院。
Heart diseases are the most important non obstetrical causes of maternal deaths during pregnancy in China. Approximately 0.9%-3.7% of pregnancies are complicated by cardiac disease in the developing country.The incidence of heart disease in pregnancy rates of China was 1.06%.
Rheumatic heart disease (RHD) accounts for the majority of cases in China before 80 years in the 20th century. Progress in the fields of diagnostic techniques and surgical intervention has dramatically improved a longer survival and a higher quality of life in patients with congenital heart diseases (CHD), to lead to the quantity of patients with heart diseases year by year. Types of heart disease and the treatment were changed. Surgical intervention carry specific problems during pregnancy, such as the best opportunity of pregnancy, perinatal management of anticoagulation. They were't unsolved.
The changes of cardiovascular physiology can impose additional load and risk on the cardiovascular system of women with heart disease during pregnancy.Hemodynamic changes pre-exist in women with cardiac disease and these of pregnancy further add to this burden, even lead to heart failure.It's report that neonatal events occurr in the pregnant women complicated the heart disease were small-for-gestational-age birthweight, premature birth, respiratory distress syndrome, intraventricular hemorrhage, and fetal or neonatal death.
Objective
Through the analysis of the clinical data of pregnant women with heart disease, which is based on five major teaching hosptials from Guangzhou,Shenzhen and Changsha 8 years, we analyze the chang trends of different types of heart disease and affecting factors on the outcome of prenant women with heart disease. According to the analysis of the original data, we hope to find out the exact and important information to afford the clinical evidence for the consultation and trearment of the pregnancy merger heart disease.
Methods
1、Data collection
The use of retrospetive data analysis methods for the collection of the NanFang hospital, ZhuJiang hospital, the Third Affiliated Hospital of Guangzhou Medical University, the First People's Hospital of Shenzhen and Second Xiangya Hospital five three-level hosptial in January 2000 to December 2008 treated at the pregnancy was diagnosed as combined the 510 cases of cardiac disease. At the same time in the same period 100 cases of randomly selected hospital delivery is not at the normal maternal complications of pregnancy as a contral group.
2、Diagnostic criteria
Obstetrician comfirm pantient gestation and embryo age with diagnoses of the last menstruate, physical examination and ultrasonic check. The diagnosis standard of heart disease rest on a carefully obtained history and examination, electrocardiography and echocardiography, stemite and computerized tomography by physicians. The patients were classified into four groups according to the New York Heart Association (NYHA) functional classification. The diagnosis standard of preeclampsia, premature delivery, fetal death and fetal growth restriction are in accordance with the seventh publication of Obsterics and Gynecology which Lejie to edit in chief. Obstetrician and paediatrician give the diagnoses of embryo and baby.
3、Method
Through collect and analyse the cases of pregnant patient with heart disease, to know the incidence and the change of the types of heart disease in five hospitals. Compare different types of heart disease, pre-pregnancy treatment, and cardiac function during pregnancy, pregnancy complications, a variety of effects on maternal and child outcomes; the use of anticoagulants during pregnancy. To analyse this data to retrieval the related high risk factor of severe factors on the outcome of prenant women with heart disease.
4、Statistical analysis
Application of SPSS 13.0 statistical software for statistical analysis, and tabulation and graphics by Excel 2003, P<0.05 indicated statistical significance. Numerical data as mean and standard deviation, and use the two-sample T-test Categorical data were expressed as number and percentage, and use the x2-test.
Results
1.The incidence about pregnant women with heart disease and heart type distribution
The incidence of heart disease in pregnancy is 0.57%. RHD is the most frequent (37.84%), CHD is the second most frequent heart disease (25.68%), arrhythmia in the pregnant patient is the third (20.21%)
2. Maternal outcome 2.1 Maternal complications observed during pregnancy
Cardiac complication was was composed of congestive heart failure (25.09%), arrhythmia(8.57%) and Primary artery hypertension (6.94%). Obstetric complication was composed of preterm delivery (20.61%), pregnancy induced hypertension (14.9%), The incidence about infection was 11.02%. The maternal mortality rate was 1.76%.
2.2 Maternal outcome in pregnancy women with heart disease according to NYHA classification
There was no maternal dead in the NYHA stageⅠ-Ⅱgroups.The maternal mortality (x2=5360,P=0.021) were significantly difference in the NYHA stageⅢ-Ⅳgroups(P< 0.05). There were significant difference in heart failure morbidity (x2=79.902, P=0.000) between the NYHA stageⅠ-Ⅳgroups and the normal pregnancy control group (P<0.05).
