婦產(chǎn)6妊娠合并心臟病課件

CardiacDiseaseinPregnancy

HuixiaYang

CardiacDiseaseinPregnancyMaternaldeathinChina(2010)Maternaldeathin21stcentury(USA)MaternaldeathinChina(2010Cardiacdiseasewithpregnancyisseriouscomplicationinobstetrics,alsothemajorcauseleadingtomaternaldeathIncidence：1%~4%Includepreexistingdiseaseaswellasconditionsthatdevelopduringpregnancyorinthepostpartumperiod

CardiacdiseasewithpregnancyThepatternofcardiacdiseaseinpregnancyhaschangedgreatlyinrecentdecades：Congenitalheartdisease

RheumaticheartdiseaseCardiacarrhythmiasPIHinducedcardiacdiseasePeripartumcardiomyopathy.

Theshiftawayfromrheumaticheartdiseasetosurgicallycorrectedcongenitalheartdisease!!Thepatternofcardiacdisease先心種類非紫紺型左向右分流

右心腔和肺循環(huán)血流明顯增加

房室間隔缺損、動脈導(dǎo)管未閉紫紺型

右向左分流，動脈血氧飽和度法四、艾森曼格氏綜合征先心種類非紫紺型無分流型先心肺動脈瓣口狹窄主動脈狹窄Marfan綜合癥（動脈瘤）三尖瓣下移畸形（Ebstein）無分流型先心Atpresent,congenitalheartdiseaseismorethanrheumaticdisaese.Peripartumcardiomyopathy--Rarebutwithhighermaternalmortality(25~50%)Atpresent,congenitalheartNormalphysicologicchangesCardiacreserveisreducedinpregnancyPlasmavolume：Beginninginearlypregnancy6~8weeks，Asteadyriseininplasmavolumewithaplateauatapproximately32~34GWs(singletonpregnancyatterm30~45%)NormalphysicologicchangesCarChangesintotalbloodvolumeChangesintotalbloodvolume

Cardiacoutput(CO)

COstartstoincreasefrom10~20weeksandreachesaplateaunear32~34weeksatlevels30%~50%abovenon-pregnantvalues

Cardiacoutput(CO)CardiacOutputindifferentpositionCardiacOutputindifferentp

O2consumptionincreasedColloidoncoticpressure,COP

(Bothplasmaandinterstitial)

CardiacSystemchangeduringpregnancy

HR:heartrate;MAP:meanarterialpressure;SVR:systemicvascularresistance;BV:bloodvolume

CardiacSystemchangeduriChangeincardiacoutlineChangeincardiacoutlineEffectsofPregnancyuponCardiacDiseaseHeartFailure:32~34weeks’gestation

Labor&DeliveryandPostpartumperiod

SignificantfluidshiftsoccurandcanleadtocongestiveheartfailureinthecardiacpatientAnemia、infection、hypertension&arrhythmiasmayaggravateheartdiseaseEffectsofPregnancyuponCardEffectsofcardiacdiseaseonfetusFetaldistress、FetalGrowthRestriction(FGR）andpretermlaborThefetusisatincreasedriskofdevelopingcongenitalheartdiseasewhenmaternalheartdiseaseiscongenital

Theincidencerangesfrom5~10%，whenthefetusisaffected,onlyabout50%willhavethesameanomalyasthemotherEffectsofcardiacdiseaseonDiagnosisSignificanthistoryorSymptoms&SignECGEchocardiographyX-rayBloodgasanalysisifnecessary(LackofimprovementinSao2withoxygensuggestsfurtherincreasedmaternalrisk)Cardiacfailure

DiagnosisSignificanthistoryoCardiacdiseasewillalwaysbeaseriousconcern,however,inviewofthemagnitudeofchangeincardiovascularstatusinpregnancy,relatingtoinincreasedintravascularvolume.Therearecertainprinciplesinrelationtocareofcardiacdiseaseinpregnancy

CardiacdiseasewillalwaysbeManangementPre-pregnancyObstetrician&cardiologistincollaborationPreconceptualevaluationandcounselingCoexistentconditionsshouldbeappropriatelytreatedandcontrolledAnynecessarycardiacsurgeryshouldbecarriedoutpriortoconceptionManangementPre-pregnancyGroup1–Mortality<1%AtrialseptaldefectVentricularseptaldefectPatentductusarteriosusMitralstenosis-NYHAclassI&IIPulmonic/TricuspidvalvediseaseCorrectedTetralogyofFallotBioprostheticvalveGroup2–Mortality5-15%2A

