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指南速递 | 2019 ACOG指南妊娠与心脏病 (中)

2019-06-20 12:02 来源: 中国乐虎app官网网 作者: 中国乐虎app官网网 浏览量: 2532

译者:黄启涛、杨泓、何泽琳、邓诗蕾(南方医科大学南方医院)

对有可能患心脏病的孕妇,有什么指标性的测试以及这些测试应该如何解释?


        出现呼吸急促、胸痛或心悸等症状或确诊的心血管疾病,无论是症状性或无症状,或两者兼而有之的孕妇,在怀孕或产后期间有必要检查其心脏状况。与心血管疾病相关的因素,如家族史和潜在的医疗状况,在评估心血管疾病的风险方面起着重要作用。测试的类型和评估的紧急性取决于潜在的心脏状况和呈现的症状(表2)。

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利钠肽

        脑钠肽 (BNP)和氨基酸末端脑钠肽前体 (NT-proBNP) 同属利钠肽  (统称BNP)。利钠肽水平升高可能意味着心脏衰竭。虽然脑钠肽参考值范围因实验室、化验、年龄、性别和BMI而不同,但一般来说,脑钠肽水平大于100 pg/mL,氨基酸末端脑钠肽前体水平大于450 pg/mL的情况,可提示非妊娠患者心力衰竭的诊断(61)。健康女性的脑利钠肽水平在怀孕期间增加1倍(62)并在分娩后早期进一步增加(63),但其值仍在正常范围内。在左心室收缩功能障碍(64)、舒张功能障碍(65),高血压疾病(包括子痫前期等)(66)引起的孕妇呼吸短促,脑钠肽水平显著升高。

        利钠肽应在出现新的临床症状或提示心力衰竭症状时测量,以防止诊断延迟。对于有高危因素或确诊心脏病女性(如扩张型心肌病和先天性心脏病)获得一个基础的脑钠肽水平是有益的。脑钠肽水平的系列测定在每个孕期和产后早期有助于临床决策。在怀孕期间,正常的或低的脑钠肽水平在排除心脏功能失代偿时是有用的(67-69)。从妊娠中期开始,升高的脑钠肽的水平似乎可以预测不良事件发生(67,70)。

心肌肌钙蛋白I、肌钙蛋白T和高敏肌钙蛋白

        心肌钙蛋白I、肌钙蛋白T和“高敏感性”肌钙蛋白是心肌损伤的特殊和灵敏的生物标志物(71)。急性冠状动脉综合征合并妊娠的诊断与一般成人人群相似,包括可比较的症状、心电 图的异常情况和肌钙蛋白等生物标志物的升高(72)。所有患有胸痛的孕妇和产后患者都应该接受标准的肌钙蛋白测试和心电图来评估急性冠状动脉综合征。心脏病会诊应按临床指征进行。值得注意的是,严重子痫前期(73)和其他非心脏疾病的女性(如急性肺栓塞或慢性肾脏疾病)(74),肌钙蛋白I在产后早期可轻度升高。

心电图

        应在出现胸痛、气短或心悸的孕妇中进行心电图,以评估缺血、梗塞或心律失常的特征。在孕妇心率和胸壁形态中的正常妊娠相关的生理改变引起良性非病理性心电图改变(75)。在14%的妊娠中发现非特异性的ST波和T波异常,通常发生在左心前导联,分娩后消失,并可在再次妊娠中再次出现。任何在心电图上发现的心律异常都应引起进一步的评估。

胸部X线检查

        一个有带铅板保护腹部的的胸部X线检查(76)应被认为是用于出现呼吸急促状况的怀孕或产后的女性评估心脏或肺的病因的重要早期检查。

超声心动图

        超声心电图应应用于患有确诊或疑似的先天性心脏病(包括假定的矫治心脏畸形),瓣膜和主动脉疾病,心肌病,以及有心脏毒性化疗史(如阿霉素) 的怀孕或产后女性。患有肺动脉高压或不明原因氧合障碍的妇女应在怀孕前、怀孕期间和产后进行超声心动图检查。如果对肺动脉高压的病因、是否存在和严重程度有疑问,应进行心脏导管术检查(52)。在怀孕和产后,临床的和超声心动图的定期复查频率是个体化的。心脏腔增大、心脏向心性重塑、心脏舒张功能不全、瓣膜环扩张和少量心包积液无症状是妊娠晚期常见的正常超声心动图表现(41,77-79)。

