心脏手术后妊娠分娩217例临床分析

目的:探讨心脏病患者孕前行心脏手术对妊娠结局的影响。方法:回顾性分析1993年1月至2010年9月上海交通大学医学院附属仁济医院妇产科收治的行心脏手术后妊娠及分娩的217例患者的临床资料,并与同期住院心脏疾病谱相同的孕前未行心脏手术的217例患者进行比较。结果:(1)手术组患者中先天性心脏病171例(78.80%),风湿性心脏病35例(16.13%),心律失常11例(5.07%)。(2)手术组患者中行先天性心房间隔缺损修补术60例(27.65%),室间隔缺损修补术47例(21.66%),动脉导管结扎/封堵术22例(10.14%),法洛氏四(三/五)联症矫治术25例(11.52%);风心二尖瓣换瓣/球囊扩张/成形/分离术28例(12.90%),二尖瓣、主动脉瓣联合换瓣术6例(2.76%);心脏起搏器术6例(2.76%),射频消融术5例(2.30%)等。(3)手术组患者孕期心功能Ⅰ～Ⅱ级209例(96.31%),心功能Ⅲ～Ⅳ级8例(3.69%),对照组患者孕期心功能Ⅰ～Ⅱ级183例(84.33%),心功能Ⅲ～Ⅳ级34例(15.67%)。手术组患者的孕前心功能分级与对照组比较无统计学意义(P=0.088),但孕期心功能Ⅰ～Ⅱ级者多于对照组,Ⅲ～Ⅳ级者明显减少,差异有统计学意义(P=0.000)。(4)手术组与对照组孕期发生急性心功能衰竭分别为4例(1.84%)、18例(8.29%),严重心律失常分别为1例(0.46%)、8例(3.69%);足月产儿分别为189例(87.10%)、147例(67.74%),早产儿分别为24例(11.06%)、57例(26.27%),小于胎龄儿分别为16例(12.44%)、42例(19.35%),新生儿窒息分别为3例(1.38%)、15例(6.91%),治疗性流产分别为2例(0.92%)、12例(5.53%),两组差异均有统计学意义(P<0.05)。(5)手术组中无孕产妇及围产儿死亡,对照组中孕产妇死亡2例(0.92%),围产儿死亡2例(0.92%)。结论:妊娠前心脏手术可改善患者孕期的心功能,约96%的患者心脏手术后心功能为Ⅰ～Ⅱ级,能顺利妊娠及分娩,且妊娠结局良好。

Clinical analysis of pregnancy and delivery in 217 women after cardiac surgery

Objective:To discuss the influence of cardiac surgery before conception on pregnancy outcomes in patients with heart disease.Methods:A retrospective analysis was carried out on clinical data of 217 patients who had undergone cardiac surgery before pregnancy and delivered in our hospital between Jan.1993 and Sep.2010.217 patients who didn't have cardiac surgery before pregnancy as the control group.Results:(1)The composition of heart disease in surgery group was congenital heart disease(CHD;n=171,78.80%),rheumatic heart disease(RHD;n=35,16.13%) and arrhythmia(n=11,5.07%).(2)Main cardiac surgeries were repair of atrial septal defect(n=60,27.65%),repair of ventricular septal defect(n=47,21.66%),ligation of ductus arteriosus(n=22,10.14%),radical correction of tetralogy/trilogy/pentalogy of Fallot(n=25,11.52%);mitral valve replacement/percutaneous balloon/ shaped/exclusion(n=28,12.90%),mitral valve and aortic valve replacement/incision(n=6,2.76%);permanent cardiac pace-maker implantation(n=6,2.76%),radio frequency ablation(n=5,2.30%),etc.(3)Proportion of patients in NYHA Class Ⅰ~Ⅱ were 96.31%(n=209) in surgery group and 84.33%(n=183) in control group,respectively(P=0.000).Proportion of patients in NYHA Class Ⅲ~Ⅳ were 3.69%(n=8) in surgery group and 15.67%(n=34) in control group,respectively(P=0.000).(4)In surgery group,there were 4 acute cardiac failure,1 serious arrhythmias,189 term deliveries,24 preterm deliveries,16 small birth weight for gestational age,3 asphyxia neonatorum and 2 therapeutic abortion.In control group,there were 18 acute cardiac failure,8 serious arrhythmias,147 term deliveries,57 preterm deliveries,42 small birth weight for gestational age,15 asphyxia neonatorum and 12 therapeutic abortion.There were statistical dfference between two groups.(5)There was no maternal and perinatal death in surgery group while there were 2 maternal death and 2 perinatal death in control group.Conclusions:Cardiac surgery before pregnancy can improve the cardiac function during pregnancy.Approximately 96% patients who have undergone cardiac surgery are in NYHA functional class Ⅰ~Ⅱ.They can conceive and deliver safely and have satisfactory pregnancy outcomes.