2BMitralstenosis-NYHAclassIII&IV Mitralstenosiswithatrialfibrillation

Aorticstenosis

MechanicalValveCoarctationofAortawithoutvalvularinvolvement

UncorrectedTetralogyofFallot Previousmyocardialinfarction Marfansyndromewithnormalaorta

Group3-Mortality25-50%Pulmonaryhypertension(Primary,EisenmengerSyndrome)CoarctationofaortawithvalvularinvolvementSevereAorticstenosis

MarfansyndromewithaorticinvolvementPeripartumcardiomyopathywithpersistentleftventriculardysfunctionGroup1–Mortality<1%ThegreatestconcerncentersonpatientswhohavepulmonaryhypertensionsuchaswithEisenmenger’ssyndromeRiskofreversaloftherighttoleftshuntandsuddencollapse.Maternalmortality:a30%riskofmortalityinpregnancyatleast.Patientsmustbecounselledpriortoconception!!

ThegreatestconcerncentersoPrenatalcareTheevaluationandcounselingatthefirstvisitTerminationisanoptionwithafewconditionswithhighermaternalmortalityAssessfunctionalclassofheartdisease(vitalsignsandweightgain)JointmanagementwithcardiologistPrenatalcareTheevaluationan

OptimizemedicalmanagementAvoid/minimizeaggravatingfactorsAvoidheartfailure

OptimizemedicalmanageFetalsurveillanceFetalGrowth(especiallywithR

LshuntsasPO2

)NST/umbilicalarteryDoppler

(especially，ifleft-rightshunt)Detailedfetalcardiacultra-ifmaternalcongenitalheartdisease

increasedriskoffetalmalformationsifmaternalcongenitaldisease.FetalsurveillanceFetalGrowth

Labor/deliveryInformanaesthetistinadvanceofdeliveryVaginaldeliveryforthepatientswithheartfunctionclassI-IIElectiveinductionmaybenecessaryformaternaland/orfetalindicationsProphylacticantibioticsasappropriateAvoidmentalandphysicalstress(epidural)Labor/deliveryInformanaestheLabor/deliveryLaborinleftlateraloruprightpositionMonitorelectrocardiogramAdministerextraoxygenContinuousfetalheartratemonitoringOperativevaginaldeliverytoshortenthesecondstageAvoidergometrine/ivpitocineforthirdstageLabor/deliveryLaborinleftla

CesareandeliveryHeartfunctionClassIII~IVPulmonaryhypertensionCyanoticheartdiseaseCesareandeliveryHeartfunc

PostnatalVigilanceforcardiacfailureintheimmediatepostpartumperiod(

circulatoryvolumefollowinguterinecontraction)AvoidfluidoverloadContinuedhigh-dependencycareAvoidbreastfeedingforheartfailureDiscusseffective/safecontraceptionPostnatalVigilanceforcardiCongenitalCardiacLesionswithHighestRisk:Mortality25-50%

Eisenmenger’sSyndromeSevereleftoutflowobstructionAorticstenosisMarfan’ssyndromewithaorticrootinvolvementCongenitalCardiacLesionswitCARPregStudy

(Circulation2001–Siu,etal)Firstprospectivestudytoestablishapredictivescore562consecutivepatientswithheartdiseaseinpregnancyIncludedpatientswithacquired,congenital……Overallrateofcardiacevent(PulmonaryEdema,Arrhythmia,Stroke,Death)=13%FetalMortalityRate=2%PretermDeliveryrate=10%Hypertensioninpregnancy=4%(increasedwithcoarctation)MayoverestimateriskCARPregStudy

