婦產(chǎn)科學(xué)課件-6-妊娠合并心臟病

1、 Cardiac Disease in Pregnancy obstetric Hemorrhag e 27.8% Pregnancy Induced Hypertension 12.3% Amniotic Fluid Embolism 9.2% Puerperal Infection 1.2% Cardiac Diseases 10.9% Liver Diseases 3.1% Vein Thrombosis 3.1% Non- obstetric Factors 32.4% Maternal death in China (2010) Maternal death in 21st cent

2、ury (USA) Cardiac disease with pregnancy is serious complication in obstetrics, also the major cause leading to maternal death Incidence：1%4% Include preexisting disease as well as conditions that develop during pregnancy or in the postpartum period The pattern of cardiac disease in pregnancy has ch

3、anged greatly in recent decades： Congenital heart disease Rheumatic heart disease Cardiac arrhythmias PIH induced cardiac disease Peripartum cardiomyopathy. The shift away from rheumatic heart disease to surgically corrected congenital heart disease! 先心種類先心種類 非紫紺型非紫紺型 左向右分流左向右分流 右心腔和肺循環(huán)血流明顯增加右心腔和肺循環(huán)

4、血流明顯增加 房室間隔缺損、動脈導(dǎo)管未閉房室間隔缺損、動脈導(dǎo)管未閉 紫紺型紫紺型 右向左分流，動脈血氧飽和度右向左分流，動脈血氧飽和度 法四、艾森曼格氏綜合征法四、艾森曼格氏綜合征 無分流型先心無分流型先心 肺動脈瓣口狹窄肺動脈瓣口狹窄 主動脈狹窄主動脈狹窄 Marfan綜合癥（動脈瘤）綜合癥（動脈瘤） 三尖瓣下移畸形（三尖瓣下移畸形（Ebstein） At present, congenital heart disease is more than rheumatic disaese. Peripartum cardiomyopathy -Rare but with higher mater

5、nal mortality (2550%) Normal physicologic changes Cardiac reserve is reduced in pregnancy Plasma volume ： Beginning in early pregnancy 68 weeks， A steady rise in in plasma volume with a plateau at approximately 3234 GWs (singleton pregnancy at term 3045%) Changes in total blood volume Cardiac output

6、 (CO) CO starts to increase from 1020 weeks and reaches a plateau near 3234 weeks at levels 30%50% above non-pregnant values Cardiac Output in different position 0 1 2 3 4 5 6 7 Rt.LatStandSupineSit OC(l/min) O2 consumption increased Colloid oncotic pressure, COP (Both plasma and interstitial) Cardi

7、ac System change during pregnancy HR: heartrate; MAP: mean arterial pressure; SVR: systemic vascular resistance;BV: blood volume -20 -10 0 10 20 30 40 50 60 HRMAPCOSVRBV Change in cardiac outline Effects of Pregnancy upon Cardiac Disease Heart Failure: 3234 weeks gestation Labor AV 30 peak) P- Prior

8、 cardiac event before preg. (Failure, Arrhyth., TIA or Stroke) E- EF systemic pressure, flow across the shunt reverses to right-to-left Decreased pulmonary perfusion, hypoxemia and worsening pulmonary hypertension Eisenmenger Syndrome Intracardiac shunt + pulmonary vascular disease + cyanosis (rever

9、sal of shunt) Reproduced with permission from: Brickner et al. NEJM 2000 Eisenmengers Syndrome Death usually in the first week postpartum Most common causes of death: worsening and intractable hypoxemia volume depletion preeclampsia thromboembolism consider anticoagulation pulmonary artery rupture 1

10、9% risk of mortality with surgery Eisenmengers Syndrome Avoids Avoid hypotension decrease in SVR causes increased right-to-left shunting, severe hypoxemia and worsening pulmonary hypertension Avoid heavy blood loss + volume depletion Avoid increase in pulmonary vascular resistance hypoxemia, hyperca

11、rbia, metabolic acidosis, excess catecholamines, high altitude Avoid iron deficiency and anemia Avoid exercise Aortic Stenosis Fixed cardiac output state Mild disease: valve area 2 cm2 peak gradient 36 mmHg Severe disease: valve area 75 mmHg Mean gradient 35 mmHg ejection fraction less than 55% Aort

12、ic Stenosis: Complications Obstructed Flow High pressure pulmonary edema “SOB” Underperfusion/low cardiac output Angina: due to decreased coronary perfusion Syncope: due to poor cerebral perfusion Sudden death: due to arrhythmias Aortic Stenosis: Avoids Avoid hypotension: coronary perfusion and angi

13、na Avoid hypovolemia and decreased LV Filling: blood loss, aorto-caval syndrome, dehydration Avoid decreased SVR: drugs, valsalva Avoid bradycardia and tachycardia Avoid hypervolemia: may lead to pulmonary edema Some Mx “ “specifics” ” for Severe AS Consider placing a PA catheter prior to labor : Ma

14、x gradient 50 mmHg, mean gradient 35 mmHg Maintain “ “preload edge” ” PCWP 16-18 mmHg Arterial line for ABG and close monitoring of BP Oxygen, Fowlers position Delivery: Assist 2nd stage, modified lithotomy (knees down) Marfans Syndrome and The Aorta Aneurysmal dilation and dissection of aorta accou

15、nt for the majority of the morbidity and mortality Rupture risk in pregnancy increases with dilation normal aortic dimension: rupture risk 4 cm: rupture risk 10% Aortic root diameter 4.5 cm is an indication for preconception repair if patient desires pregnancy The risk for dissection is decreased bu

16、t not eliminated following surgical correction 50% will require repair of aneurysm in another location Serial evaluation of aortic root is recommended even if initial diameter is normal Marfans Syndrome Mx Avoid hypertension Avoid tachycardia Goal HR 4 cm, aortic root dissection or heart failure Hyp

17、ertensive Cardiomyopathy Desai et al. Br J Obstet Gynaecol 1996;103:523-8 (Level III) Pulmonary edema and severe hypertension in preeclampsia: 25% (4/16) had impaired systolic function (? PPCM) 75% (12/16) had impaired diastolic function Diastolic dysfunction: increased LVEDP is an important cause o

18、f fulminant (flash) pulmonary edema, CCF, and sudden death: More common in chronic hypertension and superimposed preeclampsia (Mabie et al) Older, diabetic, obese Peripartum versus Hypertensive Cardiomyopathy Beware labeling the patient with preeclampsia and diastolic dysfunction as peripartum cardiomyopathy (systolic dysfunction) Suggestion: Get an echo, BNP (markedly elevated in PPCM) and work with a cardiologist PPCM: 左室擴(kuò)張伴中重度左室收縮功能下降左室擴(kuò)張伴中重度左室收縮功能