Lectures on heart disease and pregnancy
Postpartum cardiac flow returns to normal in the postpartum period. Cardiac flow increases due to the need to consume oxygen for the mother.
Circulatory and respiratory changes due to pregnancy
(Which are related to the maternal cardiovascular system)
The microcirculation system
Chest radiograph: Two dark lung umbilical is a sign of congestion in the microcirculation. Pulmonary ventilation (tachypnea) increases, and pCO2 in maternal blood decreases from 40 to 32 mmHg.
Maximum ventilation (shallow breathing) is reduced, leading to a decrease in exercise adaptation. The enlarged pregnant uterus gradually pushes the diaphragm up, causing pressure on the lungs, reducing the ventilation area.
Reduced oxygen exchange capacity, gradually leading to maternal blood metabolic acidosis.
Circulatory and cardiovascular system
- Increase the area of circulation: Because the fetus, placenta, uterus, breast of the pregnant woman develop with gestational age, increasing the perfusion area of the heart and circulation.
- Increases circulating blood volume by 40%. Increases rapidly from 4, 5, 6 months and remains at that high level until postpartum, then decreases gradually back to the level before pregnancy, throughout the postpartum period. This increase is mainly plasma, only 20% increase in erythrocytes, hematocrit decreases from 30-25% of blood viscosity decreased, resulting in physiological fluid retention, water retention in the pregnant woman's body.
- Increased tachycardia 10 times/minute compared with the period without pregnancy.
- Cardiac output: normal before pregnancy: 4.5 times / minute. During pregnancy, cardiac output increases:
Pregnancy 3 - 4 months increased to 5.5 times/minute.
The 5th - 7th-month pregnancy increased to 6.0 times/minute.
The 8th - 9th-month pregnancy increases to 5.5 times/minute.
Postpartum cardiac flow returns to normal in the postpartum period. Cardiac output increases due to the need to consume oxygen for the mother (breast, uterus), the fetus, and the fetal appendages. Since the blood volume increases, the blood flow must increase accordingly.
- Arterial blood pressure does not increase, but venous pressure increases, resulting in swelling of the legs.
- Heart position: find the word standing to horizontal, because the diaphragm is pushed up by the uterus. Large-diameter blood vessels from the heart out are slightly bent (slightly narrowed), forcing the cardiovascular system to work in more difficult conditions. The force of the heart's work is greater to pump blood into the circulation to feed the body.
- Increased cyclic speed: normal cyclic speed is 14 seconds.
During the first 3 months of pregnancy, the circulatory speed is 12.4 seconds.
During the last 3 months of pregnancy, the circulatory speed is 10.2 seconds
Increased circulation rate, due to the gradual formation (shunts) between the arteries and veins in the hematoma, uterus, and lower peripheral resistance, arterial blood pressure does not change much.
During pregnancy, blood flow increases, so the heart's mechanical work increases by 50%. The above reproductive cardiac fluctuations can only be adapted easily in healthy and normal pregnant women. Because they have a huge capacity to store activities, they adapt to pregnancy. Pregnant women with heart disease and heart disease cannot cope with these changes, so pregnancy is a burden on the sick heart. So the heart is susceptible to failure during the development of pregnancy leading to heart failure, congestion in the heart, in the lungs, in the liver and possibly heart failure, acute pulmonary edema, and arrhythmia.
Increased frequency of uterine contractions causes an increase in the need for energy-generating oxygen for the uterine muscles to contract during labor. Clinically, frequencies above 110 beats/min can be a predictor of heart failure (especially in mitral stenosis).
The blood pressure in uterine contractions increases, because blood from the uterine muscle accumulates in the mother's circulatory system is estimated at 200 ml when the uterine muscle stroke ends, blood returns to the uterus; creating hemodynamic disorders (4). Combined with increased heart rate and increased cardiac blood flow, the mechanical work of the heart increases. In heart disease, this sudden and sudden increase in the mechanical workload causes the heart to become unresponsive, leading to heart failure, acute heart failure or pulmonary edema, and acute pulmonary edema.