运动负荷测试

        运动负荷测试是一个预测妇女承受怀孕的能力的重要指标。运动负荷测试提供了一个客观的母亲的功能性的能力的评估,并便于识别运动引起的心律失常(52)。对于计划怀孕的确诊心脏病患者,应进行运动负荷测试(80)。对如果已经怀孕的疑似心脏病无症状患者,国际指南推荐亚极量运动测试(80%的预测最大心率)(80)。

计算机断层扫描

        计算机断层扫描用于当出现胸痛的孕妇或产后妇女被疑似为肺栓塞或急性主动脉夹层。碘化造影剂不是致畸性的或是致癌性的,但它穿过胎盘,并对发育中的胎儿甲状腺有短暂的抑制作用。建议仅在绝对需要时才使用造影剂,以获得额外诊断信息。小于1%的碘化造影剂在哺乳妇女会被排泄到母乳中并被婴儿通过胃肠道吸收。因此,在使用碘造影剂后,母乳喂养可以持续进行(81)。

磁共振成像
        磁共振成像很少用于妊娠期心血管疾病的紧急或紧急评估,因为与电子计算机断层扫描相比,成像效果更差,更耗时。然而,在超声心动图未诊断的情况下,对孕妇评估主动脉大小和得到心室功能及室壁运动的评价,这是首选的显象方法。当怀孕期间需要选择性横断面成像时,建议与心脏成像专家进行讨论,以帮助选择最合适的研究和方案,以便对患者进行最佳评估。没有关于怀孕期间磁共振成像对母亲或胎儿有不良影响的报道(82)。正常妊娠和产后状态下心脏磁共振成像指标的参考值已经被报道(40)。钆,用于磁共振成像的造影剂,在妊娠患者中应加以限制。只有当它显著改善诊断性能,并有望改善胎儿或母亲的结果时,它可以作为造影剂。钆造影剂被使用后,母乳喂养不应被中断(81)。

动态监视仪或长时间心脏监护装置

        动态监护仪(24小时至48小时动态心电图监测)或长时间心脏监测装置(如无线贴片式心脏监护仪)有助于评估妊娠期心悸、头晕和晕厥的症状(83)。

D-二聚体

        对于妊娠或产后期间的心脏疾病,D-二聚体不推荐作为常规评估的一部分(44)。

哪种既往存在的母体心脏病对妊娠期和产后期影响最大?

        潜在或明显的心血管疾病的证据可以在怀孕期间或产后最初的几天、几周和几个月出现。如果体制上可行,患有任何高风险心血管类型疾病的妇女,如肺动脉高压、先天性心脏病、非先天性瓣膜病、扩张性肥厚或围产期心肌病、主动脉疾病或冠状动脉疾病,应在怀孕期间和产后期间由一名具有管理这类病人的专门知识的心脏病专家或一支妊娠心脏小组进行监测。怀孕、分娩和产后的管理计划应被记录在医疗和产检记录中。

肺动脉高压

        肺动脉高压是指静息时平均肺动脉压大于25 mm Hg。它既可以是先天的,也可以是由各种疾病引起的。肺动脉高压会带来产妇死亡率上升的风险,据报道从9%到28%不等(84-86)。尽管女性肺动脉高压患者的正确诊断率有所上升,但低风险患者难被轻易诊断出。因此,所有重度肺动脉高压的妇女都应被建议避免怀孕。护理肺动脉高压妇女的保健专业人员应确保有怀孕风险的妇女了解这些危险,并获得有效的避孕措施。如果发生妊娠,应讨论人工流产(80,87)。如果患有严重肺动脉高压的妇女选择怀孕或继续妊娠,则可在怀孕期间开始或修改治疗肺动脉高压的药物治疗。

先天性心脏病

先天性心脏病包括多种心脏结构病变。许多先天性心脏病患者在怀孕期间需要额外的专门护理。定期随访是必要的,其频率取决于疾病的类型和病人对怀孕的反应(表3)。高危病变,如肺动脉高压(如,艾森曼格综合征),严重左心室梗阻,严重心室功能障碍,发绀型先天性心脏病,方坦(Fontan)循环衰竭以及与复杂心律失常相关的病变,建议避免在怀孕或怀孕前进行手术矫正,以降低未来妊娠低风险。母亲先天性心脏病对胎儿的影响,包括潜在的遗传,应加以讨论。此外,某些遗传病与先天性心脏病(如努南综合征、唐氏综合征、心手综合征、22q11微缺失)有关,因此建议进行产前遗传咨询和检测。女性先天性心脏病应提示胎儿超声心动图检查,反之,在胎儿或新生儿中鉴别先天性心脏病可提示筛查父母的先天性心脏病。

