Download Cardiovascular Complications

Cardiovascular Complications
Liu Wei
Department of Ob & Gy
Ren Ji hospital
General Consideration
• Cause of mother death
The 2nd cause
• Incidence
1%-4%
General Consideration
• Antenatal cardiovascular changes
1. Blood volume
increase by 40%-60%
Peaking at 32 –34 weeks
the expansion in plasma volume is greater
than that expansion of red cell mass.
2. Cardiac output
Increase by 40%-50%
Peaking at 20-24 weeks
General Consideration
3. Blood pressure
Decrease in the first trimester
Rise to prepregnancy levels in the third
trimester
4. Heart size
Ventricular chamber size is increased
Systolic function is unchanged.
General Consideration
• Intrapartum cardiovascular changes
1. First-stage labor
300ml –500ml↑(each contraction)
Cardiac output↑(maternal pain, anxiety)
2. Second-stage labor
Lung circulation↑(bearing-down efforts to
expel the fetus)
Venous return↓(after fetus is deliveried)
Placental circulation is lost (after placenta is
deliveried)
General Consideration
3. Postpartum
Circulating blood volume↑(Placental circulation
is lost)
Circulating blood volume further↑(mobilization
of extravascular fluid into the vascular
system)
Types of Cardiovascular Complication
• Congenital heart disease先心: the most frequent
1. Left to right shunting左向右分流型
1) Atrial septal defect (ASD)房缺: most common
asymptomatic (most patients); pulmonary blood
flow↑(lesion ≥2cm2) → pulmonary
hypertension → Eisenmenger’s syndrome
2) Ventricular septal defect (VSD)室缺
tolerated (small lesion); left ventricular
hypertrophy→ pulmonary hypertension→
biventricular hypertrophy
Types of Cardiovascular Complication
3) Patent ductus arteriosus (PDA)动脉导管未闭
rare (early surgical repair); hemodynamic
consequence are similar to VSD
2. Right to left shunting右向左分流型
1) Tetralogy of Fallot法洛氏四联征
Pulmonary stenosis, right ventricular
hypertrophy, large ventricular septal defect
and overriding aorta
the most common cyanotic lesion complicating
pregnancy
Types of Cardiovascular Complication
3. Non-shunting
1) Pulmonary stenosis
Not usually progressive
2) Aortic stenosis
rare; its outcome is bad
3) Marfan’s syndrome (genetic disorder)
Myxomatous degeneration of the heart valves;
mitral and cystic medial necrosis（囊性中层
坏死） of the aorta (aneurysms动脉瘤)
death rate: 4%-50%
Types of Cardiovascular Complication
• Rheumatic heart disease
1. Mitral stenosis is the most common lesion.
2. Severe lesion with pulmonary hypertension→
pulmonary edema → hear failure: terminate
the pregnancy
• Heart disease caused by preeclampsia
Left heart failure (increased blood pressure
and cardiac muscle ischemia)
Types of Cardiovascular Complication
• Peripartum cardiomyopathy
1. Congestive cardiomyopathy (during the late
stage of pregnancy (3 months) or within the
first 6 months postpartum)
2. Absence of other causes of heart failure
3. Its etioloty is uncertain
4. Manifestations: symptoms caused by heart
failure and embolism
5. The risk of maternal mortality is 30%-50%.
Types of Cardiovascular Complication
• Myocarditis 心肌炎
1. Manifestation: arrhythmia心律失常
2. Sequelae of myocarditis心肌炎后遗症: more
common
Effects on fetus
• Preterm labor, fetal death, fetal distress
• Drug used
• Inherited problem
Ventricular septal defect (VSD): 22%
Marfan’s syndrome: 50%
Diagnosis
• Etiology diagnosis
congenital or rheumatic or preeclampsia or
peripartum cardiomyopathy
• Anatomy diagnosis
ASD or VSD or PDA or mitral stenosis or mitral
regurgitation
• Pathophysiology diagnosis
pulmonary hypertension or Eisenmenger’s
syndrome or arrhythmia
• Functional classification
Class: I—IV
Diagnosis
• more significant signs
1. History: palpitation(心悸), short breath,
heart disease
2. Orthopnea (端坐呼吸), chest pain,
expectoration of blood (咯血)
3. Cyanosis紫绀, diastolic murmur舒张期杂音
4. Arrhythmia
5. Enlargement of heart (chest x-ray film)
6. Echocardiogram: chamber enlarge,
hypertrophy, abnormality of valve
Functional classification of heart disease
•
1.
2.
3.
New York Heart Association (NYHA)
Class I: asymptomatic
Class II: symptoms with normal activity
Class III: symptoms with less than normal
activity
4. Class IV: symptoms at rest
• Revised guideline
According to the result of objective testing (chest
x-ray, EKG, echocardiogram)
early diagnosis of heart failure
• Palpitation and short breath with less than
normal activity
• HR>110, R>20 at rest
• Orthopnea at night
• Persistent wet rale in lung
Judgment of safety of pregnancy
•
1.
2.
3.
4.
5.
6.
7.
8.
9.
Conception should be prevented if:
Severe heart disease
Functional classification: class III-IV
History of heart failure
Pulmonary hypertension
Right to left shunting
Severe arrhythmia
rheumatic fever风湿热
Combined valve disease
Acute myocarditis
Treatment
• Antenatal treatment
1. Termination of pregnancy:
Terminate before 12 weeks (cases not suitable
to pregnancy)
2. Antenatal supervise: regular and intensive
and early (early pregnancy)
3. Prevention of heart failure
1) sufficient rest
2) weigh control
3) preventing infection, correcting anemia and
arrhythmia
Treatment
4.
1)
2)
3)
4)
Treatment of heart failure
Cardiotonic强心: digoxin
Vascular dilation
Diuretic利尿
Caesarean section
Treatment
• Intrapartum treatment
1. Method of delivery: CS
2. First stage
calm down, ataractic(镇静剂), oxygen supplement
3. Second stage
Operative vaginal delivery
4. Third stage
Preventing postpartum hemorrhage
5. Puerperium
Preventing infection
END