Cardiovascular Complications

Liu WeiLiu Wei

Department of Ob & GyDepartment of Ob & Gy

Ren Ji hospital Ren Ji hospital

General Consideration

• Cause of mother deathCause of mother death

The 2The 2ndnd cause cause• IncidenceIncidence

1%-4%1%-4%

General Consideration

• Antenatal cardiovascular changesAntenatal cardiovascular changes1.1. Blood volumeBlood volume increase by 40%-60%increase by 40%-60% Peaking at 32 –34 weeksPeaking at 32 –34 weeks the expansion in plasma volume is greater the expansion in plasma volume is greater

than that expansion of red cell mass.than that expansion of red cell mass.2.2. Cardiac outputCardiac output Increase by 40%-50%Increase by 40%-50% Peaking at 20-24 weeksPeaking at 20-24 weeks

General Consideration

3.3. Blood pressureBlood pressure

Decrease in the first trimesterDecrease in the first trimester

Rise to prepregnancy levels in the third Rise to prepregnancy levels in the third trimestertrimester

4.4. Heart sizeHeart size

Ventricular chamber size is increasedVentricular chamber size is increased

Systolic function is unchanged.Systolic function is unchanged.

General Consideration

• Intrapartum cardiovascular changesIntrapartum cardiovascular changes1.1. First-stage laborFirst-stage labor 300ml –500ml300ml –500ml↑↑(each contraction)(each contraction) Cardiac outputCardiac output↑↑(maternal pain, anxiety) (maternal pain, anxiety) 2.2. Second-stage laborSecond-stage labor Lung circulationLung circulation↑↑(bearing-down efforts to expel (bearing-down efforts to expel

the fetus)the fetus) Venous returnVenous return↓↓(after fetus is deliveried)(after fetus is deliveried) Placental circulation is lost (after placenta is Placental circulation is lost (after placenta is

deliveried)deliveried)

General Consideration

3.3. PostpartumPostpartum

Circulating blood volumeCirculating blood volume↑↑(Placental circulation (Placental circulation is lost)is lost)

Circulating blood volume furtherCirculating blood volume further↑↑(mobilization (mobilization of extravascular fluid into the vascular of extravascular fluid into the vascular system)system)

Types of Cardiovascular Complication

• Congenital heart diseaseCongenital heart disease先心先心 : : the most frequentthe most frequent1.1. Left to right shuntingLeft to right shunting左向右分流型左向右分流型1)1) Atrial septal defect (ASD)Atrial septal defect (ASD)房缺房缺 : : most commonmost common asymptomatic (most patients); pulmonary blood asymptomatic (most patients); pulmonary blood

flowflow↑↑(lesion ≥2cm(lesion ≥2cm22) ) → → pulmonary hypertension pulmonary hypertension → → Eisenmenger’s syndromeEisenmenger’s syndrome

2)2) Ventricular septal defect (VSD)Ventricular septal defect (VSD)室缺室缺 tolerated (small lesion); left ventricular tolerated (small lesion); left ventricular

hypertrophyhypertrophy→→ pulmonary hypertension pulmonary hypertension→→ biventricular hypertrophybiventricular hypertrophy

Types of Cardiovascular Complication

3)3) Patent ductus arteriosus (PDA)Patent ductus arteriosus (PDA)动脉导管未闭动脉导管未闭 rare (early surgical repair); hemodynamic rare (early surgical repair); hemodynamic

consequence are similar to VSDconsequence are similar to VSD2.2. Right to left shuntingRight to left shunting右向左分流型右向左分流型1)1) Tetralogy of FallotTetralogy of Fallot法洛氏四联征法洛氏四联征Pulmonary stenosis, right ventricular hypertrophy, Pulmonary stenosis, right ventricular hypertrophy,

large ventricular septal defect and overriding large ventricular septal defect and overriding aortaaorta

the most common cyanotic lesion complicating the most common cyanotic lesion complicating pregnancypregnancy

Types of Cardiovascular Complication

3.3. Non-shuntingNon-shunting1)1) Pulmonary stenosisPulmonary stenosis Not usually progressiveNot usually progressive2)2) Aortic stenosisAortic stenosis rare; its outcome is badrare; its outcome is bad3)3) Marfan’s syndrome (genetic disorder)Marfan’s syndrome (genetic disorder) Myxomatous degeneration of the heart valves; Myxomatous degeneration of the heart valves;

mitral and cystic medial necrosismitral and cystic medial necrosis（（囊性中层坏囊性中层坏死）死） of the aorta (aneurysmsof the aorta (aneurysms动脉瘤动脉瘤 ))

death rate: 4%-50%death rate: 4%-50%

Types of Cardiovascular Complication

• Rheumatic heart diseaseRheumatic heart disease

1.1. Mitral stenosis is the most common lesion.Mitral stenosis is the most common lesion.

2.2. Severe lesion with pulmonary hypertensionSevere lesion with pulmonary hypertension→→ pulmonary edema pulmonary edema →→ hear failure: terminate hear failure: terminate the pregnancythe pregnancy

• Heart disease caused by preeclampsiaHeart disease caused by preeclampsia

Left heart failure (increased blood pressure Left heart failure (increased blood pressure and cardiac muscle ischemia)and cardiac muscle ischemia)

Types of Cardiovascular Complication

• Peripartum cardiomyopathyPeripartum cardiomyopathy1.1. Congestive cardiomyopathy (during the late Congestive cardiomyopathy (during the late

stage of pregnancy (3 months) or within the stage of pregnancy (3 months) or within the first 6 months postpartum)first 6 months postpartum)

2.2. Absence of other causes of heart failureAbsence of other causes of heart failure3.3. Its etioloty is uncertainIts etioloty is uncertain4.4. Manifestations: symptoms caused by heart Manifestations: symptoms caused by heart

failure and embolismfailure and embolism5.5. The risk of maternal mortality is 30%-50%.The risk of maternal mortality is 30%-50%.