        *心脏病史或检查结果呈阳性的孕妇,或两者兼而有之的孕妇,应在医院接受产前、产期和产后护理,根据具体的心脏病变,医院应提供适当的II级或更高级别的产妇护理。“在美国,区域化产妇护理的目标是让高危孕妇在准备提供所需水平的专门护理的设施中接受护理,从而降低产妇发病率和死亡率。” (Levels of maternal care. Obstetric Care Consensus No. 2. AmericanCollege of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15)

改编自ThorneS, MacGregor A, Nelson-Piercy C. Risks of contraception and pregnancy in heartdisease. Heart 2006;92:1520–5).

非先天性瓣膜病

        非先天性瓣膜病(例子包括风湿病瓣膜病、二尖瓣脱垂、生物瓣膜假体或与瓣膜疾病有关的瓣膜疾病感染性心内膜炎),需要专门的评价。经胸超声心动图和运动应激通常为患者推荐试验中度至重度瓣膜疾病(如瓣膜狭窄或严重的返流)、相关的心室功能障碍,或肺动脉高压。无临床瓣膜疾病症状的妇女应由心脏病专家监测,并可能需要在怀孕期间进行额外的检查或护理。必要的监测频率在患者的改良的WHO分类中显示(表3)。理想情况下,有症状的重度瓣膜应在妊娠前处理疾病。

机械瓣膜
        在妊娠期,机械瓣膜假体和一些心脏病变需要治疗性抗凝,这给妇女和胎儿带来上升的风险。关于抗凝治疗的选择和风险,频率和监测类型的详细讨论最好在怀孕前执行和备案。定期监测和进行药物调整以确定治疗水平为病情所需(80,88,89)。所有机械和生物瓣膜的孕妇在怀孕期间应保持每天服用小剂量(81毫克)阿司匹林(90)。心内膜炎预防应在高风险患者围产期实施(88,91)。

既往存在的扩张型心肌病

        妊娠前的评估将包括用基线的BNP水平、经胸超声心动图来评估的射血分数的和血流动力学,和用运动负荷测试评估的功能能力的。应评估心肌病的病因。对于家族性扩张型心肌病患者,建议进行孕前遗传咨询。与先前未确认的产后心肌病相关的心肌病也应考虑。先前患有扩张型心肌病的妇女在怀孕期间发生大型心血管不良事件(心力衰竭)的几率很高(25-40%)(92,93)。如果患者有严重的心脏病,应该建议他们避免怀孕或考虑人工流产,具体包括:射血分数小于30%或类III / IV心脏衰竭,严重瓣膜口狭窄, 主动脉直径45mm以上的马凡氏综合征,二叶主动脉瓣和主动脉直径超过50mm或肺动脉高血压(表3)(80)。此外,射血分数在30%-45%之间的妇女也应接受有关在怀孕期间发生不良心脏事件(如心力衰竭或心律失常)的风险增加的咨询(94)。一旦怀孕,药物的变化和随访频率取决于心功能和状态。

肥厚性心肌病

        肥厚性心肌病是最常见的遗传性心脏病,患病率为2%。对这些患者妊娠结局的分析表明,心血管并发症很常见,并且可以通过孕前状态预测,从而促进孕前咨询和有针对性的产前护理(95)。建议肥厚性心肌病患者进行孕前心血管和遗传咨询。

动脉瘤疾病和夹层

        育龄妇女的动脉瘤疾病和剥离通常是由遗传因素引起的,有家族性、综合征性、先天性或炎症性。怀孕前,建议进行一次彻底的心血管专科咨询,以评估动脉瘤的原因、大小和位置。这次会诊应包括超声心动图成像和计算机断层扫描或磁共振成像来评估整个主动脉。虽然年轻患者的大部分夹层发生在升主动脉,但也可能影响胸降主动脉或腹降主动脉。动脉瘤的病因、位置和大小将影响妊娠前的咨询和妊娠期间的处理。例如,所有患有血管性埃勒斯-丹洛斯综合征的患者都被建议避免怀孕。在妊娠和产后,由于主动脉的激素和血流动力学变化,与这些情况相关的主动脉夹层的风险增加。没有主动脉尺寸能保证主动脉病变患者安全妊娠。妊娠前介入治疗的主动脉大小阈值取决于动脉瘤疾病的病因 (6,80,96)。即使升主动脉置换术后,主动脉夹层仍会影响原有的主动脉,因此术前干预的患者也应密切监测。在怀孕期间,患有动脉瘤疾病的患者经常接受β-受体阻滞剂治疗,应定期复查主动脉成像。随访和成像的频率取决于潜在的疾病和主动脉瘤的位置和尺寸。或在妊娠或产后治疗主动脉瘤和夹层很少需要手术或经皮介入,只在主动脉紧急情况下才应用。侵入性母体干预的类型和时机以及首选的分娩方式应由妊娠心脏医疗团队制定。