2.3 Maternal outcome in pregnancy women with heart disease according to the type of cardiac disease
There was significant difference in the incidence about complication (x2=59.539,P=0.000) between RHD, CHD, heart disease induced by hypertensive disorders in pregnancy and arrhythmia (P<0.05). The heart failure were composed of heart disease induced by hypertensive disorders in pregnancy (46.09%) and RHD (40.63%). There were no significant difference in maternal mortality (x2=2.400, P=0.494) between RHD, CHD, heart disease induced by hypertensive disorders in pregnancy and peripartum cardiomyopathy(P>0.05).
2.4 Comparision of maternal outcome in operation group and non-operation group
2.4.1 Comparision of maternal outcome with CHD pregnancy women in operation group and non-operation group
There were no significant difference in NYHA classification (x2=1.108,P=0.293) between operation group and non-operation group(P> 0.05). There were no significant difference in the incidence about cardiac complication (x2=0.523, P=0.470) and obstetric complication (x2=0.026, P=0.871) between operation group and non-operation group (P<0.05). There were no significant difference in maternal (x2=0.000,P=0.100) between operation group and non-operation group (P>0.05).
2.4.2 Comparision of maternal outcome with RHD pregnancy women in operation group and non-operation group
The cardiac function of heart disease was significantly improved (x2=8.532, P=0.003) in operation group (P<0.05). There were significant difference in the incidence about cardiac complication (x2=26.155,P=0.000) and obstetric complication (x2=4.442, P=0.035) between operation group and non-operation group (P<0.05). There were no significant difference in maternal (x2=0.000,P=0.100) between operation group and non-operation group (P>0.05).
3. Fetal outcome
3.1 Fetal complications observed during pregnancy
Fetal complications was was composed of premature infant (17.34%), FGR (10.00%) and neonatal asphyxia (7.14%). The fetal mortality rate was 1.43%.
3.2 Fetal outcome in pregnancy women with heart disease according to NYHA classification
There were significant difference in birth weight (x2=86.109,P=0.000),Apgar score (x2=69.857,P=0.000), premature infant (x2=71.816,P=0.000), fetal growth restriction (x2=53.081,P=0.000) between the NYHA stageⅠ-Ⅳgroups and the normal pregnancy control group (P<0.05). There was no fetal dead in the NYHA stageⅠ-Ⅱgroups. There were no significant difference in perinatal mortality (x2=3.195,P=0.074) between the NYHA stageⅢand the NYHA stageⅣ(P> 0.05).
3.3 Comparision of maternal outcome in operation group and non-operation group
3.3.1 Comparision of fetal outcome with CHD pregnancy women in operation group and non-operation group
There were no significant difference in birth weight (T=0.514, P=0.608),Apgar score (T=414, P=0.680), premature infant (x2=0.004,P=0.949), fetal growth restriction (x2=0.102,P=0.749), neonatal asphyxia (x2=0.070,P=0.791) between operation group and non-operation group(P>0.05).
3.3.2 Comparision of fetal outcome with RHD pregnancy women in operation group and non-operation group
There were no significant difference in birth weight (T=1.601, P=0.111),Apgar score (T=0.608, P=0.544) between operation group and non-operation group(P> 0.05).There were significant difference in premature infant(x2=5.143, P=0.023), fetal growth restriction (x2=4.208, P=0.040) between operation group and non-operation group(P<0.05). There were no significant difference in neonatal asphyxia (x2=2.335, P=0.126) between operation group and non-operation group(P>0.05).
4. Pregnancy after cardiac operation and the treament of warfar in during pregnancy
The average time of postop with CVR,PBMV,CHD repaired were 4.83 years, 6.56 years and 9.35years respectively. The average warfarin dose was 2.764mg/d. There was none of the malformation induced by warfarin in pregnant women with CVR.
5. Cardiac Surgery during Pregnancy
There were 9 prgnant women underwent surgical treament. There were 4 PBMV,2 MVR,2 cardiac pacemaker and 1 Acute myocardial infarction. There were one maternal dead and one fetal cerebral palsy.
Conclusion
1.The incidence of heart disease in pregnancy is 0.57%, RHD,CHD, Arrhythmia are the most frequent.
