妊娠及分娩中的心脏起搏治疗

报道安置心脏起搏器的严重缓慢心律的失常孕妇７例，其中病窦综合征２例，高度房室阻滞５例。２例在临时起搏保护下终止妊娠；另５例安置永久起搏器。起搏并配以适当的药物治疗，合５例患者均顺利渡过妊娠期并安全分娩。对于严重缓慢心律失常的孕前或孕期妇女，安置心脏起搏器后，酌情调整起搏频率，或者应用频率自适应起搏器，方能适应发娩的需要。     

心脏瓣膜置换术后妊娠与分娩的临床处理(附8例分析)

随着心脏瓣膜置换术(CVR)在临床上的广泛开展，许多心脏瓣膜病患者术后心功能明显改善，这为育龄心脏瓣膜病妇女承受妊娠、分娩提供了有利条件。但在其妊娠、分娩的过程中需要进行重点监护，甚至需给予特殊处理。1982年10月至2003年4月我们共收治CVR后妊娠分娩患者8例。现结合其临床资料分析探讨CVR后妊娠、分娩的处理方法。     

HIV感染者/AIDS患者合并妊娠的处理(附5例报告)

目的探讨艾滋病病毒(HIV)感染者伎滋病(AIDS)患者合并妊娠的处理。方法回顾性分析5例HIV感染者／AIDS患者合并妊娠的临床资料和处理方法。结果5例均为产前检查发现HIV抗体阳性，3例孕妇采用抗逆转录病毒干预性治疗；3例产妇采用剖宫产术，1例阴道分娩，1例采用羊膜腔注射利凡诺尔引产术。4例新生儿出生后即服用抗病毒药物并采用人工喂养。结论及早的诊断(产前HIV抗体检测)及有效的处理(孕妇及新生儿抗逆转录病毒干预性治疗、剖宫产术、新生儿人工喂养)是降低HIV母婴传播的重要措施。     

心脏瓣膜置换术后的妊娠与分娩

报告5例心脏瓣膜置换术后6次妊娠的经过与结局,早期妊娠流产2次,中期妊娠流产1次,3次足月妊娠分娩。并对换瓣术后妇女妊娠的条件、妊娠后母儿监护及孕妇的抗凝治疗等阐述个人见解。     

心脏起搏治疗小儿缓慢性心律失常30例的经验

目的总结永久性心脏起搏器治疗小儿缓慢性心律失常的经验。方法因症状性缓慢性心律失常在我院住院置入永久心脏起搏器的患儿30例,男19例、女11例,年龄6.8±4.1(1/12~15)岁。>10 kg的患儿全麻下穿刺左锁骨下静脉,放置心内膜起搏电极,起搏器置于左锁骨下皮下脂肪与肌肉间囊袋中;<10kg的婴儿放置心外膜电极,起搏器置于腹部固定于腹直肌。依据不同年龄将起搏频率设置为70~100次/m in(VVI/AAI/DDD),或60~70/130~140次/m in(VVIR/AAIR)。结果所有患儿均成功置入起搏器,无手术并发症发生,其中VVI 19例、VVIR 7例、AAI 2例、AAIR 1例、DDD 1例;经左锁骨下静脉放置心内膜电极27例,经腹部置入心外膜电极3例。术后随访3个月~6年,患儿体力均有明显改善,异常的左室内径和左室射血分数均于术后3个月内恢复正常。结论小儿起搏器治疗有效、安全,应根据患儿体重及全身状况选择适宜的起搏系统。     

