妊娠合并心脏病课件-妇产科课件

Affiliated Hospital of YouJiang Medical College for Nationalities妊娠合并心脏病妊娠合并心脏病Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalitiesn孕妇36岁，孕3产0孕28周，心悸胸闷1周入院。患者既往有先天性心脏病史，曾中孕引产2次，后放环，此次带环受孕。查体：皮肤粘膜无明显紫绀，心率110次/分，呼吸25次/分，两肺未闻及湿性啰音。腹围84cm，宫高23cm，胎心率130次/分Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for NationalitiesAffiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities一、妊娠期心脏血管方面一、妊娠期心脏血管方面的变化的变化1 1、妊娠期、妊娠期v血容量增加（血容量增加（32343234周周高峰），心排出高峰），心排出量增加，心率加快，心脏负担量增加，心率加快，心脏负担v妊娠晚期子宫增大、妊娠晚期子宫增大、膈肌上升膈肌上升心脏向上向左移位心脏向上向左移位 大血管扭曲大血管扭曲心脏负担心脏负担Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities第一产程：第一产程：宫缩，回心血量宫缩，回心血量第二产程：第二产程：宫缩宫缩;骨骼肌及腹壁肌收骨骼肌及腹壁肌收缩，周围循环阻力；加腹压使内脏血缩，周围循环阻力；加腹压使内脏血涌向心脏。涌向心脏。第三产程：第三产程：血液动力学急剧变化：胎血液动力学急剧变化：胎盘循环停止盘循环停止 回心血量增加；回心血量增加；腹腔内压骤减腹腔内压骤减 血液向内脏灌注血液向内脏灌注 回心血量减少。回心血量减少。2 2、分娩期、分娩期Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities3 3、产褥期、产褥期v子宫缩复使血液进入体循环子宫缩复使血液进入体循环v孕期组织间液体回到体循环孕期组织间液体回到体循环回心血量增加，心脏负担加重，回心血量增加，心脏负担加重，尤其是尤其是产后产后3 3天内天内。Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities妊娠合并心脏病最危险的三个时期妊娠合并心脏病最危险的三个时期v妊娠妊娠32-3432-34周周v分娩期分娩期v产后产后3 3日内日内Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities二、心脏病对妊娠影响二、心脏病对妊娠影响心脏病不影响受孕，但可引起流产、心脏病不影响受孕，但可引起流产、早产、死胎、胎儿发育迟缓、胎窘。早产、死胎、胎儿发育迟缓、胎窘。Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities三、妊娠合并心脏病的种类三、妊娠合并心脏病的种类先天性心脏病先天性心脏病发达国家最常见心脏病类型（发达国家最常见心脏病类型（70-80%）发展中国家少见（发展中国家少见（10-20%）风湿性心脏病风湿性心脏病发展中国家常见（发展中国家常见（50-90%），发），发达国家少见（达国家少见（15%）心肌病心肌病 罕见但严重罕见但严重高血压高血压 时有发生（时有发生（6-8%）较严重）较严重Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities先天性心脏病先天性心脏病Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities按照分流方式分类按照分流方式分类n左向右分流型先天性心脏病左向右分流型先天性心脏病n房间隔缺损房间隔缺损n室间隔缺损室间隔缺损n动脉导管未闭动脉导管未闭n右向左分流型先天性心脏病右向左分流型先天性心脏病n法洛四联症法洛四联症n艾森艾森曼格综合症曼格综合症n无分流型先天性心脏病无分流型先天性心脏病n肺动脉口狭窄肺动脉口狭窄n主动脉缩窄主动脉缩窄nMarfan综合症综合症Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities妊娠合并风湿性心脏病妊娠合并风湿性心脏病Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities妊娠合并风湿性心脏病妊娠合并风湿性心脏病n二尖瓣狭窄：二尖瓣狭窄：最常见最常见n二尖瓣关闭不全二尖瓣关闭不全n 