AffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心臟病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕婦36歲，孕3產0孕28周，心悸胸悶1周入院?；颊呒韧邢忍煨孕呐K病史，曾中孕引產2次，后放環，此次帶環受孕。查體：皮膚粘膜無明顯紫紺，心率110次/分，呼吸25次/分，兩肺未聞及濕性啰音。腹圍84cm，宮高23cm，胎心率130次/分AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalitiesAffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities一、妊娠期心臟血管方面的變化1、妊娠期血容量增加（32~34周高峰），心排出量增加，心率加快，心臟負擔妊娠晚期子宮增大、膈肌上升心臟向上向左移位大血管扭曲心臟負擔AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities第一產程：宮縮，回心血量第二產程：宮縮;骨骼肌及腹壁肌收縮，周圍循環阻力；加腹壓使內臟血涌向心臟。第三產程：血液動力學急劇變化：胎盤循環停止回心血量增加；腹腔內壓驟減血液向內臟灌注回心血量減少。2、分娩期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities3、產褥期子宮縮復使血液進入體循環孕期組織間液體回到體循環回心血量增加，心臟負擔加重，尤其是產后3天內。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心臟病最危險的三個時期妊娠32-34周分娩期產后3日內AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二、心臟病對妊娠影響心臟病不影響受孕，但可引起流產、早產、死胎、胎兒發育遲緩、胎窘。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities三、妊娠合并心臟病的種類先天性心臟病發達國家最常見心臟病類型（70-80%）發展中國家少見（10-20%）風濕性心臟病發展中國家常見（50-90%），發達國家少見（15%）心肌病罕見但嚴重高血壓時有發生（6-8%）較嚴重AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities先天性心臟病

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities按照分流方式分類左向右分流型先天性心臟病房間隔缺損室間隔缺損動脈導管未閉右向左分流型先天性心臟病法洛四聯癥艾森曼格綜合癥無分流型先天性心臟病肺動脈口狹窄主動脈縮窄Marfan綜合癥AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并風濕性心臟病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并風濕性心臟病二尖瓣狹窄：最常見二尖瓣關閉不全主動脈瓣狹窄及關閉不全AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二尖瓣狹窄血容量↑左房血流量增加→左室受阻引起左心房壓力升高→肺充血→嚴重肺水腫AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠高血壓性心臟病孕前無心血管疾病史本次妊娠出現妊娠高血壓疾病晚孕、產時或產后10天內以心肌損壞為特征心衰征候群(以左心衰為主的全心衰)產后病因消除,病情會逐漸緩解AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities圍生期心肌病指妊娠后半期以前無任何心臟疾病，在妊娠最后3個月至產后5個月內發生的擴張型心肌病病因不明，心臟蒼白，心室擴大。與病毒感染、營養不良、貧血、妊高癥等有關，積極治療心衰，心臟明顯擴大者預后差AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities四、診斷1、妊娠合并心臟病的診斷：病史體征心臟擴大：叩診和x線心臟雜音：舒張期或粗糙收縮期嚴重心律不齊心電圖提示心肌損害注意：與妊娠本身癥狀及體征的鑒別AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities2、心臟病心功能分級主觀功能量據患者生活能力狀況分Ⅰ級：一般體力活動不受限Ⅱ級：一般體力活動有心慌、疲勞感，休息后好轉Ⅲ級：一般體力活動明顯受限，輕微活動亦受限，休息后好轉Ⅳ級：休息時仍有不適AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities客觀手段分級法A級：無心血管的客觀依據B級：客觀檢查表明屬于輕度心血管疾患C級：屬于中度心血管疾患D級：屬于重度心血管疾患診斷時兩種分級法并列使用AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨詢十分必要可以妊娠：心臟病變較輕，心功能Ⅰ-Ⅱ級，既往無心衰病史AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨詢不宜妊娠：心功能Ⅲ-Ⅳ級有心衰病史嚴重的心律失常右向左分流型先心肺動脈高壓、主動脈狹窄其它AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities六、常見并發癥心力衰竭心內膜炎缺氧紫紺靜脈栓塞和肺栓塞AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities識別早期心力衰竭

