神谷 千津子¹, 橋本 修治², 田中 教雄², 堀内 縁¹, 吉松 淳¹

Chizuko A. KAMIYA¹, Shuji HASHIMOTO², Norio TANAKA², Chinami HORIUCHI¹, Jun YOSHIMATSU¹

¹国立循環器病研究センター周産期・婦人科部, ²国立循環器病研究センター臨床検査部

¹Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, ²Department of Clinical Physiology, National Cerebral and Cardiovascular Center

キーワード : pregnancy, structural heart disease, echocardiography, heart failure

妊娠・出産を通じて，循環動態はダイナミックに変化する．器質的心疾患を持つ多くの女性が安全に出産する一方，一部の病態においては，母児の生命も脅かすハイリスクなものとなる．しかしながら，先天性心疾患をとりまく医療の進歩や母体の高齢化を背景に，心疾患合併妊娠数は増加傾向にある．「心疾患を持っているから妊娠は一律に禁忌」とされていた時代は過ぎ，心疾患があってもより安全に出産できるような診療体制が必要とされている．心疾患合併女性の妊娠・出産においては，循環血漿量や心拍数の増加，血管抵抗の変化，凝固亢進，血管脆弱化など，妊娠による生理的変化を時間軸とあわせて理解し，心疾患合併妊娠の診療にあたることが大切である．妊娠リスクの評価に，心エコー所見は有用である．また，心エコー検査は，非侵襲的で胎児被爆を与えず，妊娠・出産の進行に伴い繰り返し評価できる，妊娠中に最も適した循環器検査である．心疾患合併妊娠では，妊娠前もしくは初期と，妊娠中の循環血漿量の増加がほぼピークに達する30週前後に心エコー検査を行い，あとはリスクや自他覚症状に応じて検査を追加することが薦められている．また，分娩後に心機能低下や弁機能異常の増悪をきたす症例があり，分娩後の経過観察も大切である．

With recent advances in cardiovascular and neonatal medicine, the number of patients with heart disease who are giving birth has increased, and the range and severity of heart disease where pregnancy and delivery are possible are expanding. It is very important to understand that hemodynamics during pregnancy and delivery are significantly affected by changes in fluid circulation, hematology, respiratory function, endocrinology, and the autonomic nervous system for clinical management in peripartum women with heart disease. Because the cardiocirculatory changes associated with pregnancy and delivery are marked in some diseases and conditions, the maternal and fetal risks are high. Echocardiography is widely used to assess such maternal pregnancy risks. Echocardiography, a noninvasive method providing detailed information, is quite useful in evaluating hemodynamics during pregnancy. It is preferable that women with heart disease be assessed for hemodynamic status several times during pregnancy and during the puerperal period. The first assessment should be performed immediately before pregnancy or during the first trimester when changes in hemodynamics are still slight. Patients with mild to moderate risk should be evaluated for hemodynamics again during the late second trimester at around 30 weeks of gestation. Patients with severe risk require more frequent hemodynamic assessment. Hemodynamics should be reassessed during the peripartum period. Since childcare, including breast feeding, may increase cardiac load, patients with severe heart disease must be followed up carefully after childbirth.