In mitral stenosis (approximately 30% of heart valve diseases), the more narrow the stenosis prevents blood from the atrium to the ventricles increases left atrial pressure and circulatory pressure leading to pulmonary stasis, pulmonary edema. Had blood stasis in the lungs, atrium, and right ventricle, the liver will stagnate, making the liver enlarged.
Meanwhile, blood from the left ventricle is pumped out less, causing circulatory anemia. Tissue oxygen demand is very high at this stage, requiring the left and right ventricles to work harder to supply oxygen, leading to total acute heart failure.
There are the following symptoms
After the pregnancy period, uterine circulation suddenly stopped working.
Losing blood often when peeling the placenta, lack of red blood cells to transport oxygen to tissues.
The uterus shrinks into a safe block, accumulating blood from the uterus into the circulation to increase the volume of blood circulation, creating a relatively sudden burden on the heart.
Abdominal pressure drops suddenly due to uterine shrinkage, blood from two legs to the abdominal cavity, on the right atrium, right ventricle, and lungs. The amount of blood circulating through the heart increases by about 20% for a short time. This sudden change only in healthy people can adapt easily. And people with heart disease, especially mitral stenosis, are prone to cardiac arrest, acute heart failure, or acute pulmonary edema. This is the most dangerous period in a real cardiac event.
When the placenta bleeds blood vessels in the open placenta, physiological embolism appeared; active maternal circulatory coagulation factors easily lead to thrombotic events. On the other hand, the buttons to stop bleeding in the blood vessels in the area where placenta cling to are susceptible to infection. This is the premise of the stroke in the postpartum period.
The circulating blood volume caused by the contraction of the uterus into the general circulation remains and this blood volume will gradually decrease in the postpartum period, as the oxygen demand remains high due to the development of the breasts to synthesize and create milk. The volume of intercellular water in the mother's body also decreases with estrogen decreases. After childbirth, although the burden of pregnancy on the heart is over, the consequences of that burden have made the heart's capacity reserves exhausted. Hemodynamic disorder in childbirth still exists, so it is still possible to cause heart failure and pulmonary edema in resting mothers, not to mention mothers who have to work hard to breastfeed their babies.
Effects of heart disease on pregnancy
In general, mothers with heart disease, whether acquired heart disease or non-blue-purple or cyanotic elves lack oxygen and lack tissue nutrition.
The growth and development needs of the fetus require protein synthesis. To synthesize protein requires protein and oxygen raw materials to synthesize. According to Whitemore (USA 1983), about 30% of children of pregnant women with congenital heart disease are deformed. According to Metcalfe (USA 1985), these malformations are partly due to their mothers suffering from hypoxic heart disease, partly due to heredity.
Depending on the degree and time when the mother suffers from a lack of oxygen due to heart disease, there can be different effects on pregnancy, more common such as poor uterine development of intrauterine malnutrition, chronic fetal failure, underweight for gestational age. The risk of miscarriage and miscarriage, the threat of preterm and preterm delivery, stillbirth, and death in labor is also high. During labor is often fast, because the fetus is small. However, pregnant women with heart disease are still able to compensate well, pregnancy can still develop normally and give birth normally.
Cardiac pregnancy complications
The severity of heart disease, type of heart disease. Mitral stenosis is the most severe and the more severe the stenosis is. The more valves damaged, the worse.
Age of pregnant women: Heart failure 13.2% under 25 years old; 41.5% are at the age from 25 - 29; 21.6% are at the age of 30 - 34 and 23.6% are at the age of 35 and over because heart disease is often acquired at an early age.
Number of births: The number of times a child gives birth with fewer events than a chicken, the more times he gives birth, the higher the risk
Gestational age: The greater the gestational age, the more likely it will happen, which can occur in the first trimester, summarizing 14 maternal cardiac deaths (3), then 6 months: 2; 7 months: 3; 8 months: 2 and 9 months: 7 deaths.
Other factors: fear increases emotions, which can also easily lead to death.
