Thursday 6 March 2008

Heart disease during pregnancy

Heart disease during pregnancy
[Summary]



Pregnancy heart disease can be divided into two broad categories. The first category is pre-existing heart disease, rheumatic and congenital heart disease in the majority, hypertensive heart disease, mitral valve prolapse and hypertrophic heart disease rare. The second type of heart disease induced by pregnancy, such as preeclampsia heart disease, perinatal heart.



[Diagnosis]




If pre-pregnancy with organic heart disease that is known, of course, there is no diagnosis, but some patients may not seek medical treatment without symptoms. Pregnancy caused by a series of changes in the function of the cardiovascular system, and can lead to palpitation, dyspnea and edema, and other symptoms, but also may be associated with increased heart mild heart murmur and signs, such as X-ray, electrocardiogram changes, thereby increasing cardiac diagnosis difficult. However, if the abnormality found the following should be taken into account the existence of organic heart disease.

1. Ⅲ level and above, the rough systolic murmur.

2. Diastolic murmur.

3. Serious arrhythmia, such as atrial fibrillation or flutter, such as atrioventricular block.

4.X line X-ray film showed a marked widening of cardiac image, especially individual atrial or ventricular expanded significantly.

5. Echocardiography showed heart valve, atrial and ventricular lesions.


[Treatment]




Heart monitor pregnant women

1. Termination of pregnancy indications: Can the original heart of women tolerance pregnancy, the original decision to a number of factors, such as the types of heart disease, diseases of the heart condition and whether complications. Pregnant women in the assessment of heart disease tolerance pregnancy capacity, not only need to consider carefully thought pregnancy may increase the burden on the heart and life-threatening, but also avoid excessive concern, which will rise to the loss of reproductive opportunities. Where any of the following, generally not suitable for pregnancy, early termination: ① heavier heart attack, heart function Ⅲ level and above, or had history of heart failure; ② rheumatic heart disease with pulmonary hypertension, chronic atrial fibrillation and a high degree atrioventricular resistance hysteresis, or the near future with bacterial endocarditis; ③ first obviously cyanotic congenital heart disease or pulmonary hypertension; ④ merger other more serious diseases such as nephritis, severe hypertension, tuberculosis. But if pregnancy has been more than three months, does not generally consider terminating the pregnancy, because of the sick heart, the termination of pregnancy at risk of not less than continue their pregnancy. Such as congestive heart failure has occurred, the timely termination of pregnancy is still suitable.

2. Continue to pregnancy care: heart failure is fatal heart attack pregnant women, but because heart plasma load capacity and the increase in consumption has been declaration to increase the physiological changes and decompensated heart failure caused dysfunction and the key elements. Therefore, the strengthening of pregnancy care aimed at preventing heart failure, which can be summarized as specific measures to reduce the burden and improve the heart function of two cardiac decompensation.

(1) reduce the burden of heart: should pay attention to the following aspects:

1) to limit physical activity. Increased rest time, a day at least guarantee that sleep 10 to 12 hours. As far as possible from the left lying in order to increase the volume and cardiac output Rhodobryum roseum maintain stability.

2) to maintain the spirit of feeling and avoid emotional.

3) into the high protein, low fat, multi-vitamin diet. Limit sodium intake, daily 3 to 5 g of salt to prevent edema. Reasonable nutrition, weight control the rate of increase, so that not more than 0.5 kg per week, the entire pregnancy does not exceed 10 kg.

4) Elimination of damage heart function of a variety of factors, such as anemia, hypoproteinemia, especially vitamin B1 deficiency, infections, pregnancy-induced hypertension.

5) For blood transfusion, many times a small amount (150 ~ 200 ml); For rehydration limit at 500 ~ 1 000ml / d, Disu <10 to 15 drops / min.

(2) improve cardiac decompensation features: include the following:

1) Cardiovascular Surgery: serious illness, heart function Ⅲ ~ Ⅳ, surgery is not complicated, the main requirement anesthesia, in pregnancy can be three to four months out. Separation of emergency mitral valve (pure mitral stenosis cause acute pulmonary edema) in the pre-implementation. Patent ductus arteriosus patients during heart failure, or infection of patent ductus arteriosus, a surgical indications.

