429例妊娠合并肺动脉高压患者临床资料分析与心力衰竭预测指标探讨

发布时间：2019-06-08 08:43

【摘要】：目的：1.探讨妊娠合并肺动脉高压病种分布及孕前行心脏手术对孕期心功能的影响。 2.探讨采用最新的仲裁标准对妊娠期妇女肺动脉压力进行分级对心功能及妊娠结局的影响，与既往分级标准相比是否更适用于妊娠合并肺动脉高压患者。 3.探讨除临床常用指标脑钠肽外是否存在其他更好的预示妊娠合并肺动脉高压伴心力衰竭的警示指标。方法：1.对我院2003年1月至2013年12月间妇产科收治的429例妊娠合并肺动脉高压患者的相关临床资料进行回顾分析。 2.初期筛选病历资料时依据以往肺动脉高压诊断标准，，即超声心动图中肺动脉压力30mmHg时诊断为肺动脉高压，后结合最新三尖瓣反流法诊断肺动脉高压的仲裁标准：将所有患者右心房压力设定为5mmHg，进而根据连续多普勒三尖瓣反流法得到的右心房室间压差将肺动脉收缩压裁定为3种结果：(1)除外肺动脉高压：三尖瓣反流峰值速度≤2.8m/s，即估算肺动脉收缩压≤36mmHg，不存在其他支持肺动脉高压的超声心动图表现。(2)可疑肺动脉高压(包含两种情况)：①三尖瓣反流峰值速度≤2.8m/s，即估算肺动脉收缩压≤36mmHg，存在其他支持肺动脉高压的超声心动图表现；②三尖瓣反流峰值速度介于2.8-3.4m/s，即估算肺动脉收缩压介于36-50mmHg，无论是否存在其他支持肺动脉高压的超声心动图表现。(3)基本确定(或很可能存在)肺动脉高压：三尖瓣反流峰值速度3.4m/s，即估算肺动脉收缩压50mmHg，无论是否存在其他支持肺动脉高压的超声心动图表现，把429例妊娠合并肺动脉高压患者肺动脉压力分为可疑肺动脉高压与确定肺动脉高压两组来进行研究，同时对比根据既往轻、中、重三级标准进行分级所得出的结果，进行分析。 3.根据妊娠期早期心衰诊断标准，结合国际心肺研究所心衰诊断标准筛选出46例妊娠合并肺动脉高压伴心力衰竭患者进行分析研究。结果：1.妊娠合并肺动脉高压患者中，以先天性心脏病发生率最高（267例，占62.24%），其次为风湿性心脏病（81例，占18.88%），排第三位的为合并心律失常患者（27例，占6.29%）。 2.在所有分析的429例病例资料中，孕期（或孕前）曾行心脏手术治疗的有92例（21.45%），主要包括室间隔缺损/房间隔缺损修补（封堵）术，二尖瓣（主动脉瓣、三尖瓣）置换术，先心联合修补术，法洛氏四（三、五）联症矫治术，二尖瓣球囊扩张术等。其中心功能I级患者79例，II级8例，III级3例，IV级2例，心脏手术能改善孕期患者心功能状态，与非手术组相比，差异有统计学意义（P0.01)。 3.依据最新三尖瓣反流法诊断肺动脉高压的仲裁标准，把所有患者按照肺动脉压力不同分为可疑肺动脉高压组243例与确定肺动脉高压组186例，前组心功能I-II级患者有226例，占93%，而后组心功能III-IV级患者有67例，占36.02%，两组数据相比，差异较大。同时分析以往分级标准轻度（30-50mmHg）、中度（50-80mmHg）、重度组（80mmHg）的心功能I-IV级分布情况，仅轻度组与中度组、轻度组与重度组心功能数据相比，差异有统计学意义，而中度组与重度组之间心功能数据无明显差异（P0.05）。 4.可疑肺动脉高压组中，剖宫产185例，早产29例，医源性流产24例，新生儿平均体重（3029.02±546.85）g；确定肺动脉高压组中，剖宫产133例，早产64例，医源性流产41例，新生儿平均体重（2482.73±689.61）g，两组数据相比，差异均有统计学意义（P0.05)。同样分析以往分级标准轻度、中度、重度组的妊娠结局分布情况，分别分析三组活产率、医源性流产率、剖宫产率、早产率、低体重儿率、转院率，同样发现轻、中度组与轻、重度组之间数据有较大差异（P0.01），中、重度之间数据无明显差异（P0.1），其中三组剖宫产率均无明显差异（P0.1)。 5.在所有资料中共筛选出孕期发生心力衰竭或孕前有心力衰竭史的患者46例（10.72%），其中心功能III级与IV级患者各23例，主要以风湿性心脏病、先天性心脏病、高血压性心脏病为主。有7例患者在发生心衰前行相关心脏手术治疗，有34例患者同时有部分心脏结构的改变，有5例孕产妇最终因肺动脉高压导致心力衰竭而死亡。应用Logistic回归分析法得出了五项预示妊娠合并肺动脉高压伴心力衰竭的警示指标：有心脏结构改变、心功能≥III级、肺动脉压力≥50mmHg、风湿性心脏病、高血压性心脏病。同时得出两项相对保护因素：孕前发现疾病、行心脏手术治疗。结论：1.妊娠合并肺动脉高压患者主要以先天性心脏病与风湿性心脏病为主，孕前或孕期行相关心脏手术治疗能改善患者心功能，减少合并症的发生。 2.较以往轻、中、重三级分级标准，最新的分级诊断标准更适用于妊娠合并肺动脉高压患者的研究。 3.存在五项预示妊娠合并肺动脉高压伴心力衰竭的警示指标：孕期有心脏结构改变、心功能≥III级、肺动脉压力≥50mmHg、风湿性心脏病、高血压性心脏病。早期对心脏疾病进行明确诊断及行相关心脏手术后再妊娠对于预防心力衰竭的发生也有一定的效果。
[Abstract]:Objective:1. To study the distribution of high-pressure disease and the effect of pre-pregnancy on heart function during pregnancy. 2. To explore the effect of the latest arbitration standard on the cardiac function and the outcome of the pregnancy in the pregnant women with pulmonary artery pressure. 3. To explore the presence or absence of other better predictors of pregnancy associated with pulmonary hypertension and heart failure, in addition to the commonly used indicator of the brain natriuretic peptide. indicator Method:1. The clinical data of 429 cases of pregnancy combined with pulmonary hypertension in the department of obstetrics and gynecology in our hospital from January 2003 to December 2013 were returned. Looking for analysis.2. The initial screening of the medical record data is based on the prior pulmonary hypertension diagnostic criteria, namely, the diagnosis of pulmonary hypertension at 30 mmHg of the pulmonary artery pressure in the echocardiography, and the diagnosis of