Common cardiac pregnancy complications
Ranking of heart failure by the function of pregnancy: Based on the standards of the New York Heart Association (NYHA) are:
Type 1: Patients with heart problems, but not limited physical activity. Normal physical activity did not cause fatigue, nervousness, difficulty breathing, or chest pain. Clinically we call it not heart failure.
Type 2: Patients with heart disease, limited physical activity, comfortable at rest, the normal physical activity causing fatigue, nervousness, difficulty breathing or chest pain. Clinically we call it to grade 1 heart failure.
Type 3: Patients with heart disease, with marked physical limitations, comfortable at rest, light physical activity has caused fatigue, nervousness, difficulty breathing, or chest pain. Clinically we call it grade 2 heart failure.
Type 4: Patient with heart disease, incapable of performing any physical activity without discomfort. Symptoms of heart failure or chest pain are present even at rest. Unpleasant fatigue increases with physical activity. Clinically we call grade 3 heart failure: shortness of breath while resting. Examination of the liver below the ribs. Feedback venous hepatosis (+).
Clinically we call grade 4 heart failure: Patients with restlessness have to sit to breathe, irreversible enlarged liver. Negative cervical venous response (-).
Treatment rating: Clinical ratings are usually ranked according to the amount of physical activity (also by NYHA), listed here for reference.
Type A: Patients with heart disease whose physical needs are not restricted. This is rare in pregnancy, despite the increased burden of pregnancy (not heart failure).
Category B: Heart disease patients whose normal physical activity needs are limited, but they are advised to avoid strenuous effort or physical exertion (degree 1 heart failure).
Type C: Patients with heart failure whose normal physical activity has been moderately restricted and more active exertion is interrupted, because of dyspnea (heart failure degree 2).
Type D: Heart failure patient whose normal physical activity is significantly restricted, sitting only to breathe (grade 3 heart failure).
Type E: Patients with heart failure, must rest completely or have to sit to breathe also have difficulty breathing (heart failure degree 4).
Bacterial infections: respiratory infections, infectious enditis.
Stasis: Too much fluid introduced: by oral or infusion.
Fluid retention: NaCl salty food, pregnancy toxicity, pregnancy, cortisone therapy in kidney disease.
Excessive physical activity, excessive mental activity, and intercourse.
Heart rhythm disturbances.
Definition of heart failure in cardiac pregnancy
Heart failure is a medical condition where the heart muscle loses or loses the ability to contract and supply blood to feed the body according to the body's needs during exertion, and then after rest.
The hemodynamic function of the heart depends on four factors:
Pre-burden: The maximum contractile force of the end-diastolic endocardial fibers, approximately the size or volume of the left end-diastolic end ventricle.
Afterload: The force opposite to the shortening of the left ventricular fibers during systole, the resistance that the heart muscle encounters when contracting to force blood into the circulation, leading the peripheral resistance.
Myocardial contractility: Mechanical and chemical processes in the heart muscle to exert the force that shortens muscle fibers (muscle contractions), and then contracts into the rhythm.
Heart rate: normal heart rate 80 times/min. If circulatory failure, the heart rate increases by 12.4 times/minute, although the heart muscle is still contracting well.
Heart failure: when factor 3 is impaired and leads to circulatory failure. Therefore, in the treatment of heart failure, the first step is to support the heart to increase the force of the heart muscle.
Heart failure events
Can occur from the 4th month of pregnancy when blood volume starts to increase until 8 months remains at this level until postpartum begins to decrease gradually. At birth, acute heart failure. After childbirth with lactation, heart failure gradually reappeared. Heart failure events account for 84% of all cardiac events, but the mortality rate is only about 15.56 - 30.09% of all cardiac complications. (2,3).
Clinical: based on the main signs such as shortness of breath (frequency, breathing style, the posture of the patient, ...), the pulse is usually fast, rarely slow. Big liver under the ribs ...
Cardiopulmonary X-ray: on a straight and tilted film with oral contrast, the heart can be enlarged and pressed into the esophagus.
Treatment of heart failure during pregnancy
Cardiovascular drugs: Digoxin is often used to increase the force of heart muscle contraction, increase myocardial tone, slow heart rate, reduce peripheral blood tone and cause diuretics. The concentration of drugs in the heart muscle is 25 times higher than in the blood. Tablets, tubes: 1 / 4mg. Before using it should see contraindications and contraindications.