2) digitalis: the pregnant women without heart disease signs and symptoms of heart failure, digitalis in general without treatment because of digitalis non-functional at this time. Moreover, application of digitalis can not guarantee that pregnancy does not occur production congestive heart failure, in case of a reaction caused by drugs and difficulties at that time. Furthermore, the rapid digitalis and can be within a few minutes of play, such as the close observation of changes of the disease, it is not difficult to control in a timely and early heart failure. Therefore, usually only in the event of heart failure symptoms or threatened early heart failure, cardiac function Ⅲ grade 28 to 32 weeks of pregnancy (ie pregnancy hemodynamic load peak before) Application digitalis. Because pregnant women on the tolerance of poor digitalis, easy poisoning, it is chosen for rapid preparation, such as acetyl hair to spend glycosides (West to Portland) or poisonous glycoside K Mao spent drugs (drug hair Rotary Hanako glycosides K). Selection of therapy rapid excretion of digoxin, typically used to 4 to 6 weeks postpartum blood circulation have resumed normal.

In addition, heart function grade Ⅰ, Ⅱ-class pregnant women should increase the number of antenatal checks, and 20 weeks at least every two weeks ago from heart medicine, obstetric physicians inspections, a week later, if necessary, follow-up family. Except obstetric cases, the main function of cardiac decompensation and various symptoms. Regular ECG, echocardiography, and to facilitate a comprehensive estimate of the disease, found abnormal, heart failure threatened immediately hospitalized. Pre-production period of two weeks before admission to production, can be sufficient rest, but also facilitate the inspection observation. Fanxin functional class Ⅲ or heart failure should be hospitalized, and hospitalization for childbirth.

Childbirth and postpartum treatment

1. Mode of delivery options: heart disease pregnant women delivery depends primarily on the cardiac function and obstetric cases.

(1) cesarean section: cesarean section can be the end of maternity leave in a relatively short time, thus avoiding lengthy uterine contractions caused by the hemodynamic changes, such as reducing fatigue and pain caused by heart load. In addition, the continuous epidural anesthesia during surgery, pregnant women blood pressure, mean arterial pressure and heart rate changes than by vaginal delivery for small. However, the increase in surgical infection and bleeding opportunity surgery itself is a burden. Therefore, when the reasons for the existence of obstetric (such as the wrong position to abnormal fetal larger), cesarean section may be appropriate to relax indications, but only in heart function Ⅲ ~ Ⅳ, activities of rheumatic fever, pulmonary hypertension or pulmonary congestion, aortic narrow circumstances, selective cesarean section. Preoperative, intraoperative and postoperative cardiac care, anti-infection after surgery and so is the guarantee an indispensable and important safety measures.

(2) vaginal delivery: cardiac function Ⅰ and Ⅱ, unless there are obstetric complications, in principle, by vaginal delivery. Heart disease, the average middle-pregnant women and compared with normal pregnant women, there was no significant difference, but must be specifically responsible for close monitoring. After clinical use of antibiotics to prevent infection from mothers to be semi-supine, and to the oxygen. If strong contractions, pain is just unbearable, can be set for piperazine (dolantin) 50 ~ 100 mg intramuscular injection; can use continuous epidural anesthesia, can alleviate pain, and it helps the second stage of treatment. Closely observed heart rate and respiratory frequency, in the first stage, the hourly measurement once in the second stage of a measured every 10 minutes. Contractions intermittent period, such as heart rate> 100 beats / min or bilateral lung wet running at the end of a small sound and mild shortness of breath, is a precursor to severe heart failure, digitalis should be carried out immediately, intravenous injection to acetylcholine Mao Mao spent glycoside toxicity or spend glycosides K. Palace opened, and so I question the whole, appropriate fetal head high, that is, surgery to shorten the second midwifery birth process. CHD who have left to right shunt, should avoid breath action. Fetus is delivered before the shoulder immediately after the intramuscular injection of 10 mg of morphine, 10 u oxytocin. Placenta is delivered, sand bags abdominal pressure (1 kg weight). Close observation of blood pressure, pulse rate and the changes in uterine shrink. Records of vaginal bleeding.

