妇产科学教学课件：妊娠合并心脏病

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1、 Cardiac Disease in Pregnancyobstetric Hemorrhage27.8% Pregnancy Induced Hypertension 12.3%Amniotic Fluid Embolism 9.2%Puerperal Infection1.2% Cardiac Diseases 10.9%Liver Diseases 3.1%Vein Thrombosis3.1%Non-obstetric Factors 32.4%Maternal death in China (2010)Maternal death in 21st century (USA) Car

2、diac 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 changed greatly

3、 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!先心种类先心种类 非紫绀型非紫绀型 左向右分流左向右分流 右心腔和肺循环血流明显增加右心腔和肺循环血流明显增加 房室间隔缺损、

4、动脉导管未闭房室间隔缺损、动脉导管未闭 紫绀型紫绀型 右向左分流，动脉血氧饱和度右向左分流，动脉血氧饱和度 法四、艾森曼格氏综合征法四、艾森曼格氏综合征无分流型先心无分流型先心 肺动脉瓣口狭窄肺动脉瓣口狭窄 主动脉狭窄主动脉狭窄 Marfan综合症（动脉瘤）综合症（动脉瘤） 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 maternal mortality (

5、2550%)Normal physicologic changesCardiac reserve is reduced in pregnancyPlasma 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 (CO) CO starts to i

6、ncrease from 1020 weeks and reaches a plateau near 3234 weeks at levels 30%50% above non-pregnant values Cardiac Output in different position01234567Rt.LatStandSupineSitOC(l/min) O2 consumption increased Colloid oncotic pressure, COP (Both plasma and interstitial) Cardiac System change during pregna

7、ncy HR: heartrate; MAP: mean arterial pressure;SVR: systemic vascular resistance;BV: blood volume-20-100102030405060HRMAPCOSVRBVChange in cardiac outlineEffects of Pregnancy upon Cardiac Disease Heart Failure: 3234 weeks gestation Labor & Delivery and Postpartum period Significant fluid shifts occur

8、 and can lead to congestive heart failure in the cardiac patient Anemia、infection、hypertension & arrhythmias may aggravate heart diseaseEffects of cardiac disease on fetus Fetal distress、Fetal Growth Restriction ( FGR）and preterm labor The fetus is at increased risk of developing congenital heart di

9、sease when maternal heart disease is congenital The incidence ranges from 510%，when the fetus is affected , only about 50% will have the same anomaly as the motherDiagnosis Significant history or Symptoms &Sign ECG Echocardiography X-ray Blood gas analysis if necessary (Lack of improvement in Sao2 w

10、ith oxygen suggests further increased maternal risk) Cardiac failure Cardiac disease will always be a serious concern, however, in view of the magnitude of change in cardiovascular status in pregnancy, relating to in increased intravascular volume. There are certain principles in relation to care of

11、 cardiac disease in pregnancy ManangementPre-pregnancyObstetrician & cardiologist in collaboration Preconceptual evaluation and counseling Coexistent conditions should be appropriately treated and controlled Any necessary cardiac surgery should be carried out prior to conceptionGroup 1 Mortality IIO

12、- Obstruction Left Heart (MV 2cm; AV 30 peak)P- Prior 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 hypertensionEisenmenger SyndromeIntracardiac sh

13、unt + pulmonary vascular disease + cyanosis (reversal of shunt)Reproduced with permission from: Brickner et al. NEJM 2000Eisenmengers Syndrome Death usually in the first week postpartum Most common causes of death: worsening and intractable hypoxemia volume depletion preeclampsia thromboembolism con

14、sider anticoagulation pulmonary artery rupture 19% risk of mortality with surgeryEisenmengers Syndrome Avoids Avoid hypotensiondecrease in SVR causes increased right-to-left shunting, severe hypoxemia and worsening pulmonary hypertension Avoid heavy blood loss + volume depletion Avoid increase in pu

15、lmonary vascular resistancehypoxemia, hypercarbia, metabolic acidosis, excess catecholamines, high altitude Avoid iron deficiency and anemia Avoid exerciseAortic Stenosis Fixed cardiac output state Mild disease: valve area 2 cm2 peak gradient 36 mmHg Severe disease: valve area 75 mmHg Mean gradient

16、35 mmHg ejection fraction less than 55%Aortic 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 arrhythmiasAortic Stenosis: Avoids Avoi

17、d hypotension: coronary perfusion and angina 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 edemaSome Mx “ “specifics” ” for Severe AS Consider

18、placing a PA catheter prior to labor : Max 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 Aneurysma

19、l dilation and dissection of aorta account 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

20、 The risk for dissection is decreased but not eliminated following surgical correction 50% will require repair of aneurysm in another locationSerial evaluation of aortic root is recommended even if initial diameter is normalMarfans Syndrome Mx Avoid hypertension Avoid tachycardiaGoal HR 4 cm, aortic

21、 root dissection or heart failureHypertensive CardiomyopathyDesai 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: incr

22、eased LVEDP is an important cause of fulminant (flash) pulmonary edema, CCF, and sudden death: More common in chronic hypertension and superimposed preeclampsia (Mabie et al) Older, diabetic, obesePeripartum versus Hypertensive CardiomyopathyBeware labeling the patient with preeclampsia and diastoli

23、c dysfunction as peripartum cardiomyopathy (systolic dysfunction)Suggestion: Get an echo, BNP (markedly elevated in PPCM) and work with a cardiologistPPCM: 左室扩张伴中重度左室收缩功能下降左室扩张伴中重度左室收缩功能下降peripartum cardiomyopathy 预后左室功能：左室功能： 左室功能恢复多于左室功能恢复多于6个月内个月内 （ n=40，follow-up 30 29 月）月） 6个月时，个月时，LVEF50%：45-7

24、8% （n=300，publications in US） 预后影响预后的因素：影响预后的因素： LVEF （n=55） NYHA 分级分级 QRS duaration 发病时间发病时间 再次妊娠风险再次妊娠风险Elkayam：60 subsequent pregnancies in 44 patients 28 recovery vs 16 LV dysfunctionv高危妊娠逐渐增加高危妊娠逐渐增加v早识别，多学科合作，正确处理早识别，多学科合作，正确处理v医患间及时沟通医患间及时沟通v改善母儿结局，降低医疗风险改善母儿结局，降低医疗风险48Learing objectives To understand why cardiac reserve is reduced in pregnancy To understand the principles of management of cardiac disease during pregnancyWelcome to join in Department of Obstetrics and Gynecology