With tachycardia heart failure:
Attack dose: 2 tablets or 2 ampoules/day in two divided doses for the first one to two days.
Maintenance dose: 1 tablet/day for the next 3 days and then take 2 days off.
Continue maintenance dose: 1 capsule every other day, or take 5 consecutive days off for 2 days.
Tachycardia (> 120 c / min): Cedilanid (Lanatozit C) ampoule of 0.4 mg slowly intravenously, a day can be used from 1-4 ampoules. The dose is gradually increased from low to high until effective.
Contraindications to Digoxin: pulse less than 90 times/minute. Grade 2 and 3 atrioventricular block. Atrial fibrillation is associated with Wolff Parkinson White syndrome. Ventricular fibrillation, myocardial infarction, low blood potassium. If there are signs of Digoxin poisoning, stop the drug immediately.
The drug of choice: Uabain (Strophantin acetyl) ampoules of 1 / 4mg + 10 ml of 5% glucose solution by slow intravenous injection, up to 2 ampoules a day can be used.
Diuretics: Furosemid (Lasix) ampoules of 10, 20mg, 40 mg tablets. The dosage depends on the needs of treatment for each patient, short bursts, taken with potassium before bedtime, should not be used for a long time and easily cause dehydration.
Contraindications: encephalopathy, cirrhosis, sulfamide allergy, urinary retention, hypovolemia, dehydration.
Oxygen therapy: Patients should be given intermittent oxygen therapy through nasal inhalation.
Sedation: Using Diajepam (seduxen).
Care: Binge eating (Natricloride restriction). Limit movement and movement.
If the patient responds to treatment, the fetus is nearly full-term, we can continue medical treatment to keep the pregnancy until a full month; After that, it is advisable to proactively cesarean section to avoid hemodynamic disorder in labor
If the patient does not respond to treatment, the level of heart failure has not decreased or decreased significantly, it is important to actively suspend pregnancy to save the mother.
In heart failure appears acute pulmonary edema alone or acute pulmonary edema alone. The rate of acute pulmonary edema only accounts for 15% of all cardiac events but accounts for up to 50% of all cardiac deaths, commonly seen in mitral stenosis.
This process begins with left atrial stasis, pulmonary stasis, pulmonary edema, and then acute pulmonary edema. Accompanying it is lack of tissue oxygen, due to heart failure not providing enough blood to the tissue, is an increase in peripheral resistance due to circulatory stasis of heart failure or increased blood pressure.
Symptoms and diagnosis
Acute pulmonary edema: Pulmonary edema often occurs suddenly in the morning (from 5 - 12 am). At first, the patient feels very uncomfortable, anxious, chest tightness, throat itching, coughing, then suddenly very difficult to breathe, has to sit up to breathe. The difficulty in breathing increased, choking and spitting out the thin foam and pink foam in just a few minutes. The rate of pulmonary edema complications was low at 2.24%, but the mortality rate was as high as 50% of cases of acute pulmonary edema (2.3).
Physical examination: Blue-purple eyebrows, sweaty, struggling, sitting leaning to breathe.
Lung examination: Knock the chest in wine, because the alveoli is enlarged to try to compensate for breathing. hear the lungs full of rales, from the bottom of the lungs rising up very quickly across the two fields like a tidal surge.
Heart examination: It is difficult to hear the pathology as before because the physical symptoms of the lungs are blurred, the sound of heart arrhythmia, horse galloping ...
Severe acute form: The patient suddenly has very severe shortness of breath, may die immediately without spitting out pink foam. A sudden death, when the autopsy was found, pink foam filled the alveoli and enlarged lungs ...
Mild form: The patient has little difficulty breathing, although he has to sit up to breathe, spitting up a little bloody foam. This scene usually occurs during exertion in patients with mitral stenosis.
Hypotension: With 3 limbs reincarnation (2 legs and one arm), the patient is still in a semi-recumbent position (Fowler position).
