Cardiac Diseases in Pregnancy - University of Arkansas for 心脏病在妊娠-阿肯色大学

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Cardiac Diseases in Pregnancy,Ibrahim Elias Fahdi,MD,University of Arkansas for Medical Sciences,&Central Arkansas Veterans Healthcare System,Division of Cardiovascular Medicine,February 18,2005,Objectives,Normal Physiology during pregnancy,Cardiac Testing,Common cardiac problems,Cardio-circulatory changes during,normal pregnancy,parameter,Changes at various times(weeks),5,12,20,24,32,38,HR,SBP,DBP,SV,CO,SVR,LV EF,5%;6-10%;11-15%;16-20%;21-30%;30%,40%.,“Our only hope is if we all write a letter to Santa”,The Wall Street Journal,Changes in plasma volume,erythrocyte volume,and hematocrit during pregnancy,Plasma volume,50%,(20-100%).,“Physiologic anemia of pregnancy”.,Estrogen-mediated stimulation of the RAS.,Role of other hormones,deoxycorticosterone,prostaglandins,estrogen,prolactin,placental lactogen,GH,ACTH,ANP,From Pitkin RM,Nutritional support in obstetrics and gynecology.Clin Obstet Gynecol 1976;19:489.,Percent change in heart rate,stroke volume,and cardiac output measured in the lateral position throughout pregnancy compared with pregnancy values,Modified from Robson SC,Hunter S,Boys RJ,Dunlop W.Serial study of factors influencing changes in cardiac output during human pregnancy.Am J Physiol 1989;256:H1060-H1065,Cardio-circulatory changes during,normal pregnancy,parameter,Changes at various times(weeks),5,12,20,24,32,38,HR,SBP,DBP,SV,CO,SVR,LV EF,5%;6-10%;11-15%;16-20%;21-30%;30%,40%.,Hemodynamic changes during,labor and delivery,Anxiety,pain,uterine contraction.,Oxygen consumption,threefold.,CO during labor(SV and HR).,SBP&DBP(especially 2,nd,stage),Those changes are influenced by the form of anesthesia and analgesia.,Hemodynamic changes,post partum,Blood shifting“auto-transfusion”,(from the contracting uterus to the systemic circulation),Increase in effective blood volume,Substantial increase in LV filling pressure,SV and CO,Clinical deterioration,Blood loss during delivery,-,HR and CO return to pre-labor values within 1 hour.MAP and SV within 24 hours.,Hemodynamic adaptation persists post partum and return to pre-pregnancy values within 12-24 weeks after delivery.,Increase in venous return,(relief of caval compression),History,Exercise capacity,Current or past evidence of HF,Associated arrhythmias,Physical exam,Cardiac Hemodynamics,Severity of heart disease,PA pressures,Echo,MRI.,Exercise testing,Useful if the history is inadequate to allow assessment of functional capacity,During pregnancy,Evaluate once each trimester and whenever there is change in symptoms Multidisciplinary approach,Fetal Echo,Before conception,Reimold,S.C.et al.N Engl J Med 2003;349:52-59,During Labor&Delivery,Multidisciplinary approach(Obstetrician,Cardiologist,Anesthesiologist),Tailor management to specific needs,High-risk pregnancy,Pulmonary HTN and Eisenmengers syndrome.,Symptomatic obstructive cardiac lesions:,AS,PS,uncorrected coarctation of the aorta.,Marfans Syndrome with dilated aortic root.,Systemic ventricular dysfunction(LVEF 40%).,Severe cyanotic heart disease.,Patients with prosthetic valves.,Significant uncorrected CHD.,Contraindications to Pregnancy,Lesion,Maternal death rate(%),Severe Pulmonary Hypertension,50,Severe obstructive lesions:,AS,PS,HOCM,Coarctation.,17,Systemic Ventricular Dysfunction,NYHA class III or IV,7,Pregnancy Outcomes,The prevalence of clinically significant maternal heart disease is low(2 classes.,Need for urgent invasive cardiac procedure,(percutaneous cardiac valvuloplasty,permanent pacing).,N.B.:There was,no,association between the type of delivery and peripartum cardiac event rate,(3%vs.4%,P=0.46).,Siu SC,Sermer M,Colman JM,et al.Prospective multicenter study of pregnancy outcomes in women with heart disease.Circulation 2001;104:515-521.,Predictors of primary cardiac events,Odds ratio(95%CI),p,1.,Prior cardiac event(HF,TIA or stroke)or arrhythmia.,6(3-14),II or cyanosis.,6(2-22),0,009,3.,Left heart obstruction,(MVA 30 mmHg).,6(3-14),0.001,4.,Reduced systemic ventricular systolic function,(EF 40%),11(4-34),0.001,4%,27%,62%,Adverse neonatal events,Neonatal events:,Premature birth,Small-for-gestational-age birth weight.,Respiratory distress.,Inter-ventricular hemorrhage.,And death.,N.B.:in the 6 pregnancies in which the mother received warfarin during all(n=2)or part of pregnancy(n=4),embryopathy was,not,observed in this small series.,Predictors of primary cardiac events,Odds ratio(95%CI),P,1.,Abnormal functional capacity,(NYHA class II or cyanosis),3(1.1-6.1),0.035,2.,Use of anticoagulant drugs throughout pregnancy.,3(1.4-8.2),0,0093,3.,Smoking during pregnancy.,2(1.3-13.9,0.0045,4.,Multiple gestation.,22(6-85),35 years old or 5 rads:very low risk,5-10 rads:counseling for low risk,10-15 rads during 1,st,6 weeks:individual,15 rads:termination pf pregnancy,Cardiac Tests Performed 2,Colletti,rd,ed.New York,Wiley Liss,1998,pp 33-36,Magnetic Resonance Imaging,Pulmonary Artery Ca