Pregnancy with rheumatic heart disease
Introduction
Introduction to pregnancy with rheumatic heart disease Rheumatic heart disease is a condition in which the heart's normal function is impaired after rheumatic fever affects the heart disease in the heart valve (including the annulus and subvalvular structure). In patients with mitral stenosis, the most common complication of mitral stenosis is pulmonary edema and heart failure. The mitral stenosis causes the left atrium to enter the left ventricular reflow and is mechanically obstructed. At this time, the blood flow can only increase abnormally. The left atrium and left ventricular pressure gradient (cross-valve pressure) to promote, the normal adult valve area is 4 ~ 6cm2, no diastolic pressure difference between diastolic compartments, when the valve mouth 2cm2 (mild stenosis), left atrium The pressure is increased slightly, the transvalvular pressure difference and turbulence occur. When the valve orifice is reduced to 1cm2, the normal cardiac output should be 2.6kPa, and the pressure difference between the left atrium and the left ventricle should be increased. The left atrial pressure is further increased, and the left atrial pressure is increased, causing pulmonary veins, pulmonary capillaries and pulmonary arteries to increase passively. When the pulmonary capillary pressure rises above 4.0-4.7 kPa (30-35 mmHg), it can cause alveolar pulmonary edema. Continuous pulmonary hypertension can eventually lead to right ventricular failure. Increased blood volume during pregnancy, increased cardiac output, increased heart rate, increased left atrial pressure, decreased heart compensatory capacity, uterine contractions during labor, and increased breath load during childbirth. Fetus, placenta after delivery, uterine contractions Reconstruction of the placenta shunt closes the blood flow to the heart, and the left atrial pressure rises sharply, which can lead to acute pulmonary edema. basic knowledge The proportion of sickness: 0.49% Susceptible population: pregnant women Mode of infection: non-infectious Complications: heart failure, infective endocarditis, arrhythmia, pregnancy-induced hypertension
Cause
Pregnancy with rheumatic heart disease
(1) Causes of the disease
Rheumatic fever is an autoimmune connective tissue disease caused by infection of group A beta-hemolytic streptococcus. It is mainly characterized by multiple migratory arthritis, myocarditis, skin ring erythema and subcutaneous nodules. It is characterized by recurrent episodes, often leaving heart valve damage, leading to rheumatic heart valve disease.
Rheumatic valvular disease (rheumatic valvular disease) due to recurrent rheumatic heart attack, heart valve and its ancillary structures (chord, papillary muscle) lesions, resulting in valve stenosis and dysfunction of valve dysfunction, blood flow The learning disorder is chronic rheumatic valvular disease. Rheumatic valvular heart disease is most common with mitral valve, followed by aortic valve. The latter often has valvular disease associated with mitral valve disease.
(two) pathogenesis
Rheumatic fever can affect the heart and 4 valves, mitral valve disease is more common, especially mitral stenosis is the most common, which may be related to the pressure load of the four leaflets, the degree of pathological changes and the length of the disease There is a positive correlation between recurrent rheumatic fever.
1. In patients with mitral stenosis, the most common complication of mitral stenosis is pulmonary edema and heart failure. The mitral stenosis causes the left atrium to enter the left ventricular reflow and is mechanically obstructed. At this time, blood flow can only pass. Abnormally increased left atrial and left ventricular pressure gradient (trans-valve pressure) to promote, normal adult valve area is 4 ~ 6cm2, no diastolic pressure difference between diastolic compartments, when the valve mouth 2cm2 (mild stenosis), The left atrial pressure is slightly increased, the transvalvular pressure difference and turbulence occur. When the valve orifice is reduced to 1cm2, the normal cardiac output should be about 2.6kPa. The pressure difference between the left atrium and the left ventricle should be maintained at rest. Increase, left atrial pressure further increased, left atrial pressure increased after the pulmonary veins, pulmonary capillaries and pulmonary artery passively increased, when the pulmonary capillary pressure increased more than 4.0 ~ 4.7kPa (30 ~ 35mmHg), can cause alveolar Pulmonary edema, persistent pulmonary hypertension can eventually lead to right ventricular failure.