pulmonary hypertension by combining the latest tricuspid valve reflux method: setting the right atrial pressure of all patients to The systolic pressure of the pulmonary artery was determined to be 3 results according to the pressure differential between the right atrium and the right atrium obtained by the continuous Doppler tricuspid regurgitation method: (1) except for pulmonary hypertension: the peak velocity of the tricuspid regurgitation was 2.8 m/ s, that is, the estimated systolic pressure of the pulmonary artery was 3. 6 mmHg, no other ultrasound to support pulmonary hypertension Echocardiographic performance. (2) Suspicious pulmonary hypertension (including two cases): The peak velocity of the tricuspid regurgitation is 2.8m/ s, that is, the estimated pulmonary artery systolic pressure is 36mmHg, and there are other echocardiographic manifestations that support the pulmonary hypertension; the peak velocity of the tricuspid regurgitation is between 2.8 and 3. .4 m/ s, i.e., the estimated pulmonary artery systolic pressure is between 36 and 50 mmHg, regardless of any other ultrasound that supports pulmonary hypertension Echo performance. (3) Basic determination (or likely to be) pulmonary hypertension: the peak velocity of tricuspid regurgitation is 3.4 m/ s, that is, the estimated pulmonary artery systolic pressure is 50 mmHg, regardless of any other ultrasound that supports pulmonary hypertension The results showed that the pulmonary artery pressure of 429 pregnant patients with pulmonary hypertension was divided into two groups: suspicious pulmonary hypertension and pulmonary hypertension. 3. According to the diagnostic criteria of early heart failure in the period of pregnancy,46 cases of pregnancy combined with pulmonary hypertension with heart failure were selected according to the standard of heart failure diagnosis of the International Institute of Cardiorespiratory Research. Analysis of the person Results:1. The highest incidence of congenital heart disease (267 cases, 62.24%), followed by rheumatic heart disease (81 cases, 18.88%), and the third in the patients with combined arrhythmia (27 (6.29%).2. Among the 429 cases of all the analyses,92 cases (21.45%) of cardiac surgery were treated during pregnancy (or pre-pregnancy), mainly including ventricular septal defect/ atrial septal defect repair (occlusion), mitral valve (aortic valve, tricuspid valve). Repair of total replacement, first-heart combined repair, and method of the treatment of four (three and five) cases There were 79 cases of cardiac function,8 cases of grade II,3 cases of grade III and 2 cases of grade IV, and the heart operation could improve the cardiac function of the patients during pregnancy, and the difference was the same as that of the non-operative group. 