床旁体表心电图引导心脏起搏治疗心律失常的疗效

目的:探讨床旁体表心电图引导心脏起搏与介入室内X线引导心脏起搏治疗心律失常的疗效。方法:收集2005年4月-2015年4月我院收治的因严重的心动过缓等原因所致心律失常患者230例的临床资料进行回顾性分析。床旁心脏临时起搏器置入者166例作为床旁心电引导组,在介入室内X线引导下安装心脏临时起搏器患者64例作为介入室引导组。对患者术前、术中及术后进行持续心电监护,观察比较两组患者的起搏效果、操作时间、起搏阈值以及术后并发症的情况。结果:与介入室引导组比较,床旁心电引导组即刻心脏起搏成功率显著升高(87.5%比100%),P0.01。床旁心电引导组和介入室引导组的操作时间[(8.5±1.4)min比(8.2±1.1)min]和起搏阈值[(0.85±0.26)V比(0.83±0.29)V]均无显著差异,P均0.05。两组并发症发生率亦无显著差异(P0.05)。结论:床旁体表心电引导心脏起搏治疗心律失常的疗效显著,安全性高,操作简单,值得临床推广。     

宫颈妊娠的综合治疗(附10例报告)

宫颈妊娠是指孕卵种植于宫颈粘膜,是一种少见的异位妊娠,近年来,其发病呈增高趋势,多以子宫切除为治疗手段。１９９０年１０月至１９９８年１２月,我院采用综合疗法治疗本病患者１０例,既保留了患者的子宫,又取得了较好效果。１ 临床资料本组平均年龄３０（２６～３７）岁;均为经产妇,５例有人工流产史,３例有剖宫产史。发病末次妊娠时间１～５年,平均３．６年。主要临床表现为无痛性阴道流血,２例伴有轻微下腹部坠痛。其中４例呈术后流血,出血量由点滴出血至５００ｍｌ不等,１例出血休克。阴道流血距末次月经时间＜３天１例…     

心动过缓的心脏起搏治疗——(附173例次报告)

我院自1983年开展人工心脏起搏以来,用于治疗缓慢性心律失常126例,行起搏治疗173例次,效果满意,现报告如下。     

心脏手术后妊娠及分娩35例临床分析

目的 探讨心脏手术后患者妊娠经过及结果。方法 对我院18年间心脏手术后妊娠及分娩35例进行回顾性分析。术前心功能Ⅰ级者29例，Ⅱ级者4例，Ⅲ级者2例，Ⅳ级者1例。所施的手术分别为房间隔缺损修补术14例，室间隔缺损修补术10例，法乐氏四联症矫治术1例，二尖瓣狭窄分离术2例，动脉导管结扎术5例，二尖瓣置换术3例。手术后心功能Ⅰ级44例，Ⅱ级2例。结果 35例孕产妇及新生儿无一例死亡，新生儿无畸形。结论 心脏手术后心功能Ⅰ～Ⅱ级者能胜任妊娠。     

右心室间隔部起搏一例

1病例简介患者,男,76岁,因头晕9年,活动后呼吸困难10余天于2008-01-20入院。查体:体温36.8℃,脉搏48次/min,呼吸20次/min,血压110/50mmHg(1mmHg=0.133kPa),心肺听诊无异常。血常规、血生化、心肌酶学和甲状腺功能检查无异常。12导联心电图提示:Ⅲ度房室传导阻滞。X线示心肺未见     

频率适应式起搏器的临床应用和生理性起搏效应

采用动态心电图和超声心动图观察植入频率适应式起搏器９０例患者的日常活动，并观察运动试验时起搏频率和运动耐量。结果显示：４１例起搏器依赖患者的运动持续时间和最大心输出量分别较非频率适应式起搏增加３７％（３４７±６３ｓＶＳ２４７±５３ｓ，Ｐ＜０．００１）和５２％（１０．２±２．１Ｌ／ｍｉｎＶＳ６．７±１．６Ｌ／ｍｉｎ，Ｐ＜０．０５）。提示频率适应式起搏器可明显改善患者的生活质量和运动耐量。笔者体会术前应通过活动平板试验，评估患者心脏变时功能，以恰当掌握适应证；术后用动态心电图监测起搏频率及症状，以合理调整频率适应参数。     