Increased blood volume during pregnancy, increased cardiac output, increased heart rate, increased left atrial pressure, decreased heart compensatory capacity, uterine contractions during labor, and increased breath load during childbirth. Fetus, placenta after delivery, uterine contractions Reconstruction of the placenta shunt closes the blood flow to the heart, and the left atrial pressure rises sharply, which can lead to acute pulmonary edema.
2. Mitral regurgitation is simple, rheumatic mitral regurgitation is rare, and more often with stenosis, simple mitral regurgitation, generally better to adapt to increased cardiac load, rarely pulmonary edema and heart failure.
3. Aortic valve stenosis Simple aortic stenosis is rare, light can often safely pass through pregnancy, childbirth and puerperium, severe cases can have congestive heart failure, and even sudden death.
4. Aortic valve insufficiency due to accelerated pregnancy heart rate during pregnancy, diastolic phase shortened, although the blood volume increased, and the blood flow from the aorta to the left ventricle tends to decrease, so it can better tolerate hemodynamics during pregnancy The change.
Prevention
Pregnancy with rheumatic heart disease prevention
Rheumatic heart disease threatens the safety of pregnancy, childbirth and perinatal survival in women of childbearing age. Rheumatic heart disease has no special prevention method and actively treats the primary disease. Strengthening the health care during the perinatal period and timely treatment, most heart failures and deaths can be avoided.
The main causes of death in rheumatic heart disease during pregnancy are congestive heart failure, pulmonary edema and infection. The incidence and mortality of heart failure in pregnant women without pre-pregnancy counseling and perinatal care are several times to ten times higher than those undergoing prenatal care. Most heart failures and deaths can be avoided if the perinatal care can be strengthened and treated in a timely manner.
Complication
Pregnancy complicated with rheumatic heart disease complications Complications, heart failure, infective endocarditis, arrhythmia, pregnancy-induced hypertension
Rheumatic heart disease is a progressive disease. As the disease progresses, the condition will worsen, and after pregnancy, the disease will progress and a series of complications will occur. The incidence of complications in patients with mitral valve disease during pregnancy.
Heart failure
Pregnant women with rheumatic valvular disease may have left heart failure, right heart failure or whole heart failure, but especially right heart failure, especially in pregnant women with mitral stenosis.
The occurrence of heart failure is related to age, parity, type and extent of valvular disease, heart function and triggering factors. The age of pregnant women with rheumatic heart disease >35 years old, heart failure is more, and the maternal function is poor due to poor cardiac reserve. Heart failure, but if the primipara has heart failure, the mortality rate is higher than that of the mother with heart failure, rheumatic heart disease mitral stenosis combined with pregnancy, during the 3 months of pregnancy to full-term delivery and the end of delivery, at any time Pulmonary edema, right heart failure may occur; simple mitral regurgitation can better adapt to pregnancy, increased cardiac load during childbirth and puerperium, and rarely heart failure. Aortic stenosis is less common in rheumatic heart disease. In pregnancy, pregnant women can often pass through pregnancy, childbirth and puerperium, rare heart failure; pregnant women with aortic regurgitation usually can pass the pregnancy and childbirth period, heart function level III or higher, the risk of heart failure is greater, If pregnant women are accompanied by infection, excessive blood transfusion, excessive or strenuous exercise and other diseases are likely to cause heart failure.
2. Infective endocarditis
Pregnant women in pregnancy, childbirth and puerperium body resistance decreased, easy to merge infections such as respiratory tract, urinary tract and reproductive tract infections, may be due to bacteremia and infective endocarditis, if not treated in time can induce heart failure, and ultimately lead to death.
3. Arrhythmia
The incidence of atrial fibrillation in patients with rheumatic mitral stenosis and regurgitation is high. In patients with aortic stenosis, atrioventricular block may occur in addition to atrial fibrillation, and ventricular ventricular arrhythmia is common in pregnant women with aortic regurgitation. .
4. Thromboembolism
Circulatory embolism is common in mitral stenosis and mitral regurgitation in pregnant women, but the incidence of the former is higher, aortic stenosis and thrombectomy are rare, mitral stenosis with atrial fibrillation embolism.
5. Pregnancy-induced hypertension
Nearly one-third of patients with rheumatic heart disease have pregnancy-induced hypertension in the third trimester of pregnancy, especially in pregnant women with mitral stenosis, which is the main cause of diastolic blood pressure and mean arterial blood pressure in late pregnancy. Szekely listed this syndrome as A high-risk factor that affects heart function and may trigger and aggravate heart failure.
