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接上文：
译者：黄启涛、杨泓、何泽琳、邓诗蕾（南方医科大学南方医院）
审校：徐晖 （山东大学第二医院）
对于患有心血管疾病的患者，产前，产时和产后妊娠管理的一般方法是什么？
产前管理原则
患有心脏病的孕妇应该在医院接受适当的孕妇护理(60)。在分娩前应预测，概述和记录减少孕妇和胎儿并发症所需的资源。应在医疗记录中随时提供关于怀孕，分娩和产后期间的全面护理计划，并且所有涉及该妇女护理的医疗服务提供者都可以方便地获取该计划。患有复杂先天性或非先天性心脏病的女性应由妊娠心脏病小组治疗（表4）(52,80,132)，并应按照团队和诊断的指示进行全面的心脏诊断评估。对于患有先天性心脏病的女性，在妊娠18-22周时需要筛查胎儿超声心动图，因为胎儿先天性心脏缺陷的风险估计为4-10％(133,134)。胎儿生长评估应考虑通过连续临床检查或超声检查，因为胎儿生长受限发生在许多类型的母体先天性和后天性心脏病变中(133,135)。
患有慢性疾病（如孕前糖尿病或慢性高血压）的女性可能会出现其疾病的心脏和其他血管并发症(46,47)。对于子痫前期高风险的女性，建议每日服用低剂量阿司匹林，并应在妊娠12-28周之间开始并持续至分娩。对于患有多种中度子痫前期危险因素的女性，应考虑进行类似的预防(136)。对于患有心血管疾病的女性，在怀孕期间指示抗高血压治疗的精确血压水平仍然存在争议。建议使用降血压药物对患有临床心血管疾病（定义为冠心病，充血性心力衰竭和中风）和平均收缩压为130 mm Hg或更高，或者平均舒张压为80 mm Hg或更高的非妊娠患者的复发性心血管疾病事件进行二级预防(137)。很少有关于妊娠期这一主题的临床试验，证据有限(47)。建议及时治疗严重高血压（收缩压超过160 mm Hg，舒张压超过110 mm Hg）以预防并发症(47,138)。左心室肥厚伴舒张功能受损可能在长期高血压的情况下发生。由于怀孕期间和静脉内液体推注后基线体积增加，这种情况可能使孕妇处于心源性肺水肿的风险中。患有先兆子痫的患者的肺水肿可能是心源性的或非心源性的或两者的组合。超声心动图可以帮助区分这两个实体。对于肺水肿可能由于围产期心肌病或先兆子痫引起的任何孕妇或产后患者应进行超声心动图检查。
一般而言，妊娠期和产后的定期体育活动可改善或维持身体健康，有助于控制体重，降低肥胖女性患妊娠糖尿病的风险，并增强心理健康。在怀孕并发心脏病的情况下，应该由妊娠心脏小组仔细评估该妇女，然后提出有关参加体育活动的建议(139)，以确保患者没有心脏原因避免运动。
产时管理原则
详细的分娩计划应在妊娠20-30周之间确定并记录在病历中。建议通过与患者和妊娠心脏团队共同决策制定个性化计划。该策略应包括归纳，分娩和产后问题的管理以及监督计划。患有稳定心脏病的妇女可以在妊娠39周时进行阴道分娩，剖宫产预留用于产科适应症(140)。一些患有高风险心脏病的患者可能无法忍受心输出量的波动或阴道分娩期间发生的Valsalva动作。对于这些患者中，分娩期间的局部麻醉可以提供足够的疼痛缓解（从而最小化儿茶酚胺释放和由此引起的心输出量波动）以使阴道分娩成为可能。妊娠心脏病小组（表4）应确定哪些患者不适合阴道分娩或在怀孕期间需要辅助第二产程。在没有自发性分娩或在足月前指示分娩的情况下，可以考虑妊娠心脏病队的投入，为妊娠39-40周之间的心脏病孕妇安排分娩。
