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中华产科急救电子杂志

中华产科急救电子杂志 ›› 2023, Vol. 12 ›› Issue (01) : 28 -35. doi: 10.3877/cma.j.issn.2095-3259.2023.01.006

论著

超声心动图评估妊娠合并严重心脏病患者剖宫产围术期心容量及功能的变化特征
江岚, 梁伟翔, 苏春宏, 苏志源, 刘丹丹, 戴丽, 陈敦金†()   
  1. 510015　广州医科大学附属第三医院　广州重症孕产妇救治中心　广东省产科重大疾病重点实验室超声医学科
    510015　广州医科大学附属第三医院　广州重症孕产妇救治中心　广东省产科重大疾病重点实验室妇产科
    510015　广州医科大学附属第三医院　广州重症孕产妇救治中心　广东省产科重大疾病重点实验室麻醉科
  • 收稿日期:2022-10-17 出版日期:2023-02-18
  • 通信作者: 陈敦金
  • 基金资助:
    广州市科技计划项目资助(202201020167)

Evaluation of perioperative cardiac volume and function by echocardiography in pregnant patients with severe heart disease during caesarean section: 14 cases analysis

Lan Jiang, Weixiang Liang, Chunhong Su, Zhiyuan Su, Dandan Liu, Li Dai, Dunjin Chen†()   

  1. Department of Medical Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Obstetrics Major Diseases of Guangdong Province, Guangzhou Medical Center for Critical Pregnant Women, Guangzhou 510150, China
    Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Obstetrics Major Diseases of Guangdong Province, Guangzhou Medical Center for Critical Pregnant Women, Guangzhou 510150, China
    Department of Anesthesia, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Obstetrics Major Diseases of Guangdong Province, Guangzhou Medical Center for Critical Pregnant Women, Guangzhou 510150, China
  • Received:2022-10-17 Published:2023-02-18
  • Corresponding author: Dunjin Chen
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引用本文：

江岚, 梁伟翔, 苏春宏, 苏志源, 刘丹丹, 戴丽, 陈敦金. 超声心动图评估妊娠合并严重心脏病患者剖宫产围术期心容量及功能的变化特征[J]. 中华产科急救电子杂志, 2023, 12(01): 28-35.

Lan Jiang, Weixiang Liang, Chunhong Su, Zhiyuan Su, Dandan Liu, Li Dai, Dunjin Chen. Evaluation of perioperative cardiac volume and function by echocardiography in pregnant patients with severe heart disease during caesarean section: 14 cases analysis[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2023, 12(01): 28-35.

目的

探索妊娠合并严重心脏病患者剖宫产围术期的心容量及功能的连续性变化特征。

方法

选取2019年4月至2021年4月在广州医科大学附属第三医院进行剖宫产的妊娠合并严重心脏病并具有Ⅳ级心血管风险的患者进行前瞻性观察，采用超声心动图于剖宫产术前30 min内、手术开始时、取胎后、取胎盘后、静滴催产素、关腹后及产后7 d内连续性评估患者的心容量及心功能，并同时分析患者临床资料。

结果

共纳入患者14例，特发性肺高压4例，风湿性心脏病3例，扩张型心肌病2例，围产期心肌病1例，非梗阻性肥厚型心肌病1例，先天性心脏病1例，感染性心内膜炎1例，斯蒂尔病累及心脏病变1例。LAESV、LAEDV、LVEDV、LVESV、LHEDV在手术开始时、取胎后及取胎盘后容量下降，静滴催产素时容量逐渐回升并在关腹后超过术前水平，LHEDV波幅范围在－21.5%~5.44%，最大波幅位于取胎盘后；RAESV、RAEDV、RVEDV、RVESV、RHEDV在手术开始时容量上升，随后在取胎后、取胎盘后、静滴催产素阶段逐渐下降并接近术前水平，关腹后下降至最低随后逐渐回升但低于术前水平RHEDV波幅范围内在－15.51%~12.11%，最大波幅位于关腹后；LAFAC、LVEF、MAPSE、LVGCPS均在静滴催产素后下降，LVGLPS在静滴催产素后上升随后下降，RAFAC、RVFAC、TAPSE、RVGLPS均在静滴催产素后上升；但围术期各阶段容量及功能指标差异无统计学意义(P>0.05)。

结论

妊娠合并严重心脏病患者剖宫产围术期的心容量及功能变化具有一定的规律可循，左心容量在手术开始后至关腹前均明显下降，右心容量在手术开始时和关腹后波幅较大，是剖宫产术中重点监测阶段。由于本研究的影响因素较多，围手术期各阶段的差异未能获得统计学意义，但为下一步的相关研究提供了一定的参考价值。

关键词: 妊娠, 心脏病, 剖宫产术, 心脏容量, 超声心动描记术，多普勒
Objective

To explore the changes in cardiac volume and function in pregnant women with severe heart disease during perioperative period of cesarean section.