3. According to the criteria for the diagnosis of pulmonary hypertension by the most recent tricuspid valve, all the patients were divided into three groups: the high-pressure group of the suspected pulmonary artery and the determination of 186 cases of the pulmonary hypertension group, and the cardiac function I-II in the anterior group. In the second group, there were 226 cases (93%) and 67 (36.02) patients with cardiac function (III-IV). At the same time, the heart function I-IV of mild group (30-50 mmHg), moderate (50-80 mmHg) and severe group (80 mmHg) were analyzed. The difference was statistically significant in comparison with the data, while the number of cardiac function between the moderate and severe groups There was no significant difference (P0.05).4. In the group of suspicious pulmonary hypertension,185 cases of cesarean section,29 cases of premature delivery,24 cases of iatrogenic abortion, and average body weight of the newborn (3029.02-546.85) g; and the determination of 133 cases of cesarean section,64 cases of premature delivery,41 cases of iatrogenic abortion and average body weight of the newborn (2 482.73 (689.61) g, difference in two groups of data In the same way, the distribution of pregnancy outcome in mild, moderate and severe group was also analyzed, and the rate of live birth, iatrogenic abortion rate, the rate of cesarean section, the rate of premature birth and the rate of low birth weight were analyzed. The results showed that there was a significant difference between the light, moderate group and light and severe group (P0.01), and there was no significant difference between the moderate and severe groups (P0.01). There was no significant difference in the yield of the uterus (P0.01).5. In all the data,46 cases (10.72%) of patients with heart failure or history of heart failure were selected during pregnancy, of which 23 of the patients with cardiac function III and IV were mainly rheumatic heart disease. Congenital heart disease, hypertensive heart disease,7 patients were treated with heart surgery with heart failure,34 of them had a partial heart structure change, and there were 5 pregnant women. In the end, the death of heart failure due to the high pressure of the pulmonary artery was caused by the high pressure of the pulmonary artery. Logistic regression analysis was used to obtain five warning indexes for the combined pulmonary hypertension with heart failure: the changes of the heart structure, the heart function, the grade III and the pulmonary artery pressure of 50 mm. Hg, rheumatic heart disease, hypertensive heart disease, and two relative protection Factors: pre-pregnancy Conclusions:1. The patients with high-pressure pregnancy with pulmonary hypertension are mainly congenital heart disease and rheumatic heart disease, and related cardiac operation before or during pregnancy. The treatment can improve the heart function of the patient and reduce the occurrence of the complications. The criteria of break-off are more applicable to the study of high-pressure patients with pregnancy combined with pulmonary hypertension.3. There are five warning indicators for the combined pulmonary hypertension with heart failure: changes in the heart structure during pregnancy, Class III of cardiac function, and pulmonary arterial pressure 50 mmHg, rheumatic heart disease, and hypertensive heart disease. Early diagnosis of heart disease and related heart hand
【学位授予单位】：上海交通大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R714.252

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