怀孕期间必须仔细检查和管理抗凝治疗，并在椎管内麻醉和产时进行适当调整。对于正在接受预防性低分子肝素治疗的女性，建议在预定分娩或剖宫产前至少12小时停用。对于接受调整剂量治疗的患者，建议间隔为24小时(44,141,142)。对于普通肝素剂量7,500单位皮下注射，每天两次或更多，建议间隔12小时以及通过实验室检测评估凝血状态。根据机构的协议，接受抗凝治疗的妇女可能会因为华法林或低分子量肝素转换为较短半衰期的普通肝素而需要分娩。如果临床上合适，替代方案可以是在24小时内停止抗凝和诱导分娩。如果计划转换为普通肝素，则应根据自发分娩的可能性进行，目的是尽量缩短没有抗凝血覆盖的时间。这种方法对于机械瓣膜假体患者尤其重要(44,88,119)。
最常见的产时心脏并发症包括肺水肿或心律失常(54,59,133)。这些患者需要高水平的监督和护理。对于有心律失常史的女性和怀孕期间发生心律失常的女性，建议进行产时心脏监测(52)。通常可以通过保持细致的液体平衡来预防肺水肿。专家共识是，对于发生感染性心内膜炎的风险增加的患者，例如有先前感染性心内膜炎病史的患者，以及患有不良反应的高风险患者，在产时给予抗生素预防是合理的。感染性心内膜炎的结果(88,91)。
产科麻醉原则
对于所有产科手术（例如，扩宫和刮宫或清宫或环扎）以及阴道或剖宫产手术，心脏病患者可能需要提高监测和麻醉护理水平。应该对产前麻醉师进行咨询，以进行麻醉，心脏和产科风险评估和规划。
在麻醉师的指导下，应对阴道分娩的心脏病患者进行硬膜外分娩镇痛，如果可能，接受剖宫产的心脏病患者应进行椎管内麻醉。随着硬膜外麻醉使用，心血管事件（通常是心律失常）显著降低(143)。椎管内麻醉的例外情况包括常见的麻醉禁忌症和接受药物抗凝治疗的患者，如上所述(141,142,144)。还应考虑修改与降低全身血管阻力相关的心血管失代偿风险患者的椎管内麻醉管理。这些患者包括左心室流出道梗阻或紫绀型先天性心脏病。
产后即时管理原则
产后是心血管疾病相关孕妇发病率和死亡率风险增加的时期(80), 慢性病产后住院率在过去的十年上升了3倍就证明了这一点(14)。在心血管疾病相关死亡率中, 围产期心肌病被确定为产后晚期死亡的主要因素（23%）(10,144)。主动脉夹层和急性冠脉综合征通常在产后早期诊断, 并与产妇死亡的高风险相关(15,145-147)。急性冠脉综合征的发病率估计为每 100 000次分娩 2.7-8.1 例, 与非孕妇相比, 怀孕和产后的发病率为3倍至4倍(15,17,118,119,148)。心脏病尤其与产后1年的产妇晚死有关(10)。
在产褥期早期（分娩后前7天）和产后6个月患有心脏病的女性发生即刻并发症的风险很高(26)。产后即刻产科并发症（如高血压疾病，出血和感染）的常见并发症加剧了这种风险。可能需要提高护理水平或长时间监测，特别是对于有心源性肺水肿和心律失常风险的患者，或同时产科和手术并发症的患者。应考虑使用脉搏血氧仪，肺部听诊，记录液体平衡以及发生呼吸急促或咳嗽，仔细和频繁地监测心血管疾病的体征和症状（表2）。心血管检测可能适合并个性化以呈现特征。如果在护理过程中的任何时间发生与确诊疾病或新发，获得性产科心脏病相关的产科并发症，应加快与心脏病专家的早期咨询以及可能将患者转移到护理水平较高的机构。
每个机构应审查可用的静脉血栓栓塞风险评估方案，并采用并实施其中一项，以减少产后静脉血栓栓塞的发生率(44)。剖宫产，尤其是并发产后出血或感染，以及医学因素或妊娠并发症，会增加静脉血栓栓塞的风险。虽然目前的证据不足以建议在剖宫产术后普遍采用静脉血栓栓塞的药物预防措施，但对于选择的高风险患者，可能会考虑预防性疾病(44)。如果考虑血栓形成，有证据表明，对于体重指数为35或更高的女性，与固定剂量相比，基于体重的剂量（每12小时0.5 mg/kg依诺肝素）将在适当的预防中达到显着更高的抗Xa浓度范围(149,150)。然而，血栓预防的最佳剂量，途径和持续时间需要进一步评估。
有心脏病或心血管疾病的妇女，避孕的选择和考虑是什么?