Methods

According to the inclusion and exclusion criteria, pregnant patients with severe disease who underwent cesarean section in the Third Affiliated Hospital of Guangzhou Medical University were selected for prospective observation. The cardiac volume and function of the patients were assessed within 30 minutes before cesarean section, at the beginning of cesarean section, after fetal extraction, after placenta extraction, after oxytocin infusion, after abdominal closure, and within 7 days postpartum, and clinical data of the patients were collected.

Results

A total of 14 patients were included, including 4 cases of idiopathic pulmonary hypertension, 3 cases of rheumatic heart disease, 2 cases of dilated cardiomyopathy, 1 case of perinatal cardiomyopathy, 1 case of hypertrophic cardiomyopathy, 1 case of congenital heart disease, 1 case of infective endocarditis, and 1 case of Steele′s disease involving cardiac disease. The LAESV, LAEDV, LVEDV, LVESV and LHEDV decreased at the beginning of surgery, after fetal and placenta retrieval. The LHEDV gradually increased during intravenous oxytocin infusion and exceeded the preoperative level after abdominal closure. The LHEDV amplitude ranged from -21.5% to 5.44%, and the maximum amplitude was after placenta retrieval. The RAESV, RAEDV, RVEDV, RVESV and RHEDV increased at the beginning of surgery, and then gradually decreased to the preoperative level after fetal retrieval, placenta retrieval and oxytocin infusion, and then decreased to the lowest level after abdominal closure and gradually increased but was lower than the preoperative level. The RHEDV amplitude range was -15.51%-12.11%, the maximum amplitude was after abdominal closure. The LAFAC, LVEF, MAPSE and LVGCPS decreased after intravenous oxytocin, LVGLPS increased and then decreased after intravenous oxytocin, and RAFAC, RVFAC, TAPSE and RVGLPS increased after intravenous oxytocin. However, those measures have no significant difference (P>0.05).

Conclusions

Cardiovascular changes in pregnant women with severe heart disease during cesarean section have certain characteristics. The left heart volume decreases significantly after the beginning of the operation, and the right heart volume fluctuates greatly at the beginning of the operation and after abdominal closure, those stages are the key monitoring in cesarean section. Due to many influencing factors in this study, the differences at each stage of cesarean section are not statistically significant, but this paper provides certain reference values for the next related research.