心房心律失常

        引起心悸的房性心律失常是妊娠期心脏评估的常见征象。任何出现心律失常的孕妇都应该接受评估,以评估其潜在的结构性心脏病的原因和可能性。妊娠期最常见的心律失常为房性早搏和阵发性室上性心动过速,通常房室结再入性心动过速,可通过药物治疗成功。妊娠期心房颤动和扑动常发生于有结构性心脏病的妇女。取决于心律失常的影响和潜在心脏病的存在,管理是个性化的(55)。

室性心律失常

        在怀孕期间很少发生室性心律失常。如果检测到,寻找病因和潜在的结构性心脏病是合适的。无结构性心脏病时最常见的室性心动过速是右室流出道室性心动过速。这种形式的室性心动过速最初也许能怀孕期间被发现,因为它对儿茶酚胺有敏感性,并且它通常可以用β-受体阻滞剂或维拉帕米成功治疗。长QT综合征的妇女有室性心动过速的危险,尤其是在产后。妊娠期和产后用β-受体阻滞剂治疗是合适的。孕妇持续性室性心律失常的急性治疗与非孕妇相似。在患有结构性心脏病和室性心动过速的女性中,抗心律失常的药物治疗的风险和收益相比较,是否应用可植入式的心脏起搏除颤期应用应当被一个拥有一个有专业管理心律失常的电生理学家的妊娠心脏医疗团队进行评定 (80,97)。

如何识别、评估和管理高危的围产期心肌病妇女?

        在美国,每10万活产婴儿中就有25-100例发生围产期心肌病(98)。其特征为非缺血性心肌病,表现在妊娠晚期或产后最初几个月(99,100),症状为左室射血分数下降至45%以下,既往无心脏病史。病因尚不清楚。虽然自体免疫的发病机制已经被证实(101)。

        大多数女性最终会恢复心肌功能。在其余患者中,慢性心肌病和心力衰竭持续存在。在产后1年出现围产期心肌病的妇女的总死亡率或心脏移植率为5-10%(104,105)。围产期心肌病不成比例地影响非西班牙裔黑人妇女,其发生率更高(106),心肌完全恢复率更低(104,107-110)。围产期心肌病的其他危险因素包括产妇高龄、多胎妊娠、妊娠期高血压和子痫前期。有产后心肌病病史的妇女有高达20%的风险在随后的妊娠中经历复发(111-113)。

        孕妇或产后出现呼吸短促、胸部不适、心悸、心律失常或液体潴留的妇女应进行围产期心肌病的评估。超声心动图通常是最重要的诊断试验。这一评估也适用于被认为有妊娠高血压疾病的妇女。建议咨询心脏病科医师协助围产期心肌病的治疗,并应考虑转介到合适病情水平的医疗设备以允许妊娠心脏小组的多元医疗的照顾。围产期心肌病的医疗管理与减少射血分数的心力衰竭的管理遵循相同的一般的原则。溴隐亭改善围产期心肌痊愈的治疗手段仍处于研究阶段,并需要进一步研究(98,114,115)。不应劝阻患有产后心肌病的妇女母乳喂养,因为没有数据表明母乳喂养对产妇的心脏状况有负面影响。

        对于患有围产期心肌病的女性怀孕时确诊该病,治疗、分娩时机和模式应该是个性化的,需考虑产妇继续妊娠的风险以避免围产期发病率和与早产有关的死亡率,并由一个妊娠心脏医疗团队记录。出现休克(低血压、心动过速或终末器官损害)的妇女应转移到合适病情水平的设施,以做出心室辅助装置支持和移植选择的考虑。对患有围产期心肌病的妇女来说,阴道分娩是可以选择的,因为阴道分娩可以降低产妇死亡率并改善新生儿结局(116)。

        由于左室射血分数较低的妇女有较差的结局,患有围产期心肌病的妇女结局的预测可根据胎儿出产时产妇左室功能障碍的严重程度进行分类(117)。在北美妊娠相关的心肌病登记调查中(104),初始射血分数低于30%的妇女有更差的心肌恢复,和更高的左心室辅助装置植入、心脏移植和死亡率。相比之下,近90%的初期射血分数超过30%的女性心肌完全恢复。

在怀孕期间如何处理急性冠状动脉事件,包括孕妇心脏骤停?