主动脉瓣狭窄及关闭不全主动脉瓣狭窄及关闭不全Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities二尖瓣狭窄二尖瓣狭窄n血容量血容量n左房血流量增加左房血流量增加左室受阻左室受阻 n引起左心房压力升高引起左心房压力升高肺充血肺充血n严重肺水肿严重肺水肿Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities妊娠高血压性心脏病妊娠高血压性心脏病n孕前无心血管疾病史孕前无心血管疾病史n 本次妊娠出现妊娠高血压疾病本次妊娠出现妊娠高血压疾病n 晚孕、产时或产后晚孕、产时或产后1010天内天内n 以心肌损坏为特征心衰征候群以心肌损坏为特征心衰征候群 (以左心衰为主的全心衰以左心衰为主的全心衰)n 产后病因消除产后病因消除,病情会逐渐缓解病情会逐渐缓解Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities围生期心肌病围生期心肌病n指妊娠后半期以前无任何心脏疾病，在指妊娠后半期以前无任何心脏疾病，在妊娠最后妊娠最后3个月至产后个月至产后5个月内发生的扩个月内发生的扩张型心肌病张型心肌病n病因不明，心脏苍白，心室扩大。与病病因不明，心脏苍白，心室扩大。与病毒感染、营养不良、贫血、妊高症等有毒感染、营养不良、贫血、妊高症等有关，积极治疗心衰，心脏明显扩大者预关，积极治疗心衰，心脏明显扩大者预后差后差Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities四、诊四、诊 断断1 1、妊娠合并心脏病的诊断：、妊娠合并心脏病的诊断：v病史病史v体征体征心脏扩大：叩诊和心脏扩大：叩诊和x x线线心脏杂音：舒张期或粗糙收缩期心脏杂音：舒张期或粗糙收缩期严重心律不齐严重心律不齐心电图提示心肌损害心电图提示心肌损害注意：与妊娠本身症状及体征的鉴别注意：与妊娠本身症状及体征的鉴别Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities2 2、心脏病心功能分级、心脏病心功能分级主观功能量主观功能量 据患者生活能力状况分据患者生活能力状况分级：级：一般体力活动不受限一般体力活动不受限级：级：一般体力活动有心慌、一般体力活动有心慌、疲劳感，休息后好转疲劳感，休息后好转级：级：一般体力活动明显受限，一般体力活动明显受限，轻微活动亦受限，休息后好转轻微活动亦受限，休息后好转级：级：休息时仍有不适休息时仍有不适Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities客观手段分级法客观手段分级法nA A级：级：无心血管的客观依据无心血管的客观依据nB B级：级：客观检查表明属于轻度客观检查表明属于轻度心血管疾患心血管疾患nC C级：级：属于中度心血管疾患属于中度心血管疾患nD D级：级：属于重度心血管疾患属于重度心血管疾患诊断时两种分级法并列使用诊断时两种分级法并列使用Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities孕前咨询孕前咨询n十分必要十分必要n可以妊娠：可以妊娠：心脏病变较轻，心心脏病变较轻，心功能功能-级，既往无心衰病级，既往无心衰病史史Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities孕前咨询孕前咨询n不宜妊娠：不宜妊娠：n心功能心功能-级级n有心衰病史有心衰病史n严重的心律失常严重的心律失常n右向左分流型先心右向左分流型先心n肺动脉高压、主动脉狭窄肺动脉高压、主动脉狭窄n其它其它Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities六、常见并发症六、常见并发症n心力衰竭心力衰竭n心内膜炎心内膜炎n缺氧紫绀缺氧紫绀n静脉栓塞和肺栓塞静脉栓塞和肺栓塞Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities识别早期心力衰竭识别早期心力衰竭n轻微活动即胸闷轻微活动即胸闷 心悸心悸 气短气短n夜间因胸闷而坐位呼吸夜间因胸闷而坐位呼吸 窗口呼吸新鲜空气窗口呼吸新鲜空气n休息休息 HR110bpm R 20/minHR110bpm R 20/minn持续性肺底少量湿罗音持续性肺底少量湿罗音 咳嗽后不消失咳嗽后不消失Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities八、防八、防 治治妊娠合并心脏病主要死亡原因是妊娠合并心脏病主要死亡原因是心衰心衰，因此应做到孕前咨询、孕期加强监护。