Key words: Pregnancy, Heart disease, Cesarean section, Cardiac volume, Echocardiography, doppler
表1 14例妊娠合并严重心脏病患者剖宫产围术期心容量监测指标在各阶段的情况[M(P25，P75)]
监测指标 术前 手术开始时 取胎后
SBP(mmHg) 114.00(106.00，134.00) 102.00(113.00，120.00) 105.00(115.00，123.00)
DBP(mmHg) 65.00(53.00，68.00) 57.00(53.00，65.00) 57.00(50.00，73.00)
SaO2(%) 100.00(99.00，100.00) 100.00(100.00，100.00) 100.00(99.00，100.00)
CO(L/min) 5.30(5.00，7.80) 5.40(4.30，8.00) 5.00(5.70，7.10)
CI[L/(min×m2)] 3.15(2.90，5.05) 3.45(3.05，4.08) 4.10(3.40，5.70)
CVP(mmHg) 18.00(9.50，21.25) 17.20(12.00，23.85) 17.60(12.30，26.15)
HR(次/min) 87.50(72.00，110.00) 87.50(79.25，110.00) 86.00(76.00，110.50)
监测指标 取胎盘后 静滴催产素 关腹
SBP(mmHg) 91.00(87.75，123.25) 112.50(95.25，127.50) 123.00(95.25，129.75)
DBP(mmHg) 50.00(42.00，75.00) 53.50(49.75，67.00) 54.50(48.50，63.00)
SaO2(%) 100.00(92.00，100.00) 100.00(100.00，100.00) 100.00(99.25，100.00)
CO(L/min) 5.90(4.80，8.50) 5.45(4.93，7.03) 7.55(5.30，9.00)
CI[L/(min×m2)] 4.25(3.20，5.90) 3.10(2.90，4.30) 5.60(3.50，7.40)
CVP(mmHg) 16.55(8.60，24.10) 15.00(12.00，23.55) 17.60(10.05，21.35)
HR(次/min) 83.00(73.50，107.00) 76.00(70.00，83.00) 89.00(71.00，111.00)
图1 14例妊娠合并严重心脏病患者剖宫产围术期各阶段心容量变化图。A：围术期各阶段左心容量变化；B：围术期各阶段右心容量变化注：LAESV：左房收缩末容积；LAEDV：左房舒张末容积；LVEDV：左室舒张末容积；LVESV：左室收缩末容积；LHEDV：左心舒张末容量　RAESV：右房收缩末容积；RAEDV：右房舒张末容积；RVEDV：右室舒张末容积；RVESV：右室收缩末容积；RHEDV：右心舒张末容量
图2 14例妊娠合并严重心脏病患者剖宫产围术期心容量波幅、肺动脉收缩压及下腔静脉内径变化特征。A：围术期各阶段左心舒张末容量波幅变化；B：围术期各阶段下腔静脉最大内径变化；C：围术期各阶段右心舒张末容量波幅变化；D：围术期各阶段肺动脉收缩压变化注：LHEDV：左心舒张末容量；RHEDV：右心舒张末容量；IVCmax:下腔静脉最大内径；PASP：肺动脉收缩压
图3 妊娠合并严重心脏病患者剖宫产围术期经胸超声心动图。A为特发性肺高压超声心动图表现，B为风湿性心脏病左室射血分数测量，D为合并肺动脉高压的血流频谱，E为左室功能斑点追踪定量分析
表2 病例1~7妊娠合并严重心脏病患者剖宫产围术期心容积及功能变化
病例 临床诊断 检查项目 术前 手术开始时 取胎后 取胎盘后 静滴催产素 关腹
1 特发性肺高压 LAESV/LVEDV(ml) － 82.4/106 62.6/81.5 56.7/78.5 55.9/83.8 59.6/65.4
    RAESV/RVEDV(ml) － 88.9/76.2 63/55.8 57.8/36.3 57.7/44.6 70.4/37.8
    LVEF/RVFAC(%) － 60.5/69.4 75.1/60.2 66/63.1 70.6/70.6 71.9/62.2
    PASP(mmHg) 52 56 49 55 55 67
2 特发性肺高压 LAESV/LVEDV(ml) 14.1/27.5 14.2/34 10.4/16.2 8.3/12.6 － 5.42/26.8
    RAESV/RVEDV(ml) 45/174 53.4/157 47/161 42.9/146 － 46/127
    LVEF/RVFAC(%) 59/31.6 60/30.6 68.9/24.8 50/30.1 － 70.3/31
    PASP(mmHg) 105 119 114 126 － 126
3 特发性肺高压 LAESV/LVEDV(ml) 34.1/72 15.3/72.9 12.9/60 12.5/37 － 19.2/39
    RAESV/RVEDV(ml) 73.1/80.2 52/61.8 92.9/76.4 80.8/73.9 － 85/79.4
    LVEF/RVFAC(%) 60.1/43.5 72.6/43.7 60.3/41.4 61/33.2 － 64.5/48.4
    PASP(mmHg) 98 98 92 117 － 105
4 特发性肺高压 LAESV/LVEDV(ml) 26.2/33.1 15.8/26 5.6/32.1 5.1/15 5.76/39.9 11.1/45.9
    RAESV/RVEDV(ml) 88.1/79.9 79.7/131 74.2/62.4 64.1/87.8 76.0/75.5 62.6/45.3
    LVEF/RVFAC(%) 67.1/51.3 62.3/47.9 56.1/42.8 52.7/34.4 59.6/45.3 56.4/41.1
    PASP(mmHg) 110 96 76 88 75 93
