对患有围产期心肌病且需要行剖宫产的高危孕妇预防性使用主动脉内气囊泵
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Prophylactic use of an intra-aortic balloon pump in a high-risk patient with peripartum cardiomyopathy requiring cesarean delivery
背景与目的
主动脉内球囊反搏术对心衰孕妇的循环支持仅限于几个病例报告。很少有文献报道主动脉内球囊反搏术在分娩过程中的应用。在此，我们将对一例患有围产期心肌病的孕妇行剖宫产的管理中预防性应用主动脉内反搏术的案例进行报告。
方 法
一位28岁初次妊娠的妇女在妊娠37周时出现心脏衰竭恶化的迹象，经胸超声心动图显示左室射血分数降低25%。多科室进行了会诊，决定行主动脉内球囊反搏术为剖腹产手术提供血流动力学支持。
结 果
主动脉内球囊反搏开始后不久，患者的血流动力学得到改善，表现为心率下降和平均动脉血压增加。顺利剖宫，产一个3.2公斤健康的婴儿后，病人被转移到重症监护并于三小时后拔管。由于血流动力学不稳定，主动脉内球囊反搏支持和输注升压药维持到术后第四天。接受利尿剂及β受体阻滞剂治疗，病人于20天后出院。心衰仍然持续存在，25个月后需要进行心脏移植。
结 论
该报告强调在患有围产期心肌病患者的产科分娩管理中需要多学科综合治疗。
原始文献摘要
R.S. Samalavicius, L. Puodziukaite, I. Radaviciute, et al.Prophylactic use of an intra-aortic balloon pump in a high-risk patient with peripartum cardiomyopathy requiring cesarean delivery.International Journal of Obstetric Anesthesia. (2017), doi:http://dx.doi.org/10.1016/j.ijoa.2017.07.004
Abstract：
The use of intra-aortic balloon counter-pulsation for circulatory support in pregnant women with cardiac failure is limited to several case reports. Few publications have addressed the use of intra-aortic balloon counter-pulsation during delivery. We report a case using prophylactic intra-aortic counter-pulsation during the management of a cesarean delivery in a patient with peripartum cardiomyopathy. A 28-year-old primigravid female at 37 weeks of gestation was admitted with signs of worsening heart failure, and transthoracic echocardiography revealed a decreased left ventricular ejection fraction of 25%. A plan to proceed with cesarean delivery, using hemodynamic support with intra-aortic balloon counter-pulsation, was made during a multidisciplinary meeting. Shortly after initiation of intra-aortic balloon counter-pulsation, the patient’s hemodynamics improved, with a decrease in heart rate and an increase in mean arterial blood pressure. After uneventful cesarean delivery of a healthy 3.2 kg infant, the patient was transferred to intensive care and was extubated three hours later. Due to hemodynamic instability, intra-aortic balloon counter-pulsation support and vasopressor infusion were maintained for four postoperative days. The patient was discharged from the hospital on diuretics and beta blocker treatment after 20 days. Heart failure persisted, requiring heart transplantation 25 months later. This report highlights the role of a multidisciplinary team approach in the management of delivery in an obstetric patient with peripartum cardiomyopathy.
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