(Circulation2004PredictorsofaCardiacEvent

(definedas:Pulm.Edema,Arrhythmia,Stroke,orDeath)N

-NYHA>IIO

-ObstructionLeftHeart(MV<2cm;AV<1.5cm;LVOTGrad>30peak)P

-Priorcardiaceventbeforepreg.(Failure,Arrhyth.,TIAorStroke)E

-EF< 40%Adaptedfrom:Siu,Circulation2001.NumberofriskfactorsRiskofadverseevent05%127%2ormore75%Mostcommonadverseevents:pulmonaryedemaarrhythmias4PredictorsofaCardiacEvenEisenmenger’sSyndromeIntra-cardiacconnectionsallowmixingofoxygenated(leftside)andlessoxygenated(rightside)bloodOnly10%ofASD’sleadtoESBUT50%ofVSD’sleadtoESSecondarypulmonaryhypertensionfromchronicleft-to-right(systemic-to-pulmonary)shuntingIfpulmonarypressure>systemicpressure,flowacrosstheshuntreversestoright-to-leftDecreasedpulmonaryperfusion,hypoxemiaandworseningpulmonaryhypertensionEisenmenger’sSyndromeIntra-caEisenmengerSyndromeIntracardiacshunt+pulmonaryvasculardisease+cyanosis(reversalofshunt)Reproducedwithpermissionfrom:Brickneretal.NEJM2000EisenmengerSyndromeIntracardiEisenmenger’sSyndromeDeathusuallyinthefirstweekpostpartumMostcommoncausesofdeath:worseningandintractablehypoxemiavolumedepletionpreeclampsiathromboembolism–consideranticoagulationpulmonaryarteryrupture19%riskofmortalitywithsurgeryEisenmenger’sSyndromeDeathusEisenmenger’sSyndromeAvoidsAvoidhypotensiondecreaseinSVRcausesincreasedright-to-leftshunting,severehypoxemiaandworseningpulmonaryhypertensionAvoidheavybloodloss+volumedepletionAvoidincreaseinpulmonaryvascularresistancehypoxemia,hypercarbia,metabolicacidosis,excesscatecholamines,highaltitudeAvoidirondeficiencyandanemiaAvoidexerciseEisenmenger’sSyndromeAvoidsAAorticStenosisFixedcardiacoutputstateMilddisease:valvearea>2cm2

peakgradient<36mmHgSeveredisease:valvearea<1cm2peakgradient>75mmHgMeangradient>35mmHgejectionfractionlessthan55%AorticStenosisFixedcardiacoAorticStenosis:ComplicationsObstructedFlowHighpressurepulmonaryedema–“SOB”Underperfusion/lowcardiacoutputAngina:duetodecreasedcoronaryperfusionSyncope:duetopoorcerebralperfusionSuddendeath:duetoarrhythmiasAorticStenosis:ComplicationsAorticStenosis:AvoidsAvoidhypotension:coronaryperfusionandanginaAvoidhypovolemiaanddecreasedLVFilling:bloodloss,aorto-cavalsyndrome,dehydrationAvoiddecreasedSVR:drugs,valsalvaAvoidbradycardiaandtachycardiaAvoidhypervolemia:mayleadtopulmonaryedemaAorticStenosis:AvoidsAvoidhSomeMx“specifics”forSevereASConsiderplacingaPAcatheterpriortolabor:

Maxgradient>50mmHg,meangradient>35mmHgMaintain“preloadedge”

PCWP~16-18mmHgArteriallineforABGandclosemonitoringofBPOxygen,FowlerspositionDelivery:Assist

2ndstage,modifiedlithotomy

(kneesdown)SomeMx“specifics”forSevereMarfan’sSyndromeandTheAortaAneurysmaldilationanddissectionofaortaaccountforthemajorityofthemorbidityandmortalityRuptureriskinpregnancyincreaseswithdilationnormalaorticdimension:rupturerisk<1%aorticrootdiameter>4cm:rupturerisk~10%Aorticrootdiameter>4.5cmisanindicationforpreconceptionrepairifpatientdesirespregnancyTheriskfordissectionisdecreasedbutnoteliminatedfollowingsurgicalcorrection50%willrequirerepairofaneurysminanotherlocationSerialevaluationofaorticrootisrecommendedevenifinitialdiameterisnormalMarfan’sSyndromeandTheAortMarfan’sSyndrome–MxAvoidhypertensionAvoidtachycardiaGoalHR<70bpmatrest(metoprolol)AvoidvalsalvaAssistedsecondstage,painmanagementwithepidural

Cesareanmaybenefitpatientswithaorticrootdiameter>4cm,aorticrootdissectionorheartfailureMarfan’sSyndrome–MxAvoidhypHypertensiveCardiomyopathy

Desaietal.BrJObstetGynaecol1996;103:523-8(LevelIII)Pulmonaryedemaandseverehypertensioninpreeclampsia:25%(4/16)hadimpairedsystolicfunction(?PPCM)75%(12/16)hadimpaireddiastolicfunctionDiastolicdysfunction:increasedLVEDPisanimportantcauseoffulminant(flash)pulmonaryedema,CCF,andsuddendeath:

Morecommoninchronichypertensionandsuperimposedpreeclampsia(Mabieetal)Older,diabetic,obeseHypertensiveCardiomyopathy

DePeripartumversusHypertensiveCardiomyopathyBewarelabelingthepatientwithpreeclampsiaanddiastolicdysfunctionasperipartumcardiomyopathy(systolicdysfunction)Suggestion:Getanecho,BNP(markedlyelevatedinPPCM)andworkwithacardiologistPPCM:左室擴(kuò)張伴中重度左室收縮功能下降PeripartumversusHypertensiveperipartumcardiomyopathyperipartumcardiomyopathy

預(yù)后左室功能：左室功能恢復(fù)多于6個(gè)月內(nèi)

（n=40，follow-up30±29月）6個(gè)月時(shí)，LVEF≥50%：45-78%

（n=300，publicationsinUS）預(yù)后

預(yù)后影響預(yù)后的因素：

LVEF

（n=55）NYHA分級QRSduaration

發(fā)病時(shí)間預(yù)后再次妊娠風(fēng)險(xiǎn)Elkayam：60subsequentpregnanciesin44patients28recoveryvs16LVdysfunction再次妊娠風(fēng)險(xiǎn)Elkayam：60subsequentp高危妊娠逐漸增加早識別，多學(xué)科合作，正確處理醫(yī)患間及時(shí)溝通改善母兒結(jié)局，降低醫(yī)療風(fēng)險(xiǎn)48高危妊娠逐漸增加48LearingobjectivesTounderstandwhycardiacreserveisreducedinpregnancyTounderstandtheprinciplesofmanagementofcardiacdiseaseduringpregnancyLearingobjectivesTounderstan謝謝大家！WelcometojoininDepartmentofObstetricsandGynecology謝謝大家！WelcometojoininDepart

CardiacDiseaseinPregnancy

HuixiaYang

CardiacDiseaseinPregnancyMaternaldeathinChina(2010)Maternaldeathin21stcentury(USA)MaternaldeathinChina(2010Cardiacdiseasewithpregnancyisseriouscomplicationinobstetrics,alsothemajorcauseleadingtomaternaldeathIncidence：1%~4%Includepreexistingdiseaseaswellasconditionsthatdevelopduringpregnancyorinthepostpartumperiod

CardiacdiseasewithpregnancyThepatternofcardiacdiseaseinpregnancyhaschangedgreatlyinrecentdecades：Congenitalheartdisease

RheumaticheartdiseaseCardiacarrhythmiasPIHinducedcardiacdiseasePeripartumcardiomyopathy.

Theshiftawayfromrheumaticheartdiseasetosurgicallycorrectedcongenitalheartdisease!!Thepatternofcardiacdisease先心種類非紫紺型左向右分流

右心腔和肺循環(huán)血流明顯增加

房室間隔缺損、動脈導(dǎo)管未閉紫紺型

右向左分流，動脈血氧飽和度法四、艾森曼格氏綜合征先心種類非紫紺型無分流型先心肺動脈瓣口狹窄主動脈狹窄Marfan綜合癥（動脈瘤）三尖瓣下移畸形（Ebstein）無分流型先心Atpresent,congenitalheartdiseaseismorethanrheumaticdisaese.Peripartumcardiomyopathy--Rarebutwithhighermaternalmortality(25~50%)Atpresent,congenitalheartNormalphysicologicchangesCardiacreserveisreducedinpregnancyPlasmavolume：Beginninginearlypregnancy6~8weeks，Asteadyriseininplasmavolumewithaplateauatapproximately32~34GWs(singletonpregnancyatterm30~45%)NormalphysicologicchangesCarChangesintotalbloodvolumeChangesintotalbloodvolume

Cardiacoutput(CO)

COstartstoincreasefrom10~20weeksandreachesaplateaunear32~34weeksatlevels30%~50%abovenon-pregnantvalues

Cardiacoutput(CO)CardiacOutputindifferentpositionCardiacOutputindifferentp

O2consumptionincreasedColloidoncoticpressure,COP

(Bothplasmaandinterstitial)

CardiacSystemchangeduringpregnancy

HR:heartrate;MAP:meanarterialpressure;SVR:systemicvascularresistance;BV:bloodvolume

CardiacSystemchangeduriChangeincardiacoutlineChangeincardiacoutlineEffectsofPregnancyuponCardiacDiseaseHeartFailure:32~34weeks’gestation