2. Puerperium processing elements: As a result of increased care during pregnancy and labor, with more than a smooth clearance. However, if relaxed postpartum care, it is highly likely failed. According to statistics 75 per cent of maternal deaths occurred in puerperal heart disease early.

(1) continue to use antibiotics to prevent infection, to prevent subacute bacterial endocarditis occurred.

(2) had the maternal heart failure, cardiac should continue taking drugs.

(3) attention to the temperature, pulse, respiration and blood pressure, uterine bleeding and shrink complex situation.

(4) post-partum bed rest 24 to 72 hours, severe maternal heart disease should take to reduce the semi-supine Rhodobryum roseum blood and oxygen. In the absence of heart failure performance, encourage activities to get up early. Have heart failure, while bed rest should be more activities during the lower extremities to prevent thrombotic phlebitis.

(5) the cardiac function of maternal Ⅲ level and above, and after not lactating. Breastfeeding increase metabolism and amount of fluid needs, will increase the illness.

(6) post-natal hospital for observation for at least two weeks, pending improvement in cardiac function could be discharged before. Still fully discharged from the rest, restriction of activities. Strict contraception.

Diagnosis and Treatment of Heart Failure

Heart disease is based on the occurrence of congestive heart failure. From pregnancy, childbirth and postpartum hemodynamic changes of the heart impact, 32 ~ 34 weeks of pregnancy, childbirth and the postpartum period in the first three days, and patients with heart disease during the most dangerous and prone to failure. Left ventricular blood volume in excess load, faster than the right heart in heart failure; right heart in the hydrostatic load, faster than in left ventricular heart failure.

First seen at the left heart failure mitral valve disease, aortic valve disease, and because of patent ductus arteriosus or ventricular septal defect caused by the left to right shunt heart. Clinical manifestations is congestive lung and pulmonary capillary blood pressure caused by increased: difficulty breathing, sit breath, cough, hemoptysis, lung 1,10 tones, pulmonary valve area and the second heart sound hyperthyroidism FVC and venous pressure decreased to normal. Acute left ventricular failure for the performance of paroxysmal dyspnea and acute pulmonary edema.

Right heart failure usually secondary to left ventricular failure. First seen at the right heart failure pulmonary hypertension, such as pulmonary stenosis. The main clinical manifestations of the cycle of origin in venous hypertension and congestive vein: superficial venous filling, subcutaneous edema, hepatomegaly and tenderness, cyanosis, ascites, pleural effusion, pericardial effusion, as well as kidney, gastrointestinal and nervous system barriers.

1. Early diagnosis: heart decompensated heart failure functional classification that is the sub: cardiac function grade Ⅱ = mild heart failure; cardiac function grade Ⅲ = moderate heart failure; cardiac function Ⅳ class = severe heart failure.

The early symptoms of congestive heart failure: no other reasons could explain the burnout, minor activities after flu symptoms, dyspnea, and shortness of breath in sleep and awakening (or) to be boosted his head, liver pain and lower extremity edema. Early signs are: rest, heart rate> 120 beats / min, respiration> 24 beats / min, the jugular vein pulsatility increased lung wet running at the end of the sound, alternating between veins, diastolic Benma law, volume reduction and weight gain. ECG terminals V1P wave vector (PTF-V1) positive (-0.03 mm s or deeper). Continuous chest radiography (standing) shows两肺Ueno in the pulmonary vein texture thickening.

2. Treatment principles: non-pregnant women with heart failure and pregnancy were similar treatment of heart failure.

(1) strong heart: rapid myocardial digitalis preparations to improve the situation. Mao preferred to spend acetyl glycosides, with increases of 0.4 mg 25% glucose solution 20 ml, slow intravenous injection, when necessary 2 to 4 hours after the addition of 0.2 to 0.4 mg, 1.2 mg to the total available. Mao can also be used to spend glycoside toxicity K, 0.25mg a 25% increase of 20 ml of glucose, slow intravenous injection, when necessary 2 to 4 hours after injection of 0.125 to 0.25 mg, appropriate digitalis volume was 0.5 mg. Change clothes after work rapid excretion of digoxin. Pregnant women on the heart drug digitalis-like tolerance of poor, the need to closely monitor whether toxic symptoms.