妊娠合并心力衰竭孕妇分娩方式及妊娠结局分析

目的探讨妊娠合并心力衰竭孕妇的分娩方式及其对妊娠结局的影响。 方法选取2017年1月至2018年1月胶州市人民医院收治的100例妊娠合并心力衰竭孕妇作为研究对象,评估其心功能分级,并统计所有孕妇分娩方式(阴道分娩和剖宫产)与不良妊娠结局(新生儿窒息、足月低体质量、早产、围生儿死亡)发生率。 结果100例孕妇中,心功能NYHA分级Ⅰ级10例、Ⅱ级49例、Ⅲ级29例、Ⅳ级12例。Ⅰ＋Ⅱ级孕妇阴道分娩率为52.54%(31/59),Ⅲ＋Ⅳ级孕妇阴道分娩率为26.83%(11/41),差异有统计学意义(P<0.05)。Ⅰ＋Ⅱ级孕妇新生儿窒息、足月低体质量、早产、围生儿死亡发生率均低于对照组,差异有统计学意义(均P<0.05)。 结论妊娠合并心力衰竭孕妇心功能状态可对分娩方式及妊娠结局产生显著影响,且心功能分级越高,剖宫产率与不良妊娠结局发生风险越高。     

床旁紧急临时心脏起搏器在ICU室的应用

目的 探讨在ICU床旁紧急安置临时起搏器救治心动过缓、心室纤颤、心外因素所致的心脏骤停患者的安全性与有效性.方法 纳入不同心律失常及心肺复苏患者共31例,进行床旁紧急临时心脏起搏,观察治疗的有效性和并发症发生情况.结果 所有患者均左锁骨下静脉或股静脉穿刺成功,共有5例患者穿刺部位渗血,经压迫止血有效,没有出现感染、栓塞、气胸、心肌穿孔、严重心律失常等并发症.安置起搏器后,加用药物治疗,有效26例,有效率83.87%.结论 在ICU室开展床旁紧急临时心脏起搏技术,正确掌握适应证,植入漂浮起搏电极抢救严重心律失常及特殊情况下的心脏骤停患者具有快速、安全、有效的优势.     

D-二聚体水平监测在起搏器植入术中的价值

目的 通过监测植入起搏器患者D-二聚体水平,比较单腔、双腔和三腔(心脏再同步治疗,CRT)起搏器植入对静脉血栓形成和栓塞影响程度,以减少静脉栓塞并发症的发生.方法 随机选取2010年6月～2011年6月在江苏省苏北人民医院植入起搏器患者80例,根据起搏模式分为VVI、DDD、CRT起搏器3组,分别于术前2d,术后24 h、7d监测D-二聚体水平.所有患者随访至少1年,随访期间定期监测D-二聚体水平.结果 3组患者植入起搏器后24 h D-二聚体水平较术前均增高,差异有统计学意义(P=0.029,0.026,0.003);术后7d,DDD、CRT起搏器组患者的D-二聚体水平较术前均增高,差异有统计学意义(P=0.023,0.020);CRT起搏器组患者术后24 h D-二聚体水平较VVI、DDD起搏器组增高,差异有统计学意义[(3.76±2.68) μg/ml对(2.59±2.13) μg/ml,P=0.028;(3.76±2.68) μg/ml对(1.46±0.74)μg/ml,P=0.010].随访期间共发生2例血栓事件.结论 起搏器植入可以导致机体凝血和纤溶系统的激活,通过监测D-二聚体水平,发现CRT植入术后D-二聚体水平明显高于普通起搏器.能否通过监测D-二聚体水平,判断患者凝血状态、预防血栓形成的发生,还需进一步的临床研究和证据.     

