Cardiovascular Complications

1. Cardiovascular Complications Liu Wei Department of Ob & Gy Ren Ji hospital

2. General Consideration • Cause of mother death The 2nd cause • Incidence 1%-4%

3. General Consideration • Antenatal cardiovascular changes • 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. • Cardiac output Increase by 40%-50% Peaking at 20-24 weeks

4. General Consideration • Blood pressure Decrease in the first trimester Rise to prepregnancy levels in the third trimester • Heart size Ventricular chamber size is increased Systolic function is unchanged.

5. General Consideration • Intrapartum cardiovascular changes • First-stage labor 300ml –500ml↑(each contraction) Cardiac output↑(maternal pain, anxiety) • 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)

6. General Consideration • Postpartum Circulating blood volume↑(Placental circulation is lost) Circulating blood volume further↑(mobilization of extravascular fluid into the vascular system)

7. Types of Cardiovascular Complication • Congenital heart disease先心: the most frequent • Left to right shunting左向右分流型 • Atrial septal defect (ASD)房缺: most common asymptomatic (most patients); pulmonary blood flow↑(lesion ≥2cm2) → pulmonary hypertension → Eisenmenger’s syndrome • Ventricular septal defect (VSD)室缺 tolerated (small lesion); left ventricular hypertrophy→ pulmonary hypertension→ biventricular hypertrophy

8. Types of Cardiovascular Complication • Patent ductus arteriosus (PDA)动脉导管未闭 rare (early surgical repair); hemodynamic consequence are similar to VSD • Right to left shunting右向左分流型 • 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

9. Types of Cardiovascular Complication • Non-shunting • Pulmonary stenosis Not usually progressive • Aortic stenosis rare; its outcome is bad • 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%

10. Types of Cardiovascular Complication • Rheumatic heart disease • Mitral stenosis is the most common lesion. • 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)

11. Types of Cardiovascular Complication • Peripartum cardiomyopathy • Congestive cardiomyopathy (during the late stage of pregnancy (3 months) or within the first 6 months postpartum) • Absence of other causes of heart failure • Its etioloty is uncertain • Manifestations: symptoms caused by heart failure and embolism • The risk of maternal mortality is 30%-50%.

12. Types of Cardiovascular Complication • Myocarditis 心肌炎 • Manifestation: arrhythmia心律失常 • Sequelae of myocarditis心肌炎后遗症: more common

13. Effects on fetus • Preterm labor, fetal death, fetal distress • Drug used • Inherited problem Ventricular septal defect (VSD): 22% Marfan’s syndrome: 50%

14. 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

15. Diagnosis • more significant signs • History: palpitation(心悸), short breath, heart disease • Orthopnea (端坐呼吸), chest pain, expectoration of blood (咯血) • Cyanosis紫绀, diastolic murmur舒张期杂音 • Arrhythmia • Enlargement of heart (chest x-ray film) • Echocardiogram: chamber enlarge, hypertrophy, abnormality of valve

16. Functional classification of heart disease • New York Heart Association (NYHA) • Class I: asymptomatic • Class II: symptoms with normal activity • Class III: symptoms with less than normal activity • Class IV: symptoms at rest • Revised guideline According to the result of objective testing (chest x-ray, EKG, echocardiogram)

17. 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

18. Judgment of safety of pregnancy • 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

19. Treatment • Antenatal treatment • Termination of pregnancy: Terminate before 12 weeks (cases not suitable to pregnancy) • Antenatal supervise: regular and intensive and early (early pregnancy) • Prevention of heart failure • sufficient rest • weigh control • preventing infection, correcting anemia and arrhythmia

20. Treatment • Treatment of heart failure • Cardiotonic强心: digoxin • Vascular dilation • Diuretic利尿 • Caesarean section

21. Treatment • Intrapartum treatment • Method of delivery: CS • First stage calm down, ataractic(镇静剂), oxygen supplement • Second stage Operative vaginal delivery • Third stage Preventing postpartum hemorrhage • Puerperium Preventing infection

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