輕微活動即胸悶心悸氣短夜間因胸悶而坐位呼吸

窗口呼吸新鮮空氣休息HR≥110bpmR≥20/min持續性肺底少量濕羅音咳嗽后不消失AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities八、防治妊娠合并心臟病主要死亡原因是心衰，因此應做到孕前咨詢、孕期加強監護。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities1.妊娠期（1）不宜妊娠者：終止妊娠孕12周前：人工流產（有心衰者應糾正心衰后終止妊娠）。孕12周后：嚴密觀察下繼續妊娠。（2）可以妊娠者：加強產檢,預防心衰。孕20周前每2周產檢1次，20周后每周產檢1次；并提前2周住院待產。

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（3）心力衰竭的預防避免勞累和情緒激動飲食：高蛋白、高維生素等，適當低鹽預防及治療心衰的誘因關于預防性應用洋地黃的問題AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（4）心衰的處理強心利尿血管擴張劑必要時終止妊娠其他AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（1）分娩方式的選擇陰道分娩:心功能Ⅰ-Ⅱ級剖宮產:心功能Ⅲ-Ⅳ級（2）陰道分娩的處理

1）第一產程

2）第二產程

3）第三產程2.分娩期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities1）第一產程鎮靜:適當應用安定、度冷丁必要時強心：西地蘭抗菌素:臨產即開始應用,直至產后1周.AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities避免使用腹壓盡量縮短第二產程：會陰切開、產鉗、胎吸2）第二產程AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities3）第三產程鎮靜腹部放沙袋不常規使用宮縮劑，嚴禁使用麥角新鹼！AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities休息預防感染預防心衰哺乳問題：心功能Ⅲ-Ⅳ級者不宜哺乳3、產褥期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities初孕婦，36歲，有風濕性心臟病病史，現妊娠10周，輕微活動后即感胸悶、氣急、心悸，近十天來半夜胸悶需坐起。檢查：心率112次/分，呼吸22次/分，雙肺底可聞及細的濕羅音，雙下肢浮腫（+）。處理是：A.立即終止妊娠B.積極控制心衰，繼續妊娠C.控制心衰后終止妊娠D.利尿、應用抗生素，控制心衰后根據情況決定是否繼續妊娠AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities作業妊娠期早期心衰的診斷依據心臟病孕婦如何選擇分娩方式？如陰道分娩應如何處理？

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalitiesAffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities

本課結束！Thanks!AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心臟病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕婦36歲，孕3產0孕28周，心悸胸悶1周入院?；颊呒韧邢忍煨孕呐K病史，曾中孕引產2次，后放環，此次帶環受孕。查體：皮膚粘膜無明顯紫紺，心率110次/分，呼吸25次/分，兩肺未聞及濕性啰音。腹圍84cm，宮高23cm，胎心率130次/分AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalitiesAffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities一、妊娠期心臟血管方面的變化1、妊娠期血容量增加（32~34周高峰），心排出量增加，心率加快，心臟負擔妊娠晚期子宮增大、膈肌上升心臟向上向左移位大血管扭曲心臟負擔AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities第一產程：宮縮，回心血量第二產程：宮縮;骨骼肌及腹壁肌收縮，周圍循環阻力；加腹壓使內臟血涌向心臟。第三產程：血液動力學急劇變化：胎盤循環停止回心血量增加；腹腔內壓驟減血液向內臟灌注回心血量減少。2、分娩期AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities3、產褥期子宮縮復使血液進入體循環孕期組織間液體回到體循環回心血量增加，心臟負擔加重，尤其是產后3天內。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并心臟病最危險的三個時期妊娠32-34周分娩期產后3日內AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二、心臟病對妊娠影響心臟病不影響受孕，但可引起流產、早產、死胎、胎兒發育遲緩、胎窘。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities三、妊娠合并心臟病的種類先天性心臟病發達國家最常見心臟病類型（70-80%）發展中國家少見（10-20%）風濕性心臟病發展中國家常見（50-90%），發達國家少見（15%）心肌病罕見但嚴重高血壓時有發生（6-8%）較嚴重AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities先天性心臟病

