妇产-6-妊娠合并心脏病课件.ppt

Cardiac Disease in Pregnancy,Huixia Yang,Maternal death in China(2010),Maternal death in 21st century(USA),Cardiac disease with pregnancy is serious complication in obstetrics,also the major cause leading to maternal deathIncidence：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 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,非紫绀型 左向右分流 右心腔和肺循环血流明显增加 房室间隔缺损、动脉导管未闭紫绀型 右向左分流，动脉血氧饱和度 法四、艾森曼格氏综合征,无分流型先心,肺动脉瓣口狭窄主动脉狭窄Marfan综合症（动脉瘤）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(2550%),Normal physicologic changes,Cardiac 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 increase from 1020 weeks and reaches a plateau near 3234 weeks at levels 30%50%above non-pregnant values,Cardiac Output in different position,O2 consumption increased Colloid oncotic pressure,COP(Both plasma and interstitial),Cardiac System change during pregnancy HR:heartrate;MAP:mean arterial pressure;SVR:systemic vascular resistance;BV:blood volume,Change in cardiac outline,Effects of Pregnancy upon Cardiac Disease,Heart Failure:3234 weeks gestation Labor&Delivery and Postpartum period Significant fluid shifts occur and can lead to congestive heart failure in the cardiac patientAnemia、infection、hypertension&arrhythmias may aggravate heart disease,Effects of cardiac disease on fetus,Fetal distress、Fetal Growth Restriction(FGR）and preterm laborThe fetus is at increased risk of developing congenital heart disease 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 mother,Diagnosis,Significant history or Symptoms&SignECGEchocardiography X-rayBlood gas analysis if necessary(Lack of improvement in Sao2 with 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 cardiac disease in pregnancy,Manangement,Pre-pregnancyObstetrician&cardiologist in collaboration Preconceptual evaluation and counselingCoexistent conditions should be appropriately treated and controlled Any necessary cardiac surgery should be carried out prior to conception,Group 1 Mortality 1%Atrial septal defectVentricular septal defectPatent ductus arteriosusMitral stenosis-NYHA class I&IIPulmonic/Tricuspid valve diseaseCorrected Tetralogy of FallotBioprosthetic valveGroup 2 Mortality 5-15%2A 2BMitral stenosis-NYHA class III&IV Mitral stenosis with atrial fibrillation Aortic stenosis Mechanical ValveCoarctation of Aorta without valvular involvementUncorrected Tetralogy of FallotPrevious myocardial infarctionMarfan syndrome with normal aortaGroup 3-Mortality 25-50%Pulmonary hypertension(Primary,Eisenmenger Syndrome)Coarctation of aorta with valvular involvementSevere Aortic stenosisMarfan syndrome with aortic involvementPeripartum cardiomyopathy with persistent left ventricular dysfunction,The greatest concern centers on patients who have pulmonary hypertension such as with Eisenmengers syndromeRisk of reversal of the right to left shunt and sudden collapse.Maternal mortality:a 30%risk of mortality in pregnancy at least.Patients must be counselled prior to conception!,Prenatal care,The evaluation and counseling at the first visitTermination is an option with a few conditions with higher maternal mortality Assess functional class of heart disease(vital signs and weight gain)Joint management with cardiologist,Optimize medical managementAvoid/minimize aggravating factorsAvoid heart failure,Fetal surveillance,Fetal Growth(especially with R L shunts as PO2)NST/umbilical artery Doppler(especially，if left-right shunt)Detailed fetal cardiac ultra-if maternal congenital heart disease increased risk of fetal malformations if maternal congenital disease.,Labor/delivery,Inform anaesthetist in advance of delivery Vaginal delivery for the patients with heart function class I-II Elective induction may be necessary for maternal and/or fetal indicationsProphylactic antibiotics as appropriateAvoid mental and physical stress(epidural),Labor/delivery,Labor in left lateral or upright positionMonitor electrocardiogramAdminister extra oxygen Continuous fetal heart rate monitoringOperative vaginal delivery to shorten the second stage Avoid ergometrine/iv pitocine for third stage,Cesarean delivery,Heart function Class IIIIVPulmonary hypertensionCyanotic heart disease,Postnatal,Vigilance for cardiac failure in the immediate postpartum period(circulatory volume following