Symptom
Symptoms of pregnancy complicated with rheumatic heart disease Common symptoms Chest tightness, flustered, difficulty breathing, rapid heartbeat, blood stasis, arrhythmia, sitting, breathing, pink, foam, shortness of breath, fatigue
Symptom
(1) fatigue fatigue: usually limbs are weak and easy to fatigue, general physical activity (such as climbing, climbing, walking, top wind cycling or heavy household chores, etc.) after the physical strength is not supported, this is due to low blood output, The blood supply to the moving organs cannot meet the needs of exercise, and the exercise tolerance is reduced.
(2) Difficulty breathing: It starts after strenuous exercise, and after a lighter physical activity, there is an air urgency after the physical activity. Finally, even in the resting state, there is difficulty in breathing. This is because pulmonary congestion reduces lung compliance and the alveolar wall. The decrease in permeability affects the gas exchange. Patients with severe pulmonary congestion may experience paroxysmal nocturnal dyspnea, that is, sudden chest tightness during sleep at night, shortness of breath and wakefulness, which must be relieved immediately after sitting up or standing.
(3) palpitations: the patient's heartbeat is accelerated, consciously flustered, this is due to the decrease in left ventricular discharge, and the reflexive increase in heart rate to increase cardiac output.
(4) Cough, hemoptysis: Frequent dry cough or cough up pink foam or bloodshot in the sputum when you are tired or at night.
(5) Hair bun: In the mitral stenosis, the cleft of the distal part may appear. For example, in the cleft palate, the part of the lip is more prominent, forming a so-called "mitral valve face", and the extremities of the extremities are cold and cyanosis.
2. Signs
(1) mitral valve disease: apex beats diffuse, lifted pulsation on the left sternal border, apical apex and diastolic tremor; murmurs of typical mitral stenosis with diastolic transition from weak to strong ruminal; The first heart sound of the apex is hyperthyroidism; the narrow murmur in the valve area is most obvious, but it is often difficult to hear in mild stenosis. It must be taken from the left lateral position and after some activities can be heard, such as determining the first heart sound of the apex. If you do not hear the typical diastolic murmur, you should further determine the presence of mitral stenosis. When the valvular lesion is extremely "frozen-like" funnel-shaped, only the murmur or cause can be heard. The amount of blood flow through the mitral valve is very small, so that the heart murmur is not clear, so-called "dumb". When accompanied by mitral regurgitation, the apex beat can be shifted to the lower left, and the apex can be heard. During the period of right heart failure, there is a jugular vein engorgement, and the heart expands to the sides.
(2) combined aortic valve disease: apex beat more obvious, the heart to the left to expand, chest 2,3 intercostal space, sternal fossa can touch the systolic tremor caused by aortic stenosis, where you can hear Rough systolic murmur, such as combined aortic regurgitation, can be found in the apical lift pulsation, increased pulse pressure, can touch the water pulse, can hear the peripheral vascular signs such as femoral artery gunshots, chest left 3 ribs During the diastolic period, you can hear the murmur of the diastolic phase and conduct it to the apex of the heart.
(3) combined with tricuspid regurgitation: multiple secondary to pulmonary hypertension, left atrium, enlarged room, such as tricuspid valve lesions, buccal and bruising, jugular vein engorgement, heart enlargement to the left and right, liver enlargement Significantly, the jugular vein and the liver pulsate with the contraction of the heart (late), and the compression of the liver can exacerbate the jugular vein filling (hepatic-jugular venous return), the chest left 4 ribs or (and) the xiphoid can smell and the systolic period Noise.
Examine
Examination of pregnancy with rheumatic heart disease
It is important to consider a non-invasive and less invasive method of pregnancy during pregnancy.