2. The maternal mortality rate was 1.76%.The obstetric complication were preterm delivery and eclampsism;the cardiac complication were congestive heart failure and arrhythmia in the mother of heart disease during pregnancy. The fetal mortality rate was 1.43%.The fetal complication were premature infant,FGR and newborn asphyxiation.
3.The incidence of PPCM and Eisenmenger's syndrome was lower, but the maternal mortality was higher. With surgical indications of heart disease, especially RHD surgery as possible before pregnancy, can significantly improve the outcome of maternal and fetal.
4. The average warfarin dose lower 5mg/d was safe during prgnancy and lactation.
5. Cardiac Surgery is the method of emergency treatment during Pregnancy when the medicine is ineffective.
20世纪80年代以前我国妊娠合并心脏病中最多见的是风湿性心脏病(rheumatic heart disease, RHD);近30年来,随着先天性心脏病(congenital heart disease, CHD)诊断技术的进步和心脏外科手术的发展,CHD患者可以获得早期根治或部分矫正；心脏介入性手术及心脏瓣膜置换术(cardiovalve replacement, CVR)的开展可以使严重瓣膜性心脏病患者有条件接受合理的治疗,使得心脏病术后妊娠女性逐年增多。因此妊娠合并心脏病的类型、临床诊治水平均发生着巨大变化,同时产科医生也面临着很多特殊问题,例如心脏手术后妊娠的最佳时机、妊娠期的抗凝治疗、心脏病孕产妇的妊娠期管理等。
由于妊娠对心血管系统产生巨大的影响,合并心脏病的孕妇则难以耐受这些变化,使原有心脏病病情恶化,对孕妇本身及围生儿的预后产生不良影响。妊娠合并心脏病孕妇,其围生儿易发生自然流产、围生儿死亡、小于胎龄儿、呼吸窘迫综合征、早产及颅内出血等并发症。同时存在产科高危因素的心脏病孕妇与其心脏功能之间的相互作用决定了围生儿的结局。
妊娠合并心脏病属于严重高危妊娠范畴,对于已确诊或手术治疗的心脏病女性在妊娠前及妊娠期的管理需要产科医生与心内科、心胸外科、麻醉科及新生儿科医生的共同协作来完成,因此妊娠合并心脏病的孕产妇大多就诊或转诊于大型综合性医院。
目前国内关于妊娠合并心脏病的母儿预后影响因素分析的报道多为单个医院小样本的研究,或者单个影响因素的分析,缺乏大样本,多个因素分析的全面调查研究,不能全面准确反映我国近年来妊娠合并心脏病对母儿预后影响因素的全面分析。近年我国大型综合性医院妊娠合并心脏病的发病情况及其对母儿预后的影响如何,尚没有多家大型综合性医院的大样本调查分析。
【目的】
本研究旨在通过对广州、深圳、长沙5家三级甲等医院8年来诊断为妊娠合并心脏病患者的临床病例资料进行回顾性研究分析,了解妊娠合并心脏病的发病情况及心脏病的类型分布：分析其影响母儿预后的相关因素,提高对妊娠合并心脏病的认识：探讨有效的对策以减少母儿并发症发生。
【材料和方法】
1、资料收集
回顾性调查2000年～2008年广州市南方医院、珠江医院、广州医学院第三附属医院、深圳市人民医院、长沙市中南大学湘雅二医院5家教学医院收治的所有住院诊断为妊娠合并心脏病的病例共510例,年龄平均(28.513±5.144)岁,初产妇342例,经产168例,双胎16例,其余均为单胎。随机抽出100例(南方医院、珠江医院、广州医学院第三附属医院、深圳市人民医院、中南大学湘雅二医院各20例)同期在院分娩没有妊娠合并症的正常产妇做为对照组。孕期抗凝治疗的心脏病患者及其子代的随访通过电话随访或调查问卷获得。
2、诊断标准
所有心脏病的诊断于妊娠前或此次妊娠中根据病史、体格检查、心电图、超声心动图、动态心电图、胸片、CT等必要的辅助检查,经内科确诊。心功能分级采用1994年纽约心脏病协会制定的心功能分级法。早产、胎儿生长受限等诊断参照乐杰主编的第7版妇产科学。患者子代包括胎儿和新生儿情况的评估均由产科医生和儿科医生共同完成。