避孕方面的考量
决定女性最适合的避孕方法需要讨论她未来怀孕的意愿和个人偏好，以及批判性评估病人的潜在疾病和所选的避孕选择的相对风险和益处。
宫内节育器是患高危心血管疾病女性的非永久性避孕的推荐选择(155,158)。宫内节育器是一种高效可靠的长效可逆避孕方法。多种宫内节育器（含铜和孕酮）可根据患者的偏好、禁忌和对未来生育能力的意愿而选择。使用宫内节育器的年失败率低于1%，根据使用的设备类型，手术时间从3年到10年不等。宫内节育器可在门诊进行，且对有潜在心脏病的女性风险最小(155,158)。尽管节育器移位会增加（10-27%），但胎盘娩出后立即放置宫内节育器也是一种对于患高危心脏病女性的推荐方法，以确保在避孕保护方面没缺漏(159)。应向女性提供关于宫内节育器排出风险的增加及排出迹象和症状的咨询(159)。
单纯孕激素避孕（如口服、注射长效醋酸甲羟孕酮避孕针或皮下埋植剂）是患心脏病女性的潜在有效替代方法。单纯孕激素避孕片主要限制在哺乳期女性产后立即使用。然而，这种方法在避孕方面的效果较低（失败率超过9%）(155,160,161)。肌内注射长效醋酸甲羟孕酮避孕针是一种高效的避孕方式，对于患有瓣膜性心脏病、心肌病和控制良好的高血压的女性是一种安全的选择(155,162)。对于接受抗凝治疗的女性，从理论上讲，长效醋酸甲羟孕酮避孕针会增加血肿形成的风险。可逆性骨质丢失、具有保护作用的高密度脂蛋白的减少和甘油三酯的增加是由长效醋酸甲羟孕酮避孕针的低雌激素作用引起的(163,164)。孕酮埋植剂是非常有效的，对于大多数患高血压或确诊的心脏疾病女性似乎是一个安全的选择。但对于目前或曾患有缺血性心脏病或脑血管意外的女性的这种药物安全性数据有限，因为其存在增加血栓风险(155)。对于接受抗凝治疗的女性，在放置和/或取出时，也可能有血肿形成的风险。
复方激素避孕（如口服、放置避孕环或避孕贴片）虽然有效，但由于雌激素成分的存在，取决于患者的不同潜在心脏状况，可能对女性造成巨大风险。超过35岁且高血压控制不良的女性（或伴有吸烟史，或患偏头痛先兆）使用复方激素避孕药，可能与高血压、心血管疾病（如中风、急性心肌梗塞）和血栓栓塞事件恶化的风险增加有关(155,161,162,165-169)。对于有瓣膜心脏病的女性，尤其是那些有复杂瓣膜病变的女性，使用复方激素避孕药可能会增加动脉血栓形成和其他心血管不良后果的风险。在心肌病患者中使用复方激素避孕药可能与液体潴留有关，而液体潴留会加重心力衰竭(170)。基于这些考虑，对于血栓形成前状态、高血压失控、缺血性心脏病和复杂瓣膜心脏病的女性，应考虑其他避孕方案(155)。
阻碍法避孕，生育意识为基础的避孕，和其他非激素避孕方法用于减少受精的风险，虽然安全，却有高避孕失败的风险。因此，这些方法对于不想继续生育的女性或患有严重心血管疾病且不推荐或禁止怀孕的女性来说是次优的。
患有禁忌症的女性可通过使用复方激素避孕法紧急避孕(155,161)。心血管疾病并不是紧急避孕的禁忌症。单纯孕激素的紧急避孕方法通常比复方药避孕耐受性更好，更有效，可能是心血管疾病的首选方案。在无保护性交后5天内放置含铜宫内节育器是一种有效的紧急避孕方法。含铜宫内节育器能提供持续的避孕保护，建议提供给妊娠死亡率高的患者(158)。