Labor&DeliveryandPostpartumperiod

SignificantfluidshiftsoccurandcanleadtocongestiveheartfailureinthecardiacpatientAnemia、infection、hypertension&arrhythmiasmayaggravateheartdiseaseEffectsofPregnancyuponCardEffectsofcardiacdiseaseonfetusFetaldistress、FetalGrowthRestriction(FGR）andpretermlaborThefetusisatincreasedriskofdevelopingcongenitalheartdiseasewhenmaternalheartdiseaseiscongenital

Theincidencerangesfrom5~10%，whenthefetusisaffected,onlyabout50%willhavethesameanomalyasthemotherEffectsofcardiacdiseaseonDiagnosisSignificanthistoryorSymptoms&SignECGEchocardiographyX-rayBloodgasanalysisifnecessary(LackofimprovementinSao2withoxygensuggestsfurtherincreasedmaternalrisk)Cardiacfailure

DiagnosisSignificanthistoryoCardiacdiseasewillalwaysbeaseriousconcern,however,inviewofthemagnitudeofchangeincardiovascularstatusinpregnancy,relatingtoinincreasedintravascularvolume.Therearecertainprinciplesinrelationtocareofcardiacdiseaseinpregnancy

CardiacdiseasewillalwaysbeManangementPre-pregnancyObstetrician&cardiologistincollaborationPreconceptualevaluationandcounselingCoexistentconditionsshouldbeappropriatelytreatedandcontrolledAnynecessarycardiacsurgeryshouldbecarriedoutpriortoconceptionManangementPre-pregnancyGroup1–Mortality<1%AtrialseptaldefectVentricularseptaldefectPatentductusarteriosusMitralstenosis-NYHAclassI&IIPulmonic/TricuspidvalvediseaseCorrectedTetralogyofFallotBioprostheticvalveGroup2–Mortality5-15%2A

2BMitralstenosis-NYHAclassIII&IV Mitralstenosiswithatrialfibrillation

Aorticstenosis

MechanicalValveCoarctationofAortawithoutvalvularinvolvement

UncorrectedTetralogyofFallot Previousmyocardialinfarction Marfansyndromewithnormalaorta

Group3-Mortality25-50%Pulmonaryhypertension(Primary,EisenmengerSyndrome)CoarctationofaortawithvalvularinvolvementSevereAorticstenosis

MarfansyndromewithaorticinvolvementPeripartumcardiomyopathywithpersistentleftventriculardysfunctionGroup1–Mortality<1%ThegreatestconcerncentersonpatientswhohavepulmonaryhypertensionsuchaswithEisenmenger’ssyndromeRiskofreversaloftherighttoleftshuntandsuddencollapse.Maternalmortality:a30%riskofmortalityinpregnancyatleast.Patientsmustbecounselledpriortoconception!!

ThegreatestconcerncentersoPrenatalcareTheevaluationandcounselingatthefirstvisitTerminationisanoptionwithafewconditionswithhighermaternalmortalityAssessfunctionalclassofheartdisease(vitalsignsandweightgain)JointmanagementwithcardiologistPrenatalcareTheevaluationan

OptimizemedicalmanagementAvoid/minimizeaggravatingfactorsAvoidheartfailure

OptimizemedicalmanageFetalsurveillanceFetalGrowth(especiallywithR

LshuntsasPO2

)NST/umbilicalarteryDoppler

(especially，ifleft-rightshunt)Detailedfetalcardiacultra-ifmaternalcongenitalheartdisease

increasedriskoffetalmalformationsifmaternalcongenitaldisease.FetalsurveillanceFetalGrowth

Labor/deliveryInformanaesthetistinadvanceofdeliveryVaginaldeliveryforthepatientswithheartfunctionclassI-IIElectiveinductionmaybenecessaryformaternaland/orfetalindicationsProphylacticantibioticsasappropriateAvoidmentalandphysicalstress(epidural)Labor/deliveryInformanaestheLabor/deliveryLaborinleftlateraloruprightpositionMonitorelectrocardiogramAdministerextraoxygenContinuousfetalheartratemonitoringOperativevaginaldeliverytoshortenthesecondstageAvoidergometrine/ivpitocineforthirdstageLabor/deliveryLaborinleftla

CesareandeliveryHeartfunctionClassIII~IVPulmonaryhypertensionCyanoticheartdiseaseCesareandeliveryHeartfunc