头静脉途径心脏起搏器植入术中撕剥式导线导引器的应用价值

目的 探讨撕剥式导线导引器在经头静脉途径心脏起搏器植入术中的应用价值. 方法 183例经头静脉途径心脏起搏器植入术患者根据导线置入时是否应用撕剥式导线导引器分为改良组（n=91）和常规组（n=92）.比较两组手术时间、X线曝光时间、导线放置成功率、手术并发症. 结果改良组头静脉导线放置成功率97.80%.明显优于常规组80.43%（P〈0.01）.双腔起搏器植入者双导线放置成功率64.62%,明显优于常规组的26.56%（P〈0.01）.改良组手术时间、X线曝光时间分别为（61.13±12.03）min、（5.77±1.35）min.与常规组（62.22±13.26）min、（5.89±1.43）min相似（均P〉0.05）.两组各有1例术后囊袋血肿,随访3个月-2.5年未见其他并发症.结论 经头静脉途径植入心脏起搏器时,撕剥式导线导引器能明显提高导线放置成功率.     

Pregnancy,Delivery, and Pouch Function After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

PURPOSE: This study was designed to evaluate the pregnancies, method of delivery, and functional results of females with chronic ulcerative colitis who have an ileal pouch-anal anastomosis. METHODS: A mailed questionnaire was sent to all females with an ileal pouch-anal anastomosis for chronic ulcerative colitis. Information on the pregnancy, method of delivery, and outcome was collected. Those females who had a successful pregnancy and delivery were contacted by telephone to clarify results and determine pouch functional results. Other clinical information was obtained from the Mount Sinai Hospital Inflammatory Bowel Disease database. RESULTS: Thirty-eight subjects had 67 pregnancies. Of these, 29 subjects had 49 deliveries. There were 25 vaginal deliveries and 24 cesarean sections. There were two pouch-related complications during the pregnancies and four pouch-related complications postpartum. All were treated nonoperatively. Stool frequency and day and night incontinence were increased during pregnancy in most subjects, but after delivery, prepregnancy function was restored in 24 (83 percent) of them. Five subjects (17 percent) had some degree of permanent deterioration in pouch function. Of these, three had vaginal deliveries, and two had cesarean sections. Multiple births and birth weight were not found to adversely affect subsequent pouch function. CONCLUSION: Pregnancy is safe in females with ileal pouch-anal anastomosis. Functional results are altered almost exclusively during the third trimester, but pouch function promptly returns to prepregnancy status in most females. A small proportion of females have long-term disturbances in function, but these are not related to the method of delivery. Thus, the method of delivery should be dictated by obstetric considerations.     

心脏永久性起搏器植入患者门诊随访依从性分析

目的：分析心脏永久性起搏器植入患者门诊随访依从性的现状、影响因素及探讨提高随访依从性的方法。方法：回顾性分析2006-01至2013-01在我院住院植入心脏永久性起搏器的患者817例,对术后1年内的门诊随访情况进行依从性评判,并分析其影响因素。实际随访790例（96.70%）,1年内未进行门诊随访者入电话随访组（n=350例）,至少进行过1次门诊随访者入门诊随访组（n=440例）。结果：研究对象中,失访26例,失访率3.18%;非起搏器相关死亡1例,实际随访790例,实际随访率96.7%,其中门诊随访者440例（55.70％）,电话随访者350例（44.30％）。两组在文化程度、医疗费用、居住地、对心律失常的了解、固定陪护人员方面的差异有统计学意义（P<0.05）。高中以上文化程度、医疗费用可报销、本地居住、对心律失常知识了解、有固定陪护人员的患者门诊随访率高。1年内总体并发症发生率1.8%,均未造成严重后果。随访时进行优化参数设置者占59.5%。结论：心脏永久性起搏器植入患者门诊随访率较低。影响因素较多,包括文化程度、医保制度、居住地、对心律失常的认知程度、有无陪护人员。     

Pregnancy and Delivery Before and After Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: Immediate and Long-Term Consequences and Outcomes