急性心肌梗死和急性冠状动脉综合征

        缺血性心脏病孕妇围产期死亡率约5-11%,这一比例是同龄的未怀孕妇女的3-4倍(17,119)。急性冠状动脉综合征意味着怀疑心肌缺氧最终导致心肌损伤和坏死。心肌缺血的频谱包括稳定型心绞痛、不稳定型心绞痛和心肌梗死。增加的心输出量、提高的心搏量和更快的血凝增加潜在冠状动脉疾病的发生或显露。

        急性冠状动脉综合征可由冠状动脉粥样硬化、夹层、栓塞、痉挛、动脉炎和与主动脉夹层相关的冠状动脉阻塞引起。鉴别诊断还应包括应激性心肌病(119,120)。冠状动脉夹层是妊娠相关急性冠状动脉综合征最常见的原因,尽管它可以发生在怀孕期间的任何时间,但通常发生在产后早期(119,121,122)。冠状动脉造影仍然是诊断病人是ST段抬高型心肌梗死的标准。然而,由于并发症的风险,如与冠状动脉造影相关的医源性冠状动脉夹层和其他干预措施,非侵入性方法是稳定的、保留了整体左心室功能的患者的首选方法(119,122,123)。

        每一个有胸痛或心脏症状的孕妇或产后病人都应该考虑急性冠状动脉综合征。患有急性冠状动脉综合征的患者可出现典型的(胸痛或呼吸短促)或非典型的(呕吐、反流或出汗)症状,这些症状模拟了妊娠或妊娠相关疾病的生理变化,如先兆子痫,或两者兼有。有些病人出现血流动力学障碍、心律失常或心源性休克。肌钙蛋白升高对心肌损伤具有敏感性和特异性。心电图改变显示ST段升高或降低是病理的,提示急性心肌梗死或缺血。不同的鉴别诊断包括心包炎、肺栓塞和电解质异常。妊娠期间急性冠状动脉综合征最好由医疗团队管理,如妊娠心脏团队。孕妇病情状况的管理应优先考虑。在进行母体评估和初始治疗时,不稳定的患者应放置在30 - 90度的左侧倾斜位置。在合适的胎龄时,建议使用胎儿监护和激素来促进胎儿肺的成熟。最初的医疗管理通常包括氧气补充、硝酸盐、阿司匹林、静脉注射普通肝素和β-受体阻滞药治疗。如果症状持续,冠状动脉造影是首选的检查,并应立即被进行。干预的类型应根据急性冠状动脉综合征的病因、患者特点和现有医疗中心的设施个体化进行。其目的是迅速恢复冠状动脉血流以完成组织再灌注(如果原因是动脉粥样硬化性冠状动脉疾病,这是最好的通过经皮冠状动脉介入的完成方法)。然而,经皮冠脉介入治疗妇女冠状动脉夹层的结果非最佳,而且有扩大范围的风险。因此,对于稳定的冠状动脉夹层患者推荐保守治疗(123)。

        当急性心肌梗死患者出现在没有介入心导管设施的医疗中心时,选择包括紧急转移到具有这些功能的中心,或ST段抬高心肌梗死患者紧急溶栓,或在随后有计划的转移中两者兼有。产妇急性冠状动脉综合征的并发症包括心力衰竭、心源性休克、室性心律失常、复发性心肌梗死和死亡。关于生产的时机和方式的数据是有限的。

孕妇心脏骤停

        虽然不经常发生产妇心脏骤停,但医疗服务提供者应该准备好在任何医疗机构中管理这种情况(124)。产妇心脏骤停病因包括妊娠相关和非妊娠相关病症。美国心脏协会建议使用按字母顺序排列的分类法来诊断孕妇停搏,这强调了基础广泛的方法的重要性(125)(见表2)。

