UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

高风险心脏病女性临产和分娩时的麻醉：一般注意事项

Author
Katherine W Arendt, MD
Section Editors
David L Hepner, MD
Susan M Ramin, MD
Heidi M Connolly, MD, FASE
Jonathan B Mark, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA
Translators
陈新忠, 主任医师

引言

心血管疾病是当前发达国家孕产妇死亡的主要原因[1,2]。尽管先天性心脏病女性中的妊娠率不断上升，妊娠中心源性死亡的主要病因仍然是获得性心脏病：心肌梗死、主动脉夹层及心肌病[2]。

对于高风险心血管疾病的妊娠女性的麻醉处理需要充分了解下列事项：患者的心脏解剖和病理生理学；妊娠、临产和分娩相关的生理改变如何影响患者；以及医生所选用的镇痛或麻醉技术可能诱导的血流动力学的改变。理想情况下，应该组织一个由医疗保健提供者(心血管医生、产科医生和麻醉医生)组成的医疗团队，在产前为患者制定个体化的处理方案[3]。由于围生期产科和心脏并发症可能需要迅速医疗干预，跨学科的交流及准备就显得尤为重要。

本专题将讨论高风险获得性或先天性心血管疾病产科患者的麻醉处理的一般注意事项，并着重介绍在提供最佳的麻醉处理时使围生期风险降到最低的一些措施。妊娠期心脏病处理的所有其他方面，包括特定的心脏病理学，将单独讨论(参见“获得性心脏疾病与妊娠”和“先天性心脏病女性患者的妊娠：一般原则”)。普通产科患者麻醉的基本注意事项同样适用于合并有心血管疾病产妇的麻醉处理。 (参见“产科椎管内镇痛和麻醉的不良反应”和“临产和分娩过程中疼痛的药物治疗”)

妊娠、临产和分娩过程中的血流动力学变化

了解妊娠、临产、分娩相关的血流动力学改变很有必要，这样临床医生就能预见何种心脏疾病在围生期易于产生失代偿，并选择恰当的麻醉监护和麻醉技术来使这种风险降到最低。

产前 — 心血管及血流动力学的改变可早在妊娠的第4周就发生，并且会在产后持续数月。具体表现为：全身血管阻力(systemic vascular resistance, SVR)下降，心率(heart rate, HR)上升15-20次/分钟，前负荷因血容量的上升而增加。这些改变导致心输出量(cardiac output, CO)较基线值增加30%-50%。也发生生理性稀释性贫血。正常妊娠时心血管及血流动力学适应改变总结在此图中(图 1A-C)，并将单独详细讨论。 (参见“母体为适应妊娠所作出的心血管与血流动力学改变”)

                                     