因此应做到孕前咨询、孕期加强监护。Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities1.1.妊娠期妊娠期（1 1）不宜妊娠者）不宜妊娠者：终止妊娠终止妊娠孕孕1212周前：人工流产（有心衰者应周前：人工流产（有心衰者应纠正纠正心衰后终止妊娠心衰后终止妊娠）。）。孕孕1212周后：严密观察下周后：严密观察下继续妊娠继续妊娠。（2 2）可以妊娠者）可以妊娠者：加强产检：加强产检,预防心衰。预防心衰。孕孕2020周前每周前每2 2周产检周产检1 1次，次，2020周后每周产周后每周产检检1 1次；并提前次；并提前2 2周住院待产。周住院待产。Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities（3 3）心力衰竭的预防）心力衰竭的预防n避免劳累和情绪激动避免劳累和情绪激动n饮食：高蛋白、高维生素等，适饮食：高蛋白、高维生素等，适当低盐当低盐n预防及治疗心衰的诱因预防及治疗心衰的诱因n关于预防性应用洋地黄的问题关于预防性应用洋地黄的问题Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities（4 4）心衰的处理）心衰的处理n强心强心n利尿利尿n血管扩张剂血管扩张剂n必要时终止妊娠必要时终止妊娠n其他其他Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities（1 1）分娩方式的选择）分娩方式的选择v阴道分娩阴道分娩:心功能心功能-级级v剖宫产剖宫产:心功能心功能-级级（2 2）阴道分娩的处理）阴道分娩的处理 1 1）第一产程）第一产程 2 2）第二产程）第二产程 3 3）第三产程）第三产程2.2.分娩期分娩期Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities1 1）第一产程）第一产程n镇静镇静:适当应用安定、度冷丁适当应用安定、度冷丁n必要时强心必要时强心：西地兰：西地兰n抗菌素抗菌素:临产即开始应用临产即开始应用,直至产后直至产后1 1周周.Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalitiesn避免使用腹压避免使用腹压n尽量缩短第二产程：会阴切开、尽量缩短第二产程：会阴切开、产钳、胎吸产钳、胎吸2 2）第二产程）第二产程Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities3 3）第三产程）第三产程v镇静镇静v腹部放沙袋腹部放沙袋v不常规使用宫缩剂，严禁使用不常规使用宫缩剂，严禁使用麦角新硷！麦角新硷！Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities休息休息预防感染预防感染预防心衰预防心衰哺乳问题：心功能哺乳问题：心功能-级者级者不宜哺乳不宜哺乳3 3、产褥期、产褥期Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities初初孕孕妇妇，3636岁岁，有有风风湿湿性性心心脏脏病病病病史史，现现妊妊娠娠1010周周，轻轻微微活活动动后后即即感感胸胸闷闷、气气急急、心心悸悸，近近十十天天来来半半夜夜胸胸闷闷需需坐坐起起。检检查查：心心率率112112次次/分分，呼呼吸吸2222次次/分分，双双肺肺底底可可闻闻及及细细的的湿湿罗罗音音，双双下肢浮肿（下肢浮肿（+）。处理是：）。处理是：nA.A.立即终止妊娠立即终止妊娠nB.B.积极控制心衰，继续妊娠积极控制心衰，继续妊娠nC.C.控制心衰后终止妊娠控制心衰后终止妊娠nD.D.利利尿尿、应应用用抗抗生生素素，控控制制心心衰衰后后根根据据情情况况决定是否继续妊娠决定是否继续妊娠Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities作业n妊娠期早期心衰的诊断依据妊娠期早期心衰的诊断依据n心脏病孕妇如何选择分娩方式？如阴道心脏病孕妇如何选择分娩方式？如阴道分娩应如何处理？分娩应如何处理？Affiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for NationalitiesAffiliated Hospital of YouJianAffiliated Hospital of YouJiang Medical College for Nationalities 本课结束！Thanks!Affiliated Hospital of YouJian