3、方法
通过对妊娠合并心脏病患者的病例收集和分析,了解妊娠合并心脏病的发病情况、心脏病的类型分布及母儿合并症的发生情况；了解妊娠期行心脏手术的安全性；比较孕期不同心功能级别、不同类型心脏病的孕产妇死亡率、并发症发生率及其围生儿转归；比较已手术和未手术的RHD及CHD对孕产妇及围生儿转归的影响；探讨孕期抗凝剂的使用与母儿预后的关系。
4、统计学处理
应用统计软件SPSS12.0进行统计分析；在Excel2003进行制表和绘图；计量数据描述使用平均数和标准差表示,应用方差分析与t检验等方法进行统计分析；频数资料描述采用百分比(%)表示,使用卡方检验(或连续性较正卡方检验)；P<0.05表示差异有显著性。
【结果】
1、妊娠合并心脏病的发病情况及类型分布妊娠合并心脏病孕产妇占住院孕产妇总数的0.57%,RHD居首位占37.84%,CHD病次之占25.68%,心律失常第三位占20.21%。
2、孕产妇结局
2.1妊娠合并心脏病孕产妇合并症及孕产妇死亡情况妊娠合并心脏病孕产妇的内科合并症为心力衰竭(25.09%)、心律失常(8.57%)、肺动脉高压(6.94%)；产科并发症是早产(20.61%)、子痫前期(14.9%)；合并感染为11.02%。9例孕产妇死亡,死亡率1.76%,其中4例CHD(2例艾森曼格综合征),3例RHD,妊娠期高血压疾病性心脏病和围产期心肌病(peripartum cardiomyopathy, PPCM)各1例。
2.2不同心功能分级的孕产妇预后比较心功能Ⅰ、Ⅱ级均无孕产妇死亡；心功能Ⅳ级与心功能Ⅲ级孕产妇死亡率(x2=5.360,P=0.021)比较有显著性差异,P<0.05;心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级与对照组心衰发生率(x2=79.902,P=0.000)比较有显著性差异,P<0.05。
2.3不同心脏病类型的孕产妇预后比较妊娠合并CHD、RHD、心律失常及妊娠期高血压疾病性心脏病之间的并发症发生率(x2=59.539,P=0.000)比较有显著性差异,P<0.05;发生心衰的心脏病中妊娠期高血压疾病性心脏病占比例最高为59例,占46.09%。其次为RHD52例,占40.63%；其中96.72%妊娠期高血压疾病性心脏病发生心力衰竭,80%PPCM发生心力衰竭；RHD发生心力衰竭比例为26.94%。妊娠合并CHD、RHD、妊娠期高血压疾病性心脏病及PPCM之间的孕产妇死亡率(x2=2.400,P=0.494)比较无显著性差异,P>0.05。
2.4心脏手术与未手术的孕产妇预后比较
2.4.1 CHD手术组与未手术组孕产妇预后比较两组孕期心功能(x2=1.108,P=0.293)比较无显著性差异,P>0.05；两组心脏并发症发生率(x2=0.523,P=0.470)、产科并发症发生率(x2=0.026,P=0.871)比较无显著性差异,P>0.05；两组孕产妇死亡率(x2=0.000,P=0.100)、分娩方式(x2=0.506,P=0.477)比较无显著性差异,P>0.05。
2.4.2 RHD手术组与未手术组孕产妇预后比较两组心功能Ⅰ-Ⅱ级与心功能Ⅲ-Ⅳ级(x2=8.532,P=0.003)、心脏并发症发生率(x2=26.155,P=0.000)、产科并发症发生率(x2=4.442,P=0.035)比较有显著性差异,P<0.05。两组孕产妇死亡率(x2=0.000,P=1.000)比较无显著性差异,P>0.05。
3、围生儿结局
3.1围生儿并发症及死亡情况围生儿常见的并发症是早产儿(17.34%)、胎儿生长受限(fetal growth restriction, FGR) (10.00%)、新生儿窒息(7.14%),新生儿畸形(1.43%)；围生儿死亡率是1.43%。
3.2不同心功能级别患者的围生儿预后比较心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级组与对照组新生儿体重(x2=86.109,P=0.000)、评分(x2=69.857,P=0.000)、早产儿(x2=71.816,P=0.000)、FGR(x2=53.081,P=0.000)发生率比较有显著性差异,P<0.05；心功能Ⅰ、Ⅱ级组均无围生儿死亡；心功能Ⅲ、Ⅳ级组围生儿死亡率(x2=3.195,P=0.074)比较无显著性差异,P>0.05。
3.3心脏手术与未手术患者的围生儿预后比较