Oxygen therapy: Before giving oxygen, clear the upper respiratory tract by sucking up the sputum from the hat, mouth, and throat. Nasal inhalation and oxygen inhalation by the patient through inhalation, oxygen must run through a bottle of alcohol mixed with alcohol to dissolve the bubbles in the alveoli, so that oxygen comes in direct contact with the alveolar wall. That way oxygen is effective.
Strong diuretic to lower blood volume: Furosemit (Lasix, Lasilix) 20 mg / tube. Intravenous injection with high doses, so that in the first hour the patient's urine drains into the urine is about 1.5 to 2.0 liters. Usually, begin intravenous administration of 2 or more Lasix tubes.
Anti-secretion sedation: Using morphine 0.01 g intravenously or intramuscularly.
Cardiopulmonary: Use intravenous Uabain or Digoxin depending on the vein at that time.
Evaluation after treatment of acute pulmonary edema
If the patient is pregnant: After the treatment of acute pulmonary edema shows results, we should continue the treatment for a few more days, about 3-5 days, for stable pulmonary edema. When the condition has stabilized, we should have a cesarean section immediately to save the mother regardless of gestational age. If the patient waits for a long time, the patient may have another acute pulmonary edema, which is very dangerous to his life.
If the patient is in labor: this is a very dangerous condition, cesarean section or forceps delivery threatens maternal death. It is best now to treat aggressive acute pulmonary edema and delay delivery, to avoid hemodynamic disturbances during labor because of the difficulty in anaesthesia.
If a patient has a history of acute pulmonary edema, is currently pregnant, and acute pulmonary edema is likely to recur, pregnancy should be discontinued when conditions are met.
Rank arrhythmias according to origin and conduction point
Cardiac arrhythmias stemming from the Keith - Flack node (sinus arrhythmia) can be changed. The electrocardiogram appeared in two parts atrium and ventricle.
Out-of-node Keith Arrhythmia - Flack is unlikely to change. An electrocardiogram lacks part of the atria or ventricles.
Sort by clinical
Tachycardia: if there is no electrocardiogram, we will diagnose based on pulse frequency: 140 - 200 times/minute, Budder tachycardia.
120 - 140 times / minute, atrial fibrillation
80-120 times/minute, fast from the Keith - Flack button.
Average beat 70 times/minute.
Delayed rhythm: From 60 to 40 times/minute, slowly from the Keith - Flack button
From 60 to 40 times/minute, atrioventricular block.
Diagnosis of arrhythmias is easy by counting pulse/minute, or measured on an electrocardiogram with more accuracy, especially tachycardia over 140 times/min.
Irregular heartbeat (extrasystole):
There is a nerve flow that originates more strongly than usual, from a stimulating center above or outside the conduction flow, causing the ventricles to contract sooner. Because the ventricles contract early (extrasystole), then only longer, called compensatory time.
Mechanical symptoms: The patient feels palpitations or has stopped beating and may feel short of breath. If extrasystole occurs while sleeping, the patient is startled.
Physical symptoms: Hearing the heart or rotating pulse, seeing irregular heartbeat sometimes quit. Clinically, usually assess the rate of arrhythmia, from over 5% considered pathological. If there is external systole twice in a row (double extrasystole) is much of an acute risk.
Electrocardiogram: supraventricular extrasystole: undistorted QRS. QRS ventricular extrasystole has deformation.
Heart rate beats have no problem in duration and amplitude due to atrial fibrillation. Atrial fibrillation is the phenomenon of atrial dissociation, so the ventricular rhythm is slower, the ventricle beats unevenly. Insufficient blood flow to the ventricles decreases by 20-30%, especially during exertion. Look for hypertrophy and failure, blood stasis atrium, especially in mitral stenosis leading to blood clotting in the atrium and then thrombosis.
The patient feels uncomfortable suspense, irregular rapid pulse. If there is diastolic fibrillation, it is difficult to hear. Extra-systolic sometimes sparse, sometimes rushed. Therefore, monitoring and diagnosis of ectopic systole take time.
Electrocardiogram: P wave loss in leads. It is sometimes seen that a lead has many P waves, the RR interval is uneven, the amplitude of R is not equal.