2.png

        在接受分娩的患者中,产妇心脏骤停的各种病因中,最常见的是出血(38.1%),其次是羊水栓塞(13.3%)(126)。大约10%的妊娠期或产后妇女患有急性冠状动脉综合征,4%患有静脉血栓栓塞的妇女经历了产妇心脏骤停(126)。

        医疗服务提供者是多学科团队的成员之一,应立即召集设施警报“孕妇心脏骤停(maternal code)”(125)。处理产科病人的医疗机构应该有24小时经验丰富的应对此类状况的团队。怀孕或产后患者心脏骤停的管理需要熟悉妊娠的生理适应,这会影响基本和高级心脏生命支持所规定的干预措施的执行。对于怀孕的心脏骤停患者,有六个关键概念需要强调:

        1.增加的氧需求加上改变咽部/喉部标志物和失去意识时吸气的更大倾向需要优先使用100%氧气的袋式面罩通气,并由经验丰富的医疗服务提供者(6-7 mm)进行小气管插管的早期插管(125)。

        2. 在复苏过程中很早就应该通过单手或双手手动操作子宫左移位来减少大于20周妊娠的子宫的主动脉压迫,同时使患者在背板上保持完全仰卧位以最大化心脏压迫效果(127,128)。

        3. 与在无妊娠群体使用的顺序方法相比,建议进行同时干预(128)。

        4.准备胎儿分娩与母亲的复苏应该并行。

        5.以每分钟100-120次的速度在背板上进行高质量的胸部按压,当子宫向左外侧移位完成后使用相同的标志置于胸骨中下部。

        6.氧合作用仍然是一个主要目标,按照30:2胸部按压/通气的频率,由100%氧气的袋式面罩提供通气。

        其他干预类似于非妊娠状态下心脏骤停的管理。放置除颤垫以进行节律分析。当救援人员不熟悉此任务时,使用自动体外除颤器可以促进节律分析。然而,使用自动体外除颤器并不能满足复苏技能训练的要求(128)。虽然只有理论上存在除颤的电子风险,但应该移除胎儿监护仪以允许产妇状态指导复苏干预。对于适当的可电击节律,应提示进行双相除颤,每2分钟重新评估一次节律/脉搏,注意尽量减少胸部按压的中断。虽然孕妇在怀孕期间可能不愿意使用药物,但心脏骤停的严重性使得药物应该用于复苏。肾上腺素是选择的血管加压药,应通过隔膜上方的静脉内或骨内通路给药。计时员应该让复苏小组了解心脏骤停后发生的时间(125)。

濒死期剖宫产/复苏性子宫切开术

        当初始干预措施不成功时,美国心脏协会建议在子宫大小达到妊娠20周时,及时考虑进行剖宫产或剖宫产术(129)。因为实现从心脏骤停到分娩的最短时间明显增强了孕妇和新生儿的存活结果,所以应该努力促进分娩尽可能防止心脏骤停,目标是在4-5分钟的窗口内进行。如果不太可能恢复自发循环,或者没有目睹停搏,则不需要推迟4-5分钟的分娩(128,130)。进行复苏子宫切除术的准备工作应在产妇心脏骤停的第一分钟内立即开始,或明显迅速下降的母体心脏功能。医疗服务提供者应该意识到在4分钟内不管死亡或损伤都没有明显阈值(界限)。相反,因为心脏骤停,女性和胎儿无创生存的可能性逐渐降低(131)。女性和新生儿的生存曲线表明,在产妇心脏骤停后25分钟,濒死期剖宫产的无创存活率为50%(131);因此,即使在4分钟内没有发生,分娩也可能是有益的。

        理想情况下,濒死期剖宫产应该在心脏骤停现场进行,因为转移会损害心肺复苏,并导致进一步的时间延迟(124)。濒死期剖宫产的开始需要一把手术刀,通常包含在心脏骤停平车的濒死期剖宫产手术套件中(125)。垂直皮肤切口可能是最快完成的,并为进一步的探查性手术提供了更多选择。如果在濒死期剖宫产手术中没有发生心功能恢复,可以尝试开胸直接按摩(128)。体外循环和体外膜氧合已成功用于需要限时心肺支持的病因,如局部麻醉药物毒性,急性心脏代偿失调相关的心肌病和急性呼吸窘迫综合征(128)。

        产妇心脏骤停的频率较低, 正强调需要通过模拟训练来定期进行团队培训,练习复苏技能和熟悉场景(128)。

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