PURPOSE: This study was designed to evaluate pregnancy, delivery, and functional outcome in females before and after ileal pouch-anal anastomosis for chronic ulcerative colitis.METHODS: From a prospective database of 1,454 patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis between 1981 and 1995, a standardized questionnaire was sent to all female patients aged 40 years or younger at the time of ileal pouch-anal anastomosis (n = 544).RESULTS: The response rate was 83 percent (450/544) with a mean follow-up after ileal pouch-anal anastomosis of 13 years. A total of 141 females were pregnant after the chronic ulcerative colitis diagnosis, but before ileal pouch-anal anastomosis (236 pregnancies; mean, 1.7) and 87 percent delivered vaginally. A mean of five (range, 1–16) years after ileal pouch-anal anastomosis, 135 females were pregnant (232 pregnancies; mean, 1.7). Comparison of pregnancy and delivery before and after ileal pouch-anal anastomosis in the same females (n = 37) showed no difference in birth weight, duration of labor, pregnancy/delivery complications, vaginal delivery rates (59 percent before vs. 54 percent after ileal pouch-anal anastomosis), and unplanned cesarean section (19 vs.14 percent). Planned cesareans occurred only after ileal pouch-anal anastomosis and were prompted by obstetrical concerns in only one of eight. Pouch function at first follow-up after delivery (mean, 7 months) was similar to pregravida function. After ileal pouch-anal anastomosis, daytime stool frequency was the same after delivery as pregravida (5.4 vs. 5.4, not significant) but was increased at the time of last follow-up (68 months after delivery; 5.4 vs. 6.4; P < 0.001). The rate of occasional fecal incontinence also was higher (20 percent after ileal pouch-anal anastomosis and 21 percent pregravida vs. 36 percent at last follow-up; P = 0.01). No difference in functional outcome was noted compared with females who were never pregnant after ileal pouch-anal anastomosis (n = 307). Age and becoming pregnant did not affect the probability of pouch-related complications, such as stricture, pouchitis, and obstruction.CONCLUSIONS: Successful pregnancy and vaginal delivery occur routinely in females with chronic ulcerative colitis before and after ileal pouch-anal anastomosis. The method of delivery should be dictated by obstetrical considerations. Pouch function and the incidence of complications in females with pregnancies seem largely unaffected long-term.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 23 to 27, 2003.     

The Effect of Restorative Proctocolectomy on Sexual Function,Urinary Function,Fertility, Pregnancy and Delivery: A Systematic Review

Purpose This study was designed to evaluate the effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy, and delivery in patients with ulcerative colitis. Methods A systematic literature search was performed of articles published between 1980 and 2005 on patients undergoing restorative proctocolectomy for ulcerative colitis reporting data on the outcomes of interest. A random-effect, meta-analytical model was used for pooled estimates and 95 percent confidence intervals. Results A total of 22 studies, with 1,852 females, were included. Infertility rate was 12 percent before restorative proctocolectomy and 26 percent after, among 945 patients in seven studies. The incidence of sexual dysfunction was 8 percent preoperatively and 25 percent postoperatively (7 studies, n = 419). Two studies (n = 62) reported no urinary dysfunction in patients undergoing restorative proctocolectomy. There was an increased incidence of cesarean section after restorative proctocolectomy. During the third trimester of pregnancy, there was an increase in stool frequency by 1.15 stools per day compared with before pregnancy frequency (n = 49 95 percent confidence interval, 0.28–2.03 P = 0.01 chi-squared statistic, 0.04 P = 0.84). No significant differences were seen in pouch function after vaginal delivery (n = 456; weighted mean difference, 0.23; 95 percent confidence interval, 0.43–0.88; P = 0.49; chi-squared statistic, 1.29; P = 0.26). Conclusions The incidence of dyspareunia increases after restorative proctocolectomy. There was a decrease in fertility after restorative proctocolectomy. Pregnancy after restorative proctocolectomy was not associated with an increase in complications. There was an increase in stool frequency and pad usage during the third trimester. Vaginal delivery is safe after restorative proctocolectomy. Pouch function after delivery returns to pregestational function within six months.