5 风湿性心脏病 LAESV/LVEDV(ml) 178/92.8 313/101 153/108 163/71.3 196/103 279/107
    RAESV/RVEDV(ml) 83.7/51.1 92/57.3 70.9/38.2 54.4/32.8 52.4/20.1 59/21.6
    LVEF/RVFAC(%) 49/59.1 42.6/57.6 46.4/47.1 46.8/47.3 53.9/55.3 47.2/44.9
    PASP(mmHg) 58 96 62 63 56 66
6 风湿性心脏病 LAESV/LVEDV(ml) 83.6/70.3 81.7/53.7 123/83.2 129/83.7 87.0/51.8 104/59
    RAESV/RVEDV(ml) 23.5/19.8 27.4/23.9 26.6/31.7 29.3/42.1 15.3/31.1 30.1/40.9
    LVEF/RVFAC(%) 66/60.3 69/51.9 73.8/54.3 66.5/69.6 59.8/54.3 61/57.2
    PASP(mmHg) 51 56 48 54 45 51
7 风湿性心脏病 LAESV/LVEDV(ml) 60.7/45.1 103/59.4 51.6/49.5 56.4/54.5 44.3/55.4 52.6/68.6
    RAESV/RVEDV(ml) 46.8/35 55.9/37.3 58.7/44.4 48.5/30.6 47.4/40.2 37.9/33.5
    LVEF/RVFAC(%) 58.1/46.3 60.4/46.9 66.1/44.8 67.2/38.9 57.4/52.1 53.8/53.1
    PASP(mmHg) 96 93 106 87 88 72
表3 病例8~14妊娠合并严重心脏病患者剖宫产围术期心容积及功能变化
病例 临床诊断 检查项目 术前 手术开始时 取胎后 取胎盘后 静滴催产素 关腹
8 扩张型心肌病 LAESV/LVEDV(ml) 99/116 87/135 70/168 99/123 89/144 70/167
    RAESV/RVEDV(ml) 51/57 38/43 36/66 25/42 41/52 40/52
    LVEF/RVFAC(%) 43/52 52/48 38/47 41/35 51/45 51/50
    PASP(mmHg) 80 76 79 90 75 75
9 扩张型心肌病 LAESV/LVEDV(ml) 50.5/151 53.1/157 44.7/119 47.3/137 44.8/164.0 52.5/147
    RAESV/RVEDV(ml) 55.5/47.2 59/56.8 41.8/42.9 45.1/27.1 53.0/35.1 33.4/14.3
    LVEF/RVFAC(%) 37.2/58.1 31/49.5 26/49.2 24/56.1 29.3/51.3 28/57.3
    PASP(mmHg) 35 38 32 36 35 39
10 围产期心肌病 LAESV/LVEDV(ml) 58.3/133 74/118 62.8/87.5 59.2/97.9 80.3/88.5 41.6/113
    RAESV/RVEDV(ml) 51.5/17.3 39.8/31.2 48.1/61.5 34.9/71.8 25.1/52.7 46.3/49.8
    LVEF/RVFAC(%) 65.7/73.4 59.6/71.9 61.4/70.4 68.9/68.7 66.0/65.7 62.6/53.2
    PASP(mmHg) 36 46 55 51 58 57
11 肥厚型心肌病 LAESV/LVEDV(ml) 103/61 108/49 110/33.6 82.9/42.6 145/58.6 112/58
    RAESV/RVEDV(ml) 38.1/25.9 42.8/20.5 39.8/17.8 21.3/7.8 25/23.3 36/18.5
    LVEF/RVFAC(%) 67.2/65.6 60.1/37.1 61.3/37.6 74.2/49.6 76.3/50.6 74/40.5
    PASP(mmHg) 60 57 49 42 58 42
12 先天性心脏病 LAESV/LVEDV(ml) 85/165 79.1/189 90.7/164 72.2/145 75.5/127.0 59.1/158
    RAESV/RVEDV(ml) 15.8/17.3 14/25.5 25.7/36.8 27.2/26.4 25.2/22.1 14.1/11.3
    LVEF/RVFAC(%) 59.3/50.9 56/53.7 52.3/63.3 68.6/63.1 60.6/65.7 65.8/61.6
13 感染性心内膜炎 LAESV/LVEDV(ml) 113/131 107/105 74.8/114 79.6/109 98.0/91.9 119/121
    RAESV/RVEDV(ml) 23.2/29.1 22.2/29 19.4/25.5 24.5/25.1 25.2/29.0 19/33.9
    LVEF/RVFAC(%) 64.4/68.4 72.5/54.5 66.5/56.5 72.7/48.2 61.9/58.3 74.1/68.1
    PASP(mmHg) 34 28 37 43 43 47
14 斯蒂尔病 LAESV/LVEDV(ml) 46.8/88.5 39/70.6 43.3/63.3 42.9/62.1 32.8/84.2 39.1/66.7
    RAESV/RVEDV(ml) 30/25.3 27.5/15.9 24.2/17.2 29.4/25.7 31.2/20.9 27.5/19.3
    LVEF/RVFAC(%) 60.5/65.6 58.4/64.2 61.8/57.6 58.8/60.7 61.8/65.6 60.3/57.1
    PASP(mmHg) 36 35 30 35 31 31
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