In general, for the treatment of difficult arrhythmias, it is necessary to have an accurate diagnosis by electrocardiogram and there is evidence to monitor and evaluate the results of treatment. Before starting treatment, you should consult a cardiologist. The following drugs are commonly used in arrhythmias: Amiodarone, Bretyliumtosylat, Digoxin, Disopyramide (in table C); Encainamid (table B); Flecain (Group C); Lidocaine (group B); Lidocaine, Mexiletine, and Buovea can also press the eyeballs to help.
Cardiac thrombosis begins in the atria and from the mitral valve. After forming, the whole clot breaks down into small pieces and flows along the circulating blood, it gets stuck somewhere causing the embolism of that place. Thrombosis always begins with increased Prothromobin which is the basis of fibrin formation that binds platelets with red blood cells to form a thrombosis. In clinical practice, thromboembolism is common in coronary arteries, cerebral vessels, pulmonary vessels, mesenteric vessels, ...
Thrombotic complications can occur at any time of pregnancy, but are most common at the beginning of the second week after delivery, after cesarean section, and in the first week after curettage, after miscarriage; and is most common in patients with mitral stenosis. The general symptom is a pain in the blocked place, the headache has started in waves after the pain is almost constant. For example, a blockage in the brain is a headache. Coronary obstruction: chest pain. Intestinal obstruction: abdominal pain.
Signs of their consequences: Obstruction in the brain causes local paralysis. Clogged coronary arteries cause low blood pressure or cardiac arrest. Intestinal obstruction has surgical abdominal signs.
When there are clinical signs is obstructive. Medical treatment is difficult, easy to leave sequelae. It is best to prevent prothrombin from increasing so high that there is a possibility of thrombosis.
Having formed thrombosis: There is no specific thrombolytic drug. You can use Kabikinase (Streptokinase), Actilyse (Alteplase), Eminase (Anistre-plase), Urokinase, they all activate Plasminogene into Plasmin hoping to dissolve blood clots of myocardial infarction, deep venous thrombosis, large pulmonary embolism, at a very early stage. Also main medicine for symptom treatment such as anti-pain, ulcer prevention, respiratory aid, anti-infection, ...
Thrombosis prevention: Anticoagulants, anti-vitamin K preparations can be used to control prothrombin ratio by sintrom (Anodicoumaron), 4mg tablets, and oral dose according to the prothrombin level of the patient that you intend to control can be used from 1 / 2 –1 to 6 mg/day. During treatment, must always monitor and evaluate the results of clinical treatment and prothrombin rate to adjust the dose of sintrom. When there are complications of bleeding due to the drug, vitamin k should be injected immediately to neutralize sintrom in the blood, according to the following regimen:
Table: Dose of vitamin K neutralizing oral anticoagulants.
Bleeding is life-threatening:
Immediately inject vitamin K (0.5 mg) into a vein, and either a solution of factors II, IX, X with factor VII (if available) or plasma coagulation.
Bleeding or nosebleeds due to overdose for 1-2 days.
Intravenous vitamin K injection at a dose of 0.5 - 0.2 mg
No bleeding but over 4.5 percentage of normal APTT time
Warfarin overdose 1-2 days requires close monitoring
Unusual bleeding at therapeutic levels.
Contraindicated when the fetus is still in the uterus because sintrom passes through the placenta.
Prophylaxis of thrombosis by intramuscular Heparin 5000 - 10,000 units/day, long-term use of Heparin can have pitting effects. Bleeding from heparin therapy can be caused by prolonged blood clotting, due to thrombocytopenia. Therefore, it is necessary to monitor and maintain the APTT (activated partial thromboplastin time) level between 1.5-2 times the normal time (7) (normal clotting time 30-40 seconds). If there is bleeding, use Protamine sulfate to neutralize heparin, calculate the neutralizing dose of 1mg / 100 units of Heparin (6).