(2) diuresis: commonly used furosemide 40 ~ 60 mg intravenous injection, and a diuretic to reduce blood volume and reduce cycle of pulmonary edema. Can be reused, but should pay attention to the electrolyte balance.

(3) Vasodilators: heart failure, there are peripheral contraction increased, to the heart after load increased drug application Vasodilators can play "Bloodletting" role. Selection of isosorbide dinitrate 5 ~ 10 mg, mercapto Jiabing Des Voeux leucine 12.5 mg or prazosin 1 mg three times daily.

(4) sedation: small doses of morphine (5 mg) diluted intravenous injection, not only sedation, analgesia, and the prevention of excessive exciting respiratory center and peripheral expansion, reducing the heart before and after loading, and can be anti-arrhythmia, commonly used in the acute left heart failure, pulmonary edema rescue.

(5) The reduction of blood volume Rhodobryum roseum: tourniquet pressure and legs, rotating every five minutes release a limb. Semi-supine and feet can play down the same role.

(6) antiarrhythmic: arrhythmia can be caused by heart failure, may induce or aggravate heart failure, serious should be promptly corrected. Rapid atrial ectopic rhythm with cardioversion shocks safe and effective option quinidine, procainamide, such as amide. Rapid ventricular ectopic rhythm more lidocaine hydrochloride, the United States and West law (slow rhythm), phenytoin, which is suitable for digitalis poisoning. High or complete atrioventricular block installed on the principle of temporary pacemaker, intravenous infusion can Isoproterenol.


[Clinical]




1. Heart failure: heart disease if the original heart function has been damaged or barely compensated, pregnancy and cardiac decompensation further incomplete. RHD in pregnant women, cardiac dysfunction performance: ① lung disposable blood: a predilection for mitral valve disease, in patients with dyspnea, fatigue even after, at the bottom of a small-两肺wet rales. X-ray examination showed interstitial edema. ② acute pulmonary edema: a predilection for severe mitral stenosis, high blood volume due to pulmonary hypertension. Dyspnea in patients with a sudden, not supine, cough, sputum or 1,10 bubble-like blood,两肺scattered Wheezing sound or wet rales. ③ right heart failure: common in the older, more notable expansion of the heart, atrial fibrillation, which usually diminish labor, or had heart failure in the history of the Treasury. Pregnant women earlier heart disease, patent ductus arteriosus, atrial septal defect, ventricular septal defect with pulmonary hypertension, etc., often leads to right heart failure and pulmonary valve stenosis of tetralogy of Fallot, because right ventricular pressure overload, and more for the performance of right heart failure due to aortic stenosis can be left ventricular pressure overload and form for left heart failure.

2. Infective endocarditis: Regardless of rheumatic heart disease or congenital heart disease may be due to concurrent bacteremia and infective endocarditis. If not promptly control can trigger heart failure and death.

3. Cyanosis and hypoxia: a cyanotic congenital heart disease, which is usually hypoxia and cyanosis, low gestational peripheral resistance, increasing cyanosis. Non-cyanotic type, left to right shunt CHD pregnant women, if hemorrhagic blood pressure dropped and other factors, could cause temporary reverse triage, right-to-left shunt, causing cyanosis and hypoxia.

4. Embolization: during pregnancy, blood in a hypercoagulable state, and heart disease associated with the increased venous pressure and venous blood Yuzhi, easy with embolism. Likely to come from the pelvic thrombosis, pulmonary embolism caused to increased pressure on the pulmonary circulation, thereby stimulating pulmonary edema, or left to right shunt reversal for the right-to-left shunt. If the traffic around the heart cavity congenital heart disease, thrombosis may be caused by defects peripheral arterial embolization.

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