Electrocardiogram
In patients with mild mitral stenosis, the electrocardiogram can be normal or the right axis of the electric axis. The middle and upper stenosis of the left atrium enlarges the mitral valve P wave, that is, the P wave time is prolonged (0.11 s or more) and is bimodal. The first peak represents right atrial activation, the second peak represents left atrial activation, and the P wave in the V1 lead is often biphasic, and the negative part is deep and wide, suggesting that the left atrium is enlarged, and the P wave voltage is in pulmonary hypertension. The amplitude can be increased, and the image of right ventricular hypertrophy can also appear. In the case of obvious enlargement of the left atrium, the f wave of atrial fibrillation may occur, and the large atrial fibrillation wave (amplitude exceeding 1 mV) in the V1 lead may also indicate left atrial enlargement. Large presence, combined with mitral regurgitation, may have an increased left ventricular load.
Patients with aortic valve disease can be normal, mild left ventricular hypertrophy, abnormal Q wave and T wave, ST segment changes, combined with tricuspid disease showed increased right heart burden.
2. X-ray inspection
Chest heart, lung phase is directly related to the severity of the disease, mild stenosis patients can be no significant changes, moderately stenotic patients showed double pulmonary venous hypertension, pulmonary vein dilatation, pulmonary congestion, lung field transparency decreased, pulmonary interstitial edema appeared The rib angle line (Kerley line) is easy to see at 5 to 10 cm on the right lower lung rib angle; the ratio of cardiothorax increases; the right heart edge expands, and the bilateral left atrium and right atrium shadow form a bilateral shadow, pulmonary hypertension The pulmonary artery segment is prominent, the right ventricle is enlarged, and the right lower pulmonary artery is widened; after the right anterior oblique position, the enlarged left atrium compresses the esophageal formation depression and the esophagus is moved backward; the left anterior oblique position shows the enlarged left atrium. Left bronchus elevation, such as co-existing mitral regurgitation, left ventricular stenosis and other left ventricular enlargement, or left atrial systolic pulsatile pulsation, but often due to left atrial extreme dilatation and ectopic rhythm This is the sign.
Patients with aortic valve disease showed enlargement of the left ventricle and thickening of the ascending aorta. A significantly enlarged right atrium was seen in patients with tricuspid valve disease.
Considering the effects of radiation on the fetus, do not do this check as little as possible.
3. Echocardiography
Early M-mode echocardiography can reveal typical images of mitral leaflet changes in the same direction and wall-like changes, which can be used as a basis for diagnosis of mitral stenosis, but can not diagnose the degree of stenosis, the size of the valve, and can not judge the valve. The movement of the leaf and the lesions of the subvalvular structure have been widely used in recent years by color Doppler flow imaging (CDFI). The mitral and aortic valves can be observed in real time. The overall movement of the tricuspid valve is the location of the lesion. The nature and extent of the lesion, the measurement of the room, the size of the chamber, blood flow direction, velocity, pressure, anti-flow, etc., can provide diagnostic basis not only in anatomical structure but also in hemodynamics, and other structural and functional abnormalities in the heart. It can also be determined that the diagnosis of possible combined conditions is the best non-invasive examination method, invasive examination methods such as cardiac catheterization or cardiovascular angiography, and it is no longer necessary to use it except for extremely complicated malformations and special needs. For the structure of the left atrial thrombus and the intracardiac deviation, the esophageal ultrasound probe can be used to obtain a clearer image, which is more clear and beneficial for diagnosis.
Diagnosis
Diagnosis and diagnosis of pregnancy complicated with rheumatic heart disease
diagnosis
According to clinical symptoms and signs, after special examination, especially color Doppler flow imaging (CDFI), it is not difficult to make a clear diagnosis of rheumatic valvular disease, but the lesions of mild patients should be related to the cardiovascular of normal pregnancy. The physiological changes in the aspect are identified.