After giving birth, the blood vessels in the old placenta area have been sealed with hemostasis buttons, which is a convenient place for bacteria to grow, causing infection in the uterus, into the bloodstream, causing subacute endocarditis. On the other hand, after giving birth, the resistance of pregnant women decreases, so it is easier to infect the blood causing subacute endocarditis, which is a common infection after giving birth.
Clinical manifestations include intermittent or intermittent high fever, trembling malaria, dry lips, dirty tongue, infected expression. In terms of obstetrics: the uterus is slow to contract, and painless manipulation and mobility of the uterus. Production has a bad smell. Blood test: leukocytes are elevated. Blood culture: find bacteria that cause disease and do antibiotic mapping, usually only positive from 1/3 to 1/2 of cases.
Treatment according to the regimen of sepsis: select antibiotics according to the antibiotic regimen, dose according to the minimum inhibitory concentration, depending on the type of anaerobic or pathogenic anaerobes that prolong the duration of antibiotic treatment. The results of treatment are often poor. Therefore, the main prevention is: good sterility in labor, proper implementation of obstetric indications, beta lactamin antibiotics should be used for prophylaxis.
Cardiac pregnancy management
Purpose: To prevent and treat possible complications.
Closely monitor the patient's status every week from pregnancy to detect real heart complications early and treat them promptly.
Patients must rest, eat bland under the guidance of a cardiologist seriously, including daily urine monitoring.
Cardiac support: Depending on the pulse, Digoxin or Uabain is used.
Diuretic: Furosemide with intermittent potassium chloride.
Sedation: Diazepam ...
Prevention of infections: By antibiotics beta lactamin group.
Prevent Haparin blood clots while pregnant.
The motto of obstetrics: the protection of the mother is the main, with consideration to the child, according to the principle of heart failure as follows:
Pregnant women who have not had heart failure:
With the second birth: Pregnancy should be discontinued of any gestational age. If detected late, the fetus is nearly full-term, which the mother's condition allows, can keep the pregnancy until full term. At that time, it is advisable to find appropriate measures to end the pregnancy.
With the first birth: Pregnant women can keep the pregnancy to deliver with the condition that they need to be monitored and cared for weekly by a good cardiologist and obstetrician to prevent possible maternity events. Pregnant women should be cared for in the hospital, one month before delivery.
Pregnant women who have had heart failure:
With the second birth: Pregnancy must be suspended at any gestational age with the safest and most radical measures. Depending on the degree of heart failure, each type of heart disease, depending on gestational age, the appropriate method should be chosen such as sterilization abortion, mass hysterectomy, cesarean section for a partial hysterectomy. Or to treat a period of time for full-term pregnancy before terminating the pregnancy.
With the first birth: There should be careful consideration of two physicians and cardiologists
If pregnant women are suffering from heart failure grade I and II but are still young (under 6 months), they should have an abortion to protect the pregnant woman's life. If the pregnancy is over 6 months old, depending on the level of heart failure, type of heart disease, the expectation of the pregnant woman, the possibility of treatment, it is possible to keep the pregnancy until full term. During pregnancy, it is necessary to evaluate the results of daily treatment: if there is no response to treatment, the pregnancy should be suspended to protect the mother's life.
If pregnant women are suffering from grade III or IV heart failure, we should suspend pregnancy at any gestational age. Because in order for the pregnancy to continue, the heart disease will get worse. When there is a decision to suspend a pregnancy, we need to choose the best opportunity and method. For example, it is advisable to actively treat heart failure in a short time to improve the patient's condition, then need immediate indication. Do not rush when pregnant women are unprepared both expertly and easily error-prone.
Measures to suspend pregnancy in the real heart
Choosing the method of suspension of pregnancy in the maternity unit depends on the patient's condition, gestational age, fetal status, and the individual patient. These are options that can be used to suspend a pregnancy in the real heart.
Smoking regulates menstruation. Smoking regulates menstruation and sterilization.
Abortion. Abortion and sterilization.
Cesarean section. Cesarean section for further pregnancy, partial hysterectomy.
Each measure has its advantages and disadvantages. In general, before, during, and after performing one of the above measures, the following points should be noted:
Prevent sudden cardiac pregnancy
When touching the cervix to pair or dilate the cervix, it is easy to stimulate the ability to create a sudden cardiac arrest reflex. To avoid this, it is necessary to apply pre-anesthesia techniques or good anesthesia before the procedure.
