Sheffield Jeanne S, Cunningham F Gary
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, 75390-9032, USA.
Am J Obstet Gynecol. 2004 Jan;190(1):211-7. doi: 10.1016/s0002-9378(03)00944-x.
When untreated, Graves' thyrotoxicosis has profound cardiovascular effects, although it rarely causes heart failure in otherwise healthy patients. Preliminary observations suggest that pregnant women are the exception. To further elucidate this association, we studied both immediate and long-term outcomes in women who had thyrotoxicosis and heart failure during pregnancy.
We reviewed clinical outcomes of pregnant women with Graves' disease and heart failure at our institution from 1974 through 2001. Women with other underlying heart disease were excluded. A standardized antithyroid regimen and serial echocardiography and/or chest radiography were performed.
The 13 women with thyrotoxicosis and heart failure were either noncompliant with antithyroid therapy or had no medical care during pregnancy. Six women had heart failure before fetal viability; decompensation was precipitated by hemorrhage, sepsis, or both. The other 7 women were in the last trimester when heart failure developed; in 4 women, the heart failure was precipitated by severe preeclampsia-eclampsia and in 2 women was precipitated by sepsis. Overall, 11 of 13 women had an underlying obstetric event. In follow-up of 11 women from 2 to 25 years, resolution of cardiomyopathy was confirmed after successful treatment of thyrotoxicosis.
Normal pregnancy mimics and amplifies some of the hyperdynamic cardiovascular changes that are caused by thyrotoxicosis. When they occur simultaneously, there is usually a compensated high-output state. In some women, however, common pregnancy complications that include hemorrhage with associated anemia, sepsis, and severe preeclampsia-eclampsia will precipitate heart failure. The immediate treatment of heart failure and the correction of precipitating pregnancy factors usually results in good outcome. Long-term follow-up confirmed that thyrotoxic cardiac dysfunction is reversible with successful antithyroid therapy.
未经治疗的格雷夫斯甲状腺毒症对心血管系统有深远影响，尽管在其他方面健康的患者中很少导致心力衰竭。初步观察表明，孕妇是个例外。为了进一步阐明这种关联，我们研究了孕期患有甲状腺毒症和心力衰竭的女性的近期和远期结局。
我们回顾了1974年至2001年在我们机构患有格雷夫斯病和心力衰竭的孕妇的临床结局。排除患有其他潜在心脏病的女性。实施了标准化的抗甲状腺治疗方案以及系列超声心动图检查和/或胸部X线检查。
13例患有甲状腺毒症和心力衰竭的女性要么未遵行抗甲状腺治疗，要么孕期未接受医疗护理。6例女性在胎儿具有存活能力之前就出现了心力衰竭；失代偿是由出血、败血症或两者共同引发的。另外7例女性在妊娠晚期出现心力衰竭；4例女性的心力衰竭是由重度子痫前期 - 子痫引发的，2例女性的心力衰竭是由败血症引发的。总体而言，13例女性中有11例存在潜在的产科事件。在对11例女性进行2至25年的随访中，甲状腺毒症成功治疗后证实心肌病得到缓解。
正常妊娠会模拟并放大一些由甲状腺毒症引起的高动力性心血管变化。当它们同时发生时，通常会出现代偿性高输出状态。然而，在一些女性中，包括出血伴相关贫血、败血症以及重度子痫前期 - 子痫在内的常见妊娠并发症会引发心力衰竭。心力衰竭的即刻治疗以及妊娠诱发因素的纠正通常会带来良好的结局。长期随访证实，成功的抗甲状腺治疗可使甲状腺毒症性心脏功能障碍逆转。