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-09-26.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116:1302.
  2. 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. BJOG 2011; 118 Suppl 1:1.
  3. 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). Eur Heart J 2011; 32:3147.
  4. Ueland K, Hansen JM. Maternal cardiovascular dynamics. II. Posture and uterine contractions. Am J Obstet Gynecol 1969; 103:1.
  5. Kjeldsen J. Hemodynamic investigations during labour and delivery. Acta Obstet Gynecol Scand Suppl 1979; 89:1.
  6. Tihtonen K, Kööbi T, Yli-Hankala A, Uotila J. Maternal hemodynamics during cesarean delivery assessed by whole-body impedance cardiography. Acta Obstet Gynecol Scand 2005; 84:355.
  7. Niswonger JW, Langmade CF. Cardiovascular changes in vaginal deliveries and cesarean sections. Am J Obstet Gynecol 1970; 107:337.
  8. Ueland K, Gills RE, Hansen JM. Maternal cardiovascular dynamics. I. Cesarean section under subarachnoid block anesthesia. Am J Obstet Gynecol 1968; 100:42.
  9. Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
  10. Khairy P, Ouyang DW, Fernandes SM, et al. Pregnancy outcomes in women with congenital heart disease. Circulation 2006; 113:517.
  11. van Mook WN, Peeters L. Severe cardiac disease in pregnancy, part I: hemodynamic changes and complaints during pregnancy, and general management of cardiac disease in pregnancy. Curr Opin Crit Care 2005; 11:430.
  12. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  13. Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007; 28:230.
  14. Jastrow N, Meyer P, Khairy P, et al. Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center. Int J Cardiol 2011; 151:209.
  15. Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31:2124.
  16. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 2008; 118:e714.
  17. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:e521.
  18. Fayad G, Larrue B, Modine T, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure in postpartum woman with rheumatic mitral valve disease: benefit, factors furthering the success of this procedure, and review of the literature. J Extra Corpor Technol 2007; 39:112.
  19. Rasmusson K, Brunisholz K, Budge D, et al. Peripartum cardiomyopathy: post-transplant outcomes from the United Network for Organ Sharing Database. J Heart Lung Transplant 2012; 31:180.
  20. Ford AA, Wylie BJ, Waksmonski CA, Simpson LL. Maternal congenital cardiac disease: outcomes of pregnancy in a single tertiary care center. Obstet Gynecol 2008; 112:828.
  21. Maxwell BG, El-Sayed YY, Riley ET, Carvalho B. Peripartum outcomes and anaesthetic management of parturients with moderate to complex congenital heart disease or pulmonary hypertension*. Anaesthesia 2013; 68:52.
  22. Goldszmidt E, Macarthur A, Silversides C, et al. Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery. Int J Obstet Anesth 2010; 19:266.
  23. Weis FR Jr, Markello R, Mo B, Bochiechio P. Cardiovascular effects of oxytocin. Obstet Gynecol 1975; 46:211.
  24. Secher NJ, Arnsbo P, Wallin L. Haemodynamic effects of oxytocin (syntocinon) and methyl ergometrine (methergin) on the systemic and pulmonary circulations of pregnant anaesthetized women. Acta Obstet Gynecol Scand 1978; 57:97.
  25. Ramsey PS, Hogg BB, Savage KG, et al. Cardiovascular effects of intravaginal misoprostol in the mid trimester of pregnancy. Am J Obstet Gynecol 2000; 183:1100.
  26. O'Leary AM. Severe bronchospasm and hypotension after 15-methyl prostaglandin F(2alpha) in atonic post partum haemorrhage. Int J Obstet Anesth 1994; 3:42.
  27. Andersen LH, Secher NJ. Pattern of total and regional lung function in subjects with bronchoconstriction induced by 15-me PGF2 alpha. Thorax 1976; 31:685.
  28. Secher NJ, Thayssen P, Arnsbo P, Olsen J. Effect of prostaglandin E2 and F2alpha on the systemic and pulmonary circulation in pregnant anesthetized women. Acta Obstet Gynecol Scand 1982; 61:213.
  29. Abouleish E. Postpartum hypertension and convulsion after oxytocic drugs. Anesth Analg 1976; 55:813.
  30. McCubbin JM, Sibai BM, Ardella TN, Anderson GD. Cardiopulmonary arrest due to acute maternal hypermagnesaemia. Lancet 1981; 1:1058.
  31. Ellis JE, Shah MN, Briller JE, et al. A comparison of methods for the detection of myocardial ischemia during noncardiac surgery: automated ST-segment analysis systems, electrocardiography, and transesophageal echocardiography. Anesth Analg 1992; 75:764.
  32. Leung JM, Voskanian A, Bellows WH, Pastor D. Automated electrocardiograph ST segment trending monitors: accuracy in detecting myocardial ischemia. Anesth Analg 1998; 87:4.
  33. Slogoff S, Keats AS, David Y, Igo SR. Incidence of perioperative myocardial ischemia detected by different electrocardiographic systems. Anesthesiology 1990; 73:1074.
  34. London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography. Anesthesiology 1988; 69:232.
  35. Hamlyn EL, Douglass CA, Plaat F, et al. Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 2005; 14:355.
  36. Oxorn D. The risks of central neuraxial anesthesia. Anesthesiology 1998; 88:272.
  37. Ioscovich AM, Goldszmidt E, Fadeev AV, et al. Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review. Int J Obstet Anesth 2009; 18:379.
  38. Autore C, Brauneis S, Apponi F, et al. Epidural anesthesia for cesarean section in patients with hypertrophic cardiomyopathy: a report of three cases. Anesthesiology 1999; 90:1205.
  39. Arendt KW, Muehlschegel JD, Tsen LC. Cardiovascular alterations in the parturient undergoing cesarean delivery with neuraxial anesthesia. Expert Rev Obstet Gynecol 2012; 1:59.
  40. American Society of Anesthesiologists Task Force on Neuraxial Opioids, Horlocker TT, Burton AW, et al. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009; 110:218.
  41. Ngan Kee WD, Lee A, Khaw KS, et al. A randomized double-blinded comparison of phenylephrine and ephedrine infusion combinations to maintain blood pressure during spinal anesthesia for cesarean delivery: the effects on fetal acid-base status and hemodynamic control. Anesth Analg 2008; 107:1295.
  42. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm 2011; 8:1114.
  43. American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the american society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology 2011; 114:247.
  44. Dob DP, Yentis SM. UK registry of high-risk obstetric anaesthesia: report on cardiorespiratory disease. Int J Obstet Anesth 2001; 10:267.
  45. Bonnin M, Mercier FJ, Sitbon O, et al. Severe pulmonary hypertension during pregnancy: mode of delivery and anesthetic management of 15 consecutive cases. Anesthesiology 2005; 102:1133.