Prevention of thrombosis
Able to form a blood clot during and after the procedure. Thrombotic complications usually occur in the days after the procedure is completed. Prevent this accident by using drugs against blood clots. Before the procedure or surgery 2 days, use Heparin from 5,000-10,000 units/day for subcutaneous injection 12 hours apart. Take the medicine one day before the procedure to avoid bleeding because the drug has not completely metabolized. 24 hours after completion of the procedure (through possible surgical bleeding), use an additional 2 days of Heparin with the same dose and administration as above. When using Heparin, to monitor clinical bleeding signs, APTT daily, if prolonged (normally from 15 to 20 seconds) must immediately stop the next Heparin nose and immediately use Protamine sulfate 5% tube 5 ml, intravenously slow pulse to neutralize heparin. (10 mg neutralizes respectively with 1.
Following Heparin therapy, Warfarin therapy should be continued. Sintrom (Acenocoumarol), it is necessary to monitor the rate of Prothrombin, if it is too low below 25% or there are clinical signs of bleeding, stop the drug and immediately inject vitamin K intravenously to neutralize sintrom (as shown in Table 1).
Prevent infection during and after the procedure
By performing good sterility, using prophylactic antibiotics eliminates the risk factors.
When performing a procedure with bleeding, you need to resuscitate, pay attention to the amount of fluid and the amount of urine, because it easily overloads the cardiac flow, leads to worse heart failure or acute pulmonary edema.
Principles of management in labor
During labor: Need heart support, sedation, adequate oxygen, to fully meet the need for oxygen consumption due to uterine contractions, the mother's tolerance.
When the cervix is more than 4 cm open: amniotic fluid should be pressed if the amniotic fluid is flattened to shorten the time of labor, to reduce the time of hemodynamic disorders and burden on the heart
Period of pregnancy: Should give birth by forceps, to avoid exertion for pregnant women during labor force.
Avoid hemodynamic disorders during pregnancy birth: When the birth certificate, the uterus gradually decreases abdominal pressure decreases, the blood from the legs accrues to the abdomen quickly, causing more hemodynamic disorders, by placing a sandbag on the patient's abdomen. At the same time, lowering the patient's legs so that less blood is rushed to the abdomen.
The placenta period: Respecting the physiology of the normal placenta, only intervening when it becomes abnormal. After the placenta period, it is necessary to check the placenta carefully and limit control of the uterus. Because placenta and uterine control are easy to cause postpartum infections in women with heart disease are susceptible to subacute endocarditis.
Postpartum period: Antibiotics should be used to prevent infections. Should only breastfeed in the first 3 months if the mother does not have heart failure. In the process of breastfeeding, the patient must be monitored and evaluated for cardiac complications, if abnormal signs appear, breastfeeding must be stopped immediately. If the mother has heart failure or enlarged liver, she should not breastfeed her baby, including holding the baby.
Currently, many heart diseases (mitral stenosis, atrial septal defect, and ductus arteriosus) have had good surgical treatment results. Pregnant women with heart disease, pregnant under 7 months old, according to thimbert are still able to operate the heart. Because the risk ratio after surgery for pregnant women is similar to heart surgery outside of pregnancy. After cardiac surgery, cardiac events decreased compared to the group without surgical treatment.
Primary health care jobs for heart disease and pregnancy
Grassroots level: To improve the propaganda and management of the entire population's health (primary health care), especially women with heart disease, to have a plan for childbirth and child-rearing.
Propaganda and education: About cardiac events for young men and women, especially in young couples. There is a birth control plan for women with heart disease when they already have a baby.
Early pregnancy management registration: To detect pregnant women with heart disease, to take appropriate care measures for each case, to avoid possible events.
Postpartum: Pregnant women must be cared for, monitored, and examined periodically for cardiac events that may occur during breastfeeding, especially those who are breastfed.
There should be a temporary or permanent contraceptive suitable for women with heart disease.