PostnatalVigilanceforcardiacfailureintheimmediatepostpartumperiod(

circulatoryvolumefollowinguterinecontraction)AvoidfluidoverloadContinuedhigh-dependencycareAvoidbreastfeedingforheartfailureDiscusseffective/safecontraceptionPostnatalVigilanceforcardiCongenitalCardiacLesionswithHighestRisk:Mortality25-50%

Eisenmenger’sSyndromeSevereleftoutflowobstructionAorticstenosisMarfan’ssyndromewithaorticrootinvolvementCongenitalCardiacLesionswitCARPregStudy

(Circulation2001–Siu,etal)Firstprospectivestudytoestablishapredictivescore562consecutivepatientswithheartdiseaseinpregnancyIncludedpatientswithacquired,congenital……Overallrateofcardiacevent(PulmonaryEdema,Arrhythmia,Stroke,Death)=13%FetalMortalityRate=2%PretermDeliveryrate=10%Hypertensioninpregnancy=4%(increasedwithcoarctation)MayoverestimateriskCARPregStudy

(Circulation2004PredictorsofaCardiacEvent

(definedas:Pulm.Edema,Arrhythmia,Stroke,orDeath)N

-NYHA>IIO

-ObstructionLeftHeart(MV<2cm;AV<1.5cm;LVOTGrad>30peak)P

-Priorcardiaceventbeforepreg.(Failure,Arrhyth.,TIAorStroke)E

-EF< 40%Adaptedfrom:Siu,Circulation2001.NumberofriskfactorsRiskofadverseevent05%127%2ormore75%Mostcommonadverseevents:pulmonaryedemaarrhythmias4PredictorsofaCardiacEvenEisenmenger’sSyndromeIntra-cardiacconnectionsallowmixingofoxygenated(leftside)andlessoxygenated(rightside)bloodOnly10%ofASD’sleadtoESBUT50%ofVSD’sleadtoESSecondarypulmonaryhypertensionfromchronicleft-to-right(systemic-to-pulmonary)shuntingIfpulmonarypressure>systemicpressure,flowacrosstheshuntreversestoright-to-leftDecreasedpulmonaryperfusion,hypoxemiaandworseningpulmonaryhypertensionEisenmenger’sSyndromeIntra-caEisenmengerSyndromeIntracardiacshunt+pulmonaryvasculardisease+cyanosis(reversalofshunt)Reproducedwithpermissionfrom:Brickneretal.NEJM2000EisenmengerSyndromeIntracardiEisenmenger’sSyndromeDeathusuallyinthefirstweekpostpartumMostcommoncausesofdeath:worseningandintractablehypoxemiavolumedepletionpreeclampsiathromboembolism–consideranticoagulationpulmonaryarteryrupture19%riskofmortalitywithsurgeryEisenmenger’sSyndromeDeathusEisenmenger’sSyndromeAvoidsAvoidhypotensiondecreaseinSVRcausesincreasedright-to-leftshunting,severehypoxemiaandworseningpulmonaryhypertensionAvoidheavybloodloss+volumedepletionAvoidincreaseinpulmonaryvascularresistancehypoxemia,hypercarbia,metabolicacidosis,excesscatecholamines,highaltitudeAvoidirondeficiencyandanemiaAvoidexerciseEisenmenger’sSyndromeAvoidsAAorticStenosisFixedcardiacoutputstateMilddisease:valvearea>2cm2

peakgradient<36mmHgSeveredisease:valvearea<1cm2peakgradient>75mmHgMeangradient>35mmHgejectionfractionlessthan55%AorticStenosisFixedcardiacoAorticStenosis:ComplicationsObstructedFlowHighpressurepulmonaryedema–“SOB”Underperfusion/lowcardiacoutputAngina:duetodecreasedcoronaryperfusionSyncope:duetopoorcerebralperfusionSuddendeath:duetoarrhythmiasAorticStenosis:ComplicationsAorticStenosis:AvoidsAvoidhypotension:coronaryperfusionandanginaAvoidhypovolemiaanddecreasedLVFilling:bloodloss,aorto-cavalsyndrome,dehydrationAvoiddecreasedSVR:drugs,valsalvaAvoidbradycardiaandtachycardiaAvoidhypervolemia:mayleadtopulmonaryedemaAorticStenosis:AvoidsAvoidhSomeMx“specifics”forSevereASConsiderplacingaPAcatheterpriortolabor:

Maxgradient>50mmHg,meangradient>35mmHgMaintain“preloadedge”

PCWP~16-18mmHgArteriallineforABGandclosemonitoringofBPOxygen,FowlerspositionDelivery:Assist

2nd