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities按照分流方式分類左向右分流型先天性心臟病房間隔缺損室間隔缺損動脈導管未閉右向左分流型先天性心臟病法洛四聯癥艾森曼格綜合癥無分流型先天性心臟病肺動脈口狹窄主動脈縮窄Marfan綜合癥AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并風濕性心臟病AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠合并風濕性心臟病二尖瓣狹窄：最常見二尖瓣關閉不全主動脈瓣狹窄及關閉不全AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities二尖瓣狹窄血容量↑左房血流量增加→左室受阻引起左心房壓力升高→肺充血→嚴重肺水腫AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities妊娠高血壓性心臟病孕前無心血管疾病史本次妊娠出現妊娠高血壓疾病晚孕、產時或產后10天內以心肌損壞為特征心衰征候群(以左心衰為主的全心衰)產后病因消除,病情會逐漸緩解AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities圍生期心肌病指妊娠后半期以前無任何心臟疾病，在妊娠最后3個月至產后5個月內發生的擴張型心肌病病因不明，心臟蒼白，心室擴大。與病毒感染、營養不良、貧血、妊高癥等有關，積極治療心衰，心臟明顯擴大者預后差AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities四、診斷1、妊娠合并心臟病的診斷：病史體征心臟擴大：叩診和x線心臟雜音：舒張期或粗糙收縮期嚴重心律不齊心電圖提示心肌損害注意：與妊娠本身癥狀及體征的鑒別AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities2、心臟病心功能分級主觀功能量據患者生活能力狀況分Ⅰ級：一般體力活動不受限Ⅱ級：一般體力活動有心慌、疲勞感，休息后好轉Ⅲ級：一般體力活動明顯受限，輕微活動亦受限，休息后好轉Ⅳ級：休息時仍有不適AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities客觀手段分級法A級：無心血管的客觀依據B級：客觀檢查表明屬于輕度心血管疾患C級：屬于中度心血管疾患D級：屬于重度心血管疾患診斷時兩種分級法并列使用AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨詢十分必要可以妊娠：心臟病變較輕，心功能Ⅰ-Ⅱ級，既往無心衰病史AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities孕前咨詢不宜妊娠：心功能Ⅲ-Ⅳ級有心衰病史嚴重的心律失常右向左分流型先心肺動脈高壓、主動脈狹窄其它AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities六、常見并發癥心力衰竭心內膜炎缺氧紫紺靜脈栓塞和肺栓塞AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities識別早期心力衰竭

輕微活動即胸悶心悸氣短夜間因胸悶而坐位呼吸

窗口呼吸新鮮空氣休息HR≥110bpmR≥20/min持續性肺底少量濕羅音咳嗽后不消失AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities八、防治妊娠合并心臟病主要死亡原因是心衰，因此應做到孕前咨詢、孕期加強監護。AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities1.妊娠期（1）不宜妊娠者：終止妊娠孕12周前：人工流產（有心衰者應糾正心衰后終止妊娠）。孕12周后：嚴密觀察下繼續妊娠。（2）可以妊娠者：加強產檢,預防心衰。孕20周前每2周產檢1次，20周后每周產檢1次；并提前2周住院待產。

AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（3）心力衰竭的預防避免勞累和情緒激動飲食：高蛋白、高維生素等，適當低鹽預防及治療心衰的誘因關于預防性應用洋地黃的問題AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（4）心衰的處理強心利尿血管擴張劑必要時終止妊娠其他AffiliatedHospitalofYouJianAffiliatedHospitalofYouJiangMedicalCollegeforNationalities（1）分娩方式的選擇陰道分娩:心功能Ⅰ-Ⅱ級剖宮產:心功能Ⅲ-Ⅳ級（2）陰道分娩的處理

1）第一產程

2）第二產程

3）第三產程2.分娩期AffiliatedHospitalofYouJianAffiliatedHospital