3.3.1 CHD手术组与未手术组围生儿预后比较两组新生儿体重(T=0.514,P=0.608)及评分(T=0.414,P=0.680)比较无显著性差异,P>0.05。两组早产儿(x2=0.004,P=0.949)、新生儿窒息(x2=0.070,P=0.791)、FGR(x2=0.102,P=0.749)发生率比较无显著性差异,P>0.05。
3.3.2 RHD手术组与未手术组围生儿预后比较两组新生儿体重(T=1.601,P=0.111)及评分(T=0.608,P=0.544)比较无显著性差异,P>0.05；未手术组有1例新生儿六指畸形,手术组未见新生儿畸形发生。两组早产儿(x2=5.143,P=0.023)、FGR(x2=4.208,P=0.040)发生率比较有显著性差异,P<0.05；两组新生儿窒息(x2=2.335,P=0.126)比较无显著性差异,P>0.05。
4、心脏病术后的妊娠时间及华法令的使用心脏瓣膜置换术的患者此次妊娠距手术时间为1.5年～16年,平均4.83年；瓣膜扩张术后患者此次妊娠距手术时间为1年～18年,平均6.56年；CHD手术患者此次妊娠距手术时间为1年～25年,平均9.35年。55例行CVR者均使用机械人工瓣膜,均是整个孕期口服华法令抗凝,平均2.764mg／d。63.64%子代远期随访未见华法令相关畸形发生,其中42.85%为母乳喂养。
5、孕期心脏病手术9例孕期心脏手术患者中6例为风湿性瓣膜性心脏病(4例行经皮二尖瓣球囊成形术；2例行二尖瓣置换术)；2例Ⅲ度房室传导阻滞,分娩前安放临时起搏器；1例急性前壁心肌梗塞,剖宫产术3后天行冠状动脉照影。除1例在孕22周行经皮二尖瓣球囊成形术的孕产妇死亡外,其余8位母亲均健康；围生儿1例早产,7例足月,均剖宫产分娩；1例行二尖瓣置换术患者的新生儿出现脑瘫。
【结论】
1、妊娠合并心脏病孕产妇占住院孕产妇总数的0.57%,位于前三位的是RHD、CHD、心律失常。
2、妊娠合并心脏病的孕产妇死亡率是1.76%；常见心脏并发症是心力衰竭和心律失常；常见产科合并症是早产和子痫前期。妊娠合并心脏病的围生儿死亡率是1.43%；常见并发症是早产儿、FGR。
3、围产期心肌病、艾森曼格综合征发病率低,预后差,死亡率高。对于有手术指征的心脏病患者,尤其是RHD尽量在孕前接受手术治疗,可以明显改善母儿结局。
4、心脏瓣膜置换术后整个孕期服用低剂量(＜5mg／d)华法令未见胎儿畸形、产后出血及栓塞性疾病发生；随访3.29年哺乳期服用低剂量华法令是安全的。
5、妊娠期行心脏手术不失为药物治疗无效时的急救方法,其安全性有待大样本循证医学考证。
妊娠合并心脏病属于严重高危妊娠范畴,对于心脏病女性在妊娠前及妊娠期的管理需要产科医生与心内科、心胸外科、麻醉科及新生儿科等医生的协作才能保证妊娠和分娩的顺利进行,因此妊娠合并心脏病的孕妇最好就诊于大型综合性医院。
Heart diseases are the most important non obstetrical causes of maternal deaths during pregnancy in China. Approximately 0.9%-3.7% of pregnancies are complicated by cardiac disease in the developing country.The incidence of heart disease in pregnancy rates of China was 1.06%.
Rheumatic heart disease (RHD) accounts for the majority of cases in China before 80 years in the 20th century. Progress in the fields of diagnostic techniques and surgical intervention has dramatically improved a longer survival and a higher quality of life in patients with congenital heart diseases (CHD), to lead to the quantity of patients with heart diseases year by year. Types of heart disease and the treatment were changed. Surgical intervention carry specific problems during pregnancy, such as the best opportunity of pregnancy, perinatal management of anticoagulation. They were't unsolved.
