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

2. General Consideration Cause of mother deathCause of mother death The 2 nd cause The 2 nd cause IncidenceIncidence 1%-4% 1%-4%

3. General Consideration Antenatal cardiovascular changesAntenatal cardiovascular changes 1.Blood volume increase by 40%-60% increase by 40%-60% Peaking at 32 –34 weeks Peaking at 32 –34 weeks the expansion in plasma volume is greater than that expansion of red cell mass. the expansion in plasma volume is greater than that expansion of red cell mass. 2.Cardiac output Increase by 40%-50% Increase by 40%-50% Peaking at 20-24 weeks Peaking at 20-24 weeks

4. General Consideration 3.Blood pressure Decrease in the first trimester Decrease in the first trimester Rise to prepregnancy levels in the third trimester Rise to prepregnancy levels in the third trimester 4.Heart size Ventricular chamber size is increased Ventricular chamber size is increased Systolic function is unchanged. Systolic function is unchanged.

5. General Consideration Intrapartum cardiovascular changesIntrapartum cardiovascular changes 1.First-stage labor 300ml –500ml ↑ (each contraction) 300ml –500ml ↑ (each contraction) Cardiac output ↑ (maternal pain, anxiety) Cardiac output ↑ (maternal pain, anxiety) 2.Second-stage labor Lung circulation ↑ (bearing-down efforts to expel the fetus) Lung circulation ↑ (bearing-down efforts to expel the fetus) Venous return ↓ (after fetus is deliveried) Venous return ↓ (after fetus is deliveried) Placental circulation is lost (after placenta is deliveried) Placental circulation is lost (after placenta is deliveried)

6. General Consideration 3.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 frequentCongenital 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 ≥2cm 2 ) → pulmonary hypertension → Eisenmenger’s syndrome asymptomatic (most patients); pulmonary blood flow ↑ (lesion ≥2cm 2 ) → pulmonary hypertension → Eisenmenger’s syndrome 2)Ventricular septal defect (VSD) 室缺 tolerated (small lesion); left ventricular hypertrophy → pulmonary hypertension → biventricular hypertrophy tolerated (small lesion); left ventricular hypertrophy → pulmonary hypertension → biventricular hypertrophy

8. 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 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

9. Types of Cardiovascular Complication 3.Non-shunting 1)Pulmonary stenosis Not usually progressive Not usually progressive 2)Aortic stenosis rare; its outcome is bad 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 ) 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% death rate: 4%-50%

10. Types of Cardiovascular Complication Rheumatic heart diseaseRheumatic 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 preeclampsiaHeart disease caused by preeclampsia Left heart failure (increased blood pressure and cardiac muscle ischemia) Left heart failure (increased blood pressure and cardiac muscle ischemia)

11. Types of Cardiovascular Complication Peripartum cardiomyopathyPeripartum 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%.

12. Types of Cardiovascular Complication Myocarditis 心肌炎Myocarditis 心肌炎 1.Manifestation: arrhythmia 心律失常 2.Sequelae of myocarditis 心肌炎后遗症 : more common

13. 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%

14. Diagnosis Etiology diagnosisEtiology diagnosis congenital or rheumatic or preeclampsia or peripartum cardiomyopathy congenital or rheumatic or preeclampsia or peripartum cardiomyopathy Anatomy diagnosisAnatomy diagnosis ASD or VSD or PDA or mitral stenosis or mitral regurgitation ASD or VSD or PDA or mitral stenosis or mitral regurgitation Pathophysiology diagnosisPathophysiology diagnosis pulmonary hypertension or Eisenmenger’s syndrome or arrhythmia pulmonary hypertension or Eisenmenger’s syndrome or arrhythmia Functional classificationFunctional classification Class: I—IV Class: I—IV

15. Diagnosis more significant signsmore 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

16. Functional classification of heart disease New York Heart Association (NYHA)New York Heart Association (NYHA) 1.Class I: asymptomatic 2.Class II: symptoms with normal activity 3.Class III: symptoms with less than normal activity 4.Class IV: symptoms at rest Revised guidelineRevised 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 activityPalpitation and short breath with less than normal 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

18. Judgment of safety of pregnancy Conception should be prevented if:Conception should be prevented if: 1.Severe heart disease 2.Functional classification: class III-IV 3.History of heart failure 4.Pulmonary hypertension 5.Right to left shunting 6.Severe arrhythmia 7.rheumatic fever 风湿热 8.Combined valve disease 9.Acute myocarditis

19. Treatment Antenatal treatmentAntenatal treatment 1.Termination of pregnancy: Terminate before 12 weeks (cases not suitable to 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

20. Treatment 4.Treatment of heart failure 1)Cardiotonic 强心 : digoxin 2)Vascular dilation 3)Diuretic 利尿 4)Caesarean section

21. Treatment Intrapartum treatmentIntrapartum 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

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