2025 年第 4 期 第 20 卷

先天性心脏病相关性肺动脉高压孕妇产后心脏指标及心功能变化的临床研究

Clinical study of postpartum cardiac indexes and cardiac function changes in pregnant women with pulmonary hypertension associated with congenital heart disease

作者：吴林芹张军

英文作者：Wu Linqin Zhang Jun

单位：首都医科大学附属北京安贞医院妇产科心血管重症妇产医学中心，北京100029

英文单位：Department of Obstetrics and Gynecology Obstetrics and Gynecology Medical Center for Cardiovascular Intensive Care Beijing Anzhen Hospital Capital Medical University Beijing 100029 China

关键词：肺动脉高压；先天性心脏病；妊娠

英文关键词：Pulmonaryhypertension;Congenitalheartdisease;Pregnancy

• 摘要：

• 目的 探讨妊娠合并先天性心脏病相关性肺动脉高压（CHD-PAH）孕妇妊娠期及产后6个月心脏指标及心功能的变化。方法 选取2018年8月至2022年12月在首都医科大学附属北京安贞医院分娩的妊娠合并CHD-PAH患者75例为研究对象。根据产前超声心动图结果 将妊娠合并CHD-PAH患者进行分组。依据肺动脉收缩压（SPAP）分为轻度组(41例）、中度组(22例）、重度组(12例）。观察3组孕妇的妊娠结局，并分析妊娠期及产后6个月心脏指标及心功能的变化。结果 中度组、重度组终止妊娠孕周数均小于轻度组，剖宫产、早产比例均高于轻度组，重度组产后出血量多于轻度组（均P<0.05）。重度组新生儿出生体重低于轻度组，中度组、重度组低出生体重儿比例均高于轻度组，重度组新生儿窒息比例高于轻度组（均P<0.05）。中度组、重度组孕前/孕早期、产前、产后6个月SPAP均高于轻度组（均P＜0.05），但各组内不同时点SPAP比较差异均无统计学意义（均P＞0.05）。3组各时点左心室舒张末期内径、右心房面积和B型脑钠肽水平比较差异均无统计学意义（均P＞0.05）。随访结果显示，中度组1例、重度组4例患者心功能由Ⅲ~Ⅳ级转为Ⅰ~Ⅱ级，轻、中、重度组心功能分级Ⅰ~Ⅱ级比例比较差异无统计学意义［100.0%（41/41）、100.0%（22/22）、91.7%（11/12）］(P=0.70)。重度组远期随访心功能Ⅲ~Ⅳ级比例低于产前［91.7%（11/12）比41.7%（5/12）］（P＜0.05）。结论 妊娠合并重度CHD-PAH孕妇的SPAP在妊娠期增加，产后6个月有所下降，但仍高于其孕前/早孕期的SPAP水平，远期随访心功能恢复良好。妊娠合并重度CHD-PAH孕妇的母儿不良结局发生率高，综合使用强心利尿剂、血管活性剂和靶向药物可有效降低妊娠合并CHD-PAH孕妇的病死率，但重度PAH患者仍属妊娠禁忌，建议避免妊娠。

• Objective To investigate the changes of cardiac indexes and cardiac function in pregnant women with pulmonary hypertension associated with congenital heart disease (CHD-PAH) during pregnancy and 6 months after delivery. Methods A total of 75 pregnant women with CHD-PAH who delivered in Beijing Anzhen Hospital, Capital Medical University from August 2018 to December 2022 were selected as the research objects. The pregnant women with CHD-PAH were grouped according to the results of prenatal echocardiography. According to pulmonary artery systolic pressure (SPAP), the patients were divided into mild group (41 cases), moderate group (22 cases) and severe group (12 cases). The pregnancy outcomes of the three groups were observed, and the changes of cardiac indexes and cardiac function during pregnancy and 6 months after delivery were analyzed. Results The gestational weeks of termination of pregnancy in the moderate group and the severe group were less than those in the mild group, the proportion of cesarean section and premature delivery were higher than those in the mild group, and the amount of postpartum hemorrhage in the severe group was more than that in the mild group (all P<0.05). The birth weight of neonates in the severe group was lower than that in the mild group, the proportions of low birth weight infants in the moderate and severe groups was higher than that in the mild group, and the proportion of neonatal asphyxia in the severe group was higher than that in the mild group (all P<0.05）. The SPAP of the moderate and severe groups before pregnancy/early pregnancy, prenatal and 6 months after delivery were higher than those of the mild group (all P<0.05), but there was no significant difference in SPAP among different time points within each group (all P>0.05). There were no significant differences in left ventricular end-diastolic diameter, right atrial area and brain natriuretic peptide level among the three groups at each time point (all P>0.05). The follow-up results showed that the cardiac function of 1 case in the moderate group and 4 cases in the severe group changed from grade Ⅲ-Ⅳ to grade Ⅰ-Ⅱ, and there was no significant difference in the proportion of grade Ⅰ-Ⅱ of cardiac function in the mild, moderate, and severe groups ［100.0%(41/41), 100.0%(22/22) and 91.7%(11/12)］(P=0.70). The long-term follow-up proportion of cardiac function grade Ⅲ-Ⅳ in the severe group was lower than that in the prenatal period ［91.7%(11/12) vs 41.7%(5/12)］(P<0.05). Conclusions  The SPAP of pregnant women with severe CHD-PAH increases during pregnancy and decreases at 6 months after delivery, but it is still higher than the SPAP level of pregnancy/early pregnancy, and the cardiac function recovers well in long-term follow-up. The incidence of adverse maternal and fetal outcomes in pregnant women with severe CHD-PAH is high. The comprehensive use of cardiac diuretics, vasoactive agents and targeted drugs can effectively reduce the mortality of pregnant women with CHD-PAH, but patients with severe PAH are still contraindications to pregnancy, and it is recommended to avoid pregnancy.