Types of Cardiovascular Complication

• Myocarditis Myocarditis 心肌炎心肌炎1.1. Manifestation: arrhythmiaManifestation: arrhythmia 心律失常心律失常2.2. Sequelae of myocarditisSequelae of myocarditis 心肌炎后遗症心肌炎后遗症 : : more more

commoncommon

Effects on fetus

• Preterm labor, fetal death, fetal distressPreterm labor, fetal death, fetal distress

• Drug usedDrug used

• Inherited problemInherited problem

Ventricular septal defect (VSD): 22%Ventricular septal defect (VSD): 22%

Marfan’s syndrome: 50%Marfan’s syndrome: 50%

Diagnosis

• Etiology diagnosisEtiology diagnosis congenital or rheumatic or preeclampsia or peripartum congenital or rheumatic or preeclampsia or peripartum

cardiomyopathycardiomyopathy• Anatomy diagnosisAnatomy diagnosis ASD or VSD or PDA or mitral stenosis or mitral ASD or VSD or PDA or mitral stenosis or mitral

regurgitationregurgitation• Pathophysiology diagnosisPathophysiology diagnosis pulmonary hypertension or Eisenmenger’s syndrome or pulmonary hypertension or Eisenmenger’s syndrome or

arrhythmiaarrhythmia• Functional classificationFunctional classification Class: I—IVClass: I—IV

Diagnosis

• more significant signsmore significant signs1.1. History: palpitation(History: palpitation(心悸心悸 ), ), short breath, heart short breath, heart

diseasedisease2.2. Orthopnea (Orthopnea (端坐呼吸端坐呼吸 ), ), chest pain, chest pain,

expectoration of blood (expectoration of blood (咯血咯血 ))3.3. CyanosisCyanosis紫绀紫绀 , , diastolic murmurdiastolic murmur舒张期杂音舒张期杂音4.4. ArrhythmiaArrhythmia5.5. Enlargement of heart (chest x-ray film)Enlargement of heart (chest x-ray film)6.6. Echocardiogram: chamber enlarge, Echocardiogram: chamber enlarge,

hypertrophy, abnormality of valve hypertrophy, abnormality of valve

Functional classification of heart disease

• New York Heart Association (NYHA)New York Heart Association (NYHA)1.1. Class I: asymptomaticClass I: asymptomatic2.2. Class II: symptoms with normal activityClass II: symptoms with normal activity3.3. Class III: symptoms with less than normal Class III: symptoms with less than normal

activityactivity4.4. Class IV: symptoms at restClass IV: symptoms at rest• Revised guidelineRevised guidelineAccording to the result of objective testing (chest According to the result of objective testing (chest

x-ray, EKG, echocardiogram)x-ray, EKG, echocardiogram)

early diagnosis of heart failure

• Palpitation and short breath with less than Palpitation and short breath with less than normal activitynormal activity

• HR>110, R>20 at restHR>110, R>20 at rest• Orthopnea at nightOrthopnea at night

• Persistent wet rale in lungPersistent wet rale in lung

Judgment of safety of pregnancy

• Conception should be prevented if:Conception should be prevented if:1.1. Severe heart diseaseSevere heart disease2.2. Functional classification: class III-IVFunctional classification: class III-IV3.3. History of heart failureHistory of heart failure4.4. Pulmonary hypertensionPulmonary hypertension5.5. Right to left shuntingRight to left shunting6.6. Severe arrhythmiaSevere arrhythmia7.7. rheumatic feverrheumatic fever风湿热风湿热8.8. Combined valve diseaseCombined valve disease9.9. Acute myocarditisAcute myocarditis

Treatment

• Antenatal treatmentAntenatal treatment1.1. Termination of pregnancy:Termination of pregnancy: Terminate before 12 weeks (cases not suitable to Terminate before 12 weeks (cases not suitable to

pregnancy)pregnancy)2.2. Antenatal supervise: regular and intensive and early Antenatal supervise: regular and intensive and early

(early pregnancy)(early pregnancy)3.3. Prevention of heart failurePrevention of heart failure1)1) sufficient restsufficient rest2)2) weigh controlweigh control3)3) preventing infection, correcting anemia and preventing infection, correcting anemia and

arrhythmiaarrhythmia

Treatment

4.4. Treatment of heart failureTreatment of heart failure

1)1) CardiotonicCardiotonic 强心强心 : : digoxindigoxin

2)2) Vascular dilationVascular dilation

3)3) DiureticDiuretic利尿利尿4)4) Caesarean sectionCaesarean section

Treatment

• Intrapartum treatmentIntrapartum treatment1.1. Method of delivery: CSMethod of delivery: CS2.2. First stageFirst stagecalm down, ataractic(calm down, ataractic(镇静剂镇静剂 ), ), oxygen supplementoxygen supplement3.3. Second stageSecond stageOperative vaginal deliveryOperative vaginal delivery4.4. Third stageThird stagePreventing postpartum hemorrhagePreventing postpartum hemorrhage5.5. PuerperiumPuerperiumPreventing infectionPreventing infection

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