uterine contraction)Avoid fluid overloadContinued high-dependency care Avoid breast feeding for heart failureDiscuss effective/safe contraception,Congenital Cardiac Lesions with Highest Risk:Mortality 25-50%,Eisenmengers SyndromeSevere left outflow obstruction Aortic stenosisMarfans syndrome with aortic root involvement,CARPreg Study(Circulation 2001 Siu,et al),First prospective study to establish a predictive score562 consecutive patients with heart disease in pregnancyIncluded patients with acquired,congenital Overall rate of cardiac event(Pulmonary Edema,Arrhythmia,Stroke,Death)=13%Fetal Mortality Rate=2%Preterm Delivery rate=10%Hypertension in pregnancy=4%(increased with coarctation)May overestimate risk,4 Predictors of a Cardiac Event(defined as:Pulm.Edema,Arrhythmia,Stroke,or Death),N-NYHA IIO-Obstruction Left Heart(MV 30 peak)P-Prior cardiac event before preg.(Failure,Arrhyth.,TIA or Stroke)E-EF 40%,Adapted from:Siu,Circulation 2001.,Most common adverse events:pulmonary edemaarrhythmias,Eisenmengers Syndrome,Intra-cardiac connections allow mixing of oxygenated(left side)and less oxygenated(right side)bloodOnly 10%of ASDs lead to ES BUT 50%of VSDs lead to ESSecondary pulmonary hypertension from chronic left-to-right(systemic-to-pulmonary)shuntingIf pulmonary pressure systemic pressure,flow across the shunt reverses to right-to-leftDecreased pulmonary perfusion,hypoxemia and worsening pulmonary hypertension,Eisenmenger Syndrome,Intracardiac shunt+pulmonary vascular disease+cyanosis(reversal of shunt),Reproduced with permission from:Brickner et al.NEJM 2000,Eisenmengers Syndrome,Death usually in the first week postpartumMost common causes of death:worsening and intractable hypoxemiavolume depletionpreeclampsiathromboembolism consider anticoagulationpulmonary artery rupture19%risk of mortality with surgery,Eisenmengers Syndrome Avoids,Avoid hypotensiondecrease in SVR causes increased right-to-left shunting,severe hypoxemia and worsening pulmonary hypertensionAvoid heavy blood loss+volume depletionAvoid increase in pulmonary vascular resistancehypoxemia,hypercarbia,metabolic acidosis,excess catecholamines,high altitudeAvoid iron deficiency and anemiaAvoid exercise,Aortic Stenosis,Fixed cardiac output stateMild disease:valve area 2 cm2 peak gradient 75 mmHgMean gradient 35 mmHgejection 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 arrhythmias,Aortic Stenosis:Avoids,Avoid hypotension:coronary perfusion and anginaAvoid hypovolemia and decreased LV Filling:blood loss,aorto-caval syndrome,dehydrationAvoid decreased SVR:drugs,valsalvaAvoid bradycardia and tachycardiaAvoid hypervolemia:may lead to pulmonary edema,Some Mx“specifics”for Severe AS,Consider placing a PA catheter prior to labor:Max gradient 50 mmHg,mean gradient 35 mmHgMaintain“preload edge”PCWP 16-18 mmHgArterial line for ABG and close monitoring of BPOxygen,Fowlers positionDelivery:Assist 2nd stage,modified lithotomy(knees down),Marfans Syndrome and The Aorta,Aneurysmal dilation and dissection of aorta account for the majority of the morbidity and mortality Rupture risk in pregnancy increases with dilationnormal aortic dimension:rupture risk 4 cm:rupture risk 10%Aortic root diameter 4.5 cm is an indication for preconception repair if patient desires pregnancyThe risk for dissection is decreased but not eliminated following surgical correction50%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 hypertensionAvoid tachycardiaGoal HR 4 cm,aortic root dissection or heart failure,Hypertensive 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 functionDiastolic dysfunction:increased 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,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 cardiologistPPCM:左室扩张伴中重度左室收缩功能下降,peripartum cardiomyopathy,预后,左室功能：左室功能恢复多于6个月内（n=40，follow-up 30 29 月）6个月时，LVEF50%：45-78%（n=300，publications in US）,预后,影响预后的因素：LVEF（n=55）NYHA 分级 QRS duaration 发病时间,再次妊娠风险,Elkayam：60 subsequent pregnancies in 44 patients 28 recovery vs 16 LV dysfunction,高危妊娠逐渐增加早识别，多学科合作，正确处理医患间及时沟通改善母儿结局，降低医疗风险,48,Learing objectives,To understand why cardiac reserve is reduced in pregnancyTo understand the principles of management of cardiac disease during pregnancy,谢谢大家！,Welcome to join in Department of Obstetrics and Gynecology,