The changes of cardiovascular physiology can impose additional load and risk on the cardiovascular system of women with heart disease during pregnancy.Hemodynamic changes pre-exist in women with cardiac disease and these of pregnancy further add to this burden, even lead to heart failure.It's report that neonatal events occurr in the pregnant women complicated the heart disease were small-for-gestational-age birthweight, premature birth, respiratory distress syndrome, intraventricular hemorrhage, and fetal or neonatal death.
Objective
Through the analysis of the clinical data of pregnant women with heart disease, which is based on five major teaching hosptials from Guangzhou,Shenzhen and Changsha 8 years, we analyze the chang trends of different types of heart disease and affecting factors on the outcome of prenant women with heart disease. According to the analysis of the original data, we hope to find out the exact and important information to afford the clinical evidence for the consultation and trearment of the pregnancy merger heart disease.
Methods
1、Data collection
The use of retrospetive data analysis methods for the collection of the NanFang hospital, ZhuJiang hospital, the Third Affiliated Hospital of Guangzhou Medical University, the First People's Hospital of Shenzhen and Second Xiangya Hospital five three-level hosptial in January 2000 to December 2008 treated at the pregnancy was diagnosed as combined the 510 cases of cardiac disease. At the same time in the same period 100 cases of randomly selected hospital delivery is not at the normal maternal complications of pregnancy as a contral group.
2、Diagnostic criteria
Obstetrician comfirm pantient gestation and embryo age with diagnoses of the last menstruate, physical examination and ultrasonic check. The diagnosis standard of heart disease rest on a carefully obtained history and examination, electrocardiography and echocardiography, stemite and computerized tomography by physicians. The patients were classified into four groups according to the New York Heart Association (NYHA) functional classification. The diagnosis standard of preeclampsia, premature delivery, fetal death and fetal growth restriction are in accordance with the seventh publication of Obsterics and Gynecology which Lejie to edit in chief. Obstetrician and paediatrician give the diagnoses of embryo and baby.
3、Method
Through collect and analyse the cases of pregnant patient with heart disease, to know the incidence and the change of the types of heart disease in five hospitals. Compare different types of heart disease, pre-pregnancy treatment, and cardiac function during pregnancy, pregnancy complications, a variety of effects on maternal and child outcomes; the use of anticoagulants during pregnancy. To analyse this data to retrieval the related high risk factor of severe factors on the outcome of prenant women with heart disease.
4、Statistical analysis
Application of SPSS 13.0 statistical software for statistical analysis, and tabulation and graphics by Excel 2003, P<0.05 indicated statistical significance. Numerical data as mean and standard deviation, and use the two-sample T-test Categorical data were expressed as number and percentage, and use the x2-test.
Results
1.The incidence about pregnant women with heart disease and heart type distribution
The incidence of heart disease in pregnancy is 0.57%. RHD is the most frequent (37.84%), CHD is the second most frequent heart disease (25.68%), arrhythmia in the pregnant patient is the third (20.21%)
2. Maternal outcome 2.1 Maternal complications observed during pregnancy
Cardiac complication was was composed of congestive heart failure (25.09%), arrhythmia(8.57%) and Primary artery hypertension (6.94%). Obstetric complication was composed of preterm delivery (20.61%), pregnancy induced hypertension (14.9%), The incidence about infection was 11.02%. The maternal mortality rate was 1.76%.
2.2 Maternal outcome in pregnancy women with heart disease according to NYHA classification
There was no maternal dead in the NYHA stageⅠ-Ⅱgroups.The maternal mortality (x2=5360,P=0.021) were significantly difference in the NYHA stageⅢ-Ⅳgroups(P< 0.05). There were significant difference in heart failure morbidity (x2=79.902, P=0.000) between the NYHA stageⅠ-Ⅳgroups and the normal pregnancy control group (P<0.05).
2.3 Maternal outcome in pregnancy women with heart disease according to the type of cardiac disease
There was significant difference in the incidence about complication (x2=59.539,P=0.000) between RHD, CHD, heart disease induced by hypertensive disorders in pregnancy and arrhythmia (P<0.05). The heart failure were composed of heart disease induced by hypertensive disorders in pregnancy (46.09%) and RHD (40.63%). There were no significant difference in maternal mortality (x2=2.400, P=0.494) between RHD, CHD, heart disease induced by hypertensive disorders in pregnancy and peripartum cardiomyopathy(P>0.05).