永久性绝育是育龄女性完成生育后最有效的避孕选择之一，特别是对有高危心脏病或心血管疾病的女性而言。男性输精管切除术是一种非常有效的男性绝育方法，并发症低，失败率低于1%(155,172,173)。输精管切除术的局限性有：在非一夫一妻制或与新伴侣发生性关系的情况下怀孕的可能性低。女性绝育可以通过几种方法进行（如腹腔镜、小切口手术、剖宫产术中）(172)。虽然腹腔镜手术是一种有效和安全的绝育方法，但全身麻醉和气腹（导致腹腔内压力增加）可能改变心脏和肺功能，从而危及某些严重心脏异常的女性的生命安全(174,175)。低压气腹腹腔镜似乎不能减轻这些手术的生理影响(176)。局部麻醉下可施行小切口输卵管结扎术，可将心脏病患者术中风险降到最低(172)。
有心血管疾病的女性怀孕后的长远考虑是什么?
对于患有先天性或获得性心脏病和心血管疾病的女性，有短期和长期的持续性护理考虑。短期和长期的考虑包括：
确保在孕中或产后进行适当的心脏病随访。
认识到慢性疾病诊断的作用和长期用药的可能需要。如果临床需要，考虑3个月（或更长）的处方(177)。
当出现通常由早产引起的母乳喂养不便时，将心血管疾病患者转介给哺乳服务机构(178)。
注意生产前后心血管疾病对孕妇心理健康的影响。早产还与孕妇的抑郁、焦虑和创伤后应激障碍有关(179)。值得注意的是，大多数用于治疗这些疾病的药物都不与母乳喂养相冲突，甚至可以与心脏药物联合使用。如所述，调动一切可用资源在这段时间内支持病人及其家属。
讨论患者未来的怀孕意愿，并提供相应的避孕措施。
通过常规产后随访筛查患者是否有抑郁症状和创伤后应激障碍的，若有，则转介社会服务中心和/或心理服务中心(179)。
这些都是妊娠早期的首要考虑内容，因为许多女性在产后42天后就失去了健康保险。这些步骤在产后阶段尤为重要，因为此时患有心血管疾病的女性正专注于新生儿护理，不太可能把自己的健康放在首位。
专家简介
徐晖
徐晖，男，1973年3月出生。1997年6月毕业于山东医科大学临床医学系，获得学士学位，2010年6月毕业于山东大学医学院，获得妇产科硕士学位。自1997年7月至今在在山东大学第二医院妇产科从事临床医疗工作。2013年9月聘为副主任医师。主要擅长妇科肿瘤、微创领域。承担山东省科技厅及卫计委基金项目各一项，迄今在国内外杂志发表论文7篇，SCI收录2篇, 主编专著2部，参编专著7部。
主要社会兼职
1.山东中西医结合学会生殖内分泌专业委员会常务委员
2.山东省微量元素科学研究会妇产科专业委员会第一届委员
3.山东省抗癌协会妇科肿瘤分会首届青年委员会委员
4.山东省医师协会妇科微创医师分会第一届委员会委员
5. 山东省医师协会妇产科医师分会子宫内膜异位症和慢性盆腔痛委员会第一届委员
6. 济南市健康服务促进会常务理事
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