The difference between physiological changes during pregnancy and heart disease: due to the hemodynamic changes during pregnancy, the cardiac output during the whole period of pregnancy continues to increase, an average increase of 30% to 50% before pregnancy, the average stroke volume per heart is increased by 80ml, Peripheral vasodilation during pregnancy, blood thinning, placental formation, venous short circuit, so that peripheral circulation resistance is reduced, pelvic blood flow to the inferior vena cava increases blood volume, and pregnancy uterus compression of the inferior vena cava causes blood flow backflow, cardiac output The amount of decline, these changes and the gradual increase of maternal burden, so the heart rate gradually increased from 10 to 15 times / min from 14 weeks of gestation, 24 hours increased by about 14,000 times to meet the needs of pregnancy, the diaphragm in the third trimester rose, the heart to the left, up Position, apical beat to the left, large blood vessels twisted, heart, blood vessel position changes also increase the burden of the heart, but in the normal heart with compensatory function can be loaded, due to physiological changes in the body during pregnancy, make normal Pregnancy may have lower extremity edema, mild palpitations, shortness of breath, mild expansion of the heart sounds, pulmonary valvular area, apical and subclavian areas without systolic murmur, first heart sound In the third trimester, there may be a second heart sound fixed split, etc. The ECG shows that the ECG axis is left-biased, and the ST segment can be slightly flat. Do not misdiagnose as a structural heart disease, but when pregnant women have the following performance, they should be considered rheumatic. Cardiac mitral or combined aortic valve, tricuspid valve disease may be diagnosed.
1. Progressive breathing difficulties and wake up at night, sitting and breathing.
2. Peripheral hair loss occurs, that is, the mitral valve face.
3. Hemoptysis, bloody or massive hemoptysis.
4. Diastolic murmur occurs in the apex of the apex, which is a typical weak-to-strong rumbling-like diastolic murmur with the first apical apex of the apex, which may touch tremor or merge systolic murmur. If this murmur is found, neither or other findings are found. The presence of mitral stenosis should also be considered first, but further examination of left atrial myxoma should be performed, as well as the typical murmurs and manifestations of the aortic or tricuspid valve should be identified as a diagnosis of organic heart disease.
5. Arrhythmia, such as atrial fibrillation is a common ectopic rhythm for rheumatic mitral valve disease.
Differential diagnosis
Rheumatic heart disease is a progressive disease. As the disease progresses, the condition will worsen, and after pregnancy, the disease will progress and a series of complications will occur. The incidence of complications in patients with mitral valve disease during pregnancy.
Heart failure
Pregnant women with rheumatic valvular disease may have left heart failure, right heart failure or whole heart failure, but especially right heart failure, especially in pregnant women with mitral stenosis.
The occurrence of heart failure is related to age, parity, type and extent of valvular disease, heart function and triggering factors. The age of pregnant women with rheumatic heart disease >35 years old, heart failure is more, and the maternal function is poor due to poor cardiac reserve. Heart failure, but if the primipara has heart failure, the mortality rate is higher than that of the mother with heart failure, rheumatic heart disease mitral stenosis combined with pregnancy, during the 3 months of pregnancy to full-term delivery and the end of delivery, at any time Pulmonary edema, right heart failure may occur; simple mitral regurgitation can better adapt to pregnancy, increased cardiac load during childbirth and puerperium, and rarely heart failure. Aortic stenosis is less common in rheumatic heart disease. In pregnancy, pregnant women can often pass through pregnancy, childbirth and puerperium, rare heart failure; pregnant women with aortic regurgitation usually can pass the pregnancy and childbirth period, heart function level III or higher, the risk of heart failure is greater, If pregnant women are accompanied by infection, excessive blood transfusion, excessive or strenuous exercise and other diseases are likely to cause heart failure.
2. Infective endocarditis
Pregnant women in pregnancy, childbirth and puerperium body resistance decreased, easy to merge infections such as respiratory tract, urinary tract and reproductive tract infections, may be due to bacteremia and infective endocarditis, if not treated in time can induce heart failure, and ultimately lead to death.
3. Arrhythmia
The incidence of atrial fibrillation in patients with rheumatic mitral stenosis and regurgitation is high. In patients with aortic stenosis, atrioventricular block may occur in addition to atrial fibrillation, and ventricular ventricular arrhythmia is common in pregnant women with aortic regurgitation. .
4. Thromboembolism
Circulatory embolism is common in mitral stenosis and mitral regurgitation in pregnant women, but the incidence of the former is higher, aortic stenosis and thrombectomy are rare, mitral stenosis with atrial fibrillation embolism.
5. Pregnancy-induced hypertension
Nearly one-third of patients with rheumatic heart disease have pregnancy-induced hypertension in the third trimester of pregnancy, especially in pregnant women with mitral stenosis, which is the main cause of diastolic blood pressure and mean arterial blood pressure in late pregnancy. Szekely listed this syndrome as A high-risk factor that affects heart function and may trigger and aggravate heart failure.