2.4 Comparision of maternal outcome in operation group and non-operation group
2.4.1 Comparision of maternal outcome with CHD pregnancy women in operation group and non-operation group
There were no significant difference in NYHA classification (x2=1.108,P=0.293) between operation group and non-operation group(P> 0.05). There were no significant difference in the incidence about cardiac complication (x2=0.523, P=0.470) and obstetric complication (x2=0.026, P=0.871) between operation group and non-operation group (P<0.05). There were no significant difference in maternal (x2=0.000,P=0.100) between operation group and non-operation group (P>0.05).
2.4.2 Comparision of maternal outcome with RHD pregnancy women in operation group and non-operation group
The cardiac function of heart disease was significantly improved (x2=8.532, P=0.003) in operation group (P<0.05). There were significant difference in the incidence about cardiac complication (x2=26.155,P=0.000) and obstetric complication (x2=4.442, P=0.035) between operation group and non-operation group (P<0.05). There were no significant difference in maternal (x2=0.000,P=0.100) between operation group and non-operation group (P>0.05).
3. Fetal outcome
3.1 Fetal complications observed during pregnancy
Fetal complications was was composed of premature infant (17.34%), FGR (10.00%) and neonatal asphyxia (7.14%). The fetal mortality rate was 1.43%.
3.2 Fetal outcome in pregnancy women with heart disease according to NYHA classification
There were significant difference in birth weight (x2=86.109,P=0.000),Apgar score (x2=69.857,P=0.000), premature infant (x2=71.816,P=0.000), fetal growth restriction (x2=53.081,P=0.000) between the NYHA stageⅠ-Ⅳgroups and the normal pregnancy control group (P<0.05). There was no fetal dead in the NYHA stageⅠ-Ⅱgroups. There were no significant difference in perinatal mortality (x2=3.195,P=0.074) between the NYHA stageⅢand the NYHA stageⅣ(P> 0.05).
3.3 Comparision of maternal outcome in operation group and non-operation group
3.3.1 Comparision of fetal outcome with CHD pregnancy women in operation group and non-operation group
There were no significant difference in birth weight (T=0.514, P=0.608),Apgar score (T=414, P=0.680), premature infant (x2=0.004,P=0.949), fetal growth restriction (x2=0.102,P=0.749), neonatal asphyxia (x2=0.070,P=0.791) between operation group and non-operation group(P>0.05).
3.3.2 Comparision of fetal outcome with RHD pregnancy women in operation group and non-operation group
There were no significant difference in birth weight (T=1.601, P=0.111),Apgar score (T=0.608, P=0.544) between operation group and non-operation group(P> 0.05).There were significant difference in premature infant(x2=5.143, P=0.023), fetal growth restriction (x2=4.208, P=0.040) between operation group and non-operation group(P<0.05). There were no significant difference in neonatal asphyxia (x2=2.335, P=0.126) between operation group and non-operation group(P>0.05).
4. Pregnancy after cardiac operation and the treament of warfar in during pregnancy
The average time of postop with CVR,PBMV,CHD repaired were 4.83 years, 6.56 years and 9.35years respectively. The average warfarin dose was 2.764mg/d. There was none of the malformation induced by warfarin in pregnant women with CVR.
5. Cardiac Surgery during Pregnancy
There were 9 prgnant women underwent surgical treament. There were 4 PBMV,2 MVR,2 cardiac pacemaker and 1 Acute myocardial infarction. There were one maternal dead and one fetal cerebral palsy.
Conclusion
1.The incidence of heart disease in pregnancy is 0.57%, RHD,CHD, Arrhythmia are the most frequent.
2. The maternal mortality rate was 1.76%.The obstetric complication were preterm delivery and eclampsism;the cardiac complication were congestive heart failure and arrhythmia in the mother of heart disease during pregnancy. The fetal mortality rate was 1.43%.The fetal complication were premature infant,FGR and newborn asphyxiation.
3.The incidence of PPCM and Eisenmenger's syndrome was lower, but the maternal mortality was higher. With surgical indications of heart disease, especially RHD surgery as possible before pregnancy, can significantly improve the outcome of maternal and fetal.
4. The average warfarin dose lower 5mg/d was safe during prgnancy and lactation.
5. Cardiac Surgery is the method of emergency treatment during Pregnancy when the medicine is ineffective.
引文
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