Pregnancy with atrial septal defect
Introduction
Introduction to pregnancy with atrial septal defect Pregnancy with congenital heart disease (congenital heart disease) is a high-risk pregnancy and is one of the leading causes of maternal mortality. Congenital heart disease is an indication of cardiovascular structural or functional abnormalities that occur during birth, due to abnormal cardiovascular development or developmental disorders during the fetal period, and cardiovascular malformations caused by the failure of tissues that should be degraded after birth. The symptoms of mild cases are not obvious, it is not easy to find before pregnancy, and it is diagnosed after symptoms due to aggravation of heart burden after pregnancy; most of them are diagnosed before pregnancy, and even have surgery. No matter which type, after pregnancy, with gestational age Increased total circulating blood volume, heart shift to the left, large blood vessels twisted and hemodynamic changes, increased heart burden, and thus more prone to heart failure, in recent years with the progress of congenital heart disease, pregnancy with congenital heart disease Rise. basic knowledge Sickness ratio: 0.0001% Susceptible population: pregnant women Mode of infection: non-infectious Complications: ventricular septal defect, patent ductus arteriosus, sepsis
Cause
Pregnancy with atrial septal defect
(1) Causes of the disease
In the process of embryonic development, if the interatrial septum occurs, the absorption and fusion are abnormal, and the unclosed room hole remains between the left and right atrium, which is the atrial septal defect.
(two) pathogenesis
Pathological anatomy
Atrial septal defect has a variety of different anatomical types, including patent foramen ovale, primary hole is not closed, secondary hole is not closed, high defect, posterior inferior defect and complete absence of atrial septum.
During the fetal period, the foramen ovale allows blood to flow from the right atrium into the left atrium; at this time, the oxygen-containing mixed blood from the placenta enters the right atrium and flows into the left atrium. After birth, the pressure in the left atrium is higher than that in the right atrium, thus making this alive. The petal-like pores are occluded, and no shunting occurs. Although 20 to 25% of adults still have very small cracks, the patent foramen ovale usually does not cause shunting of the two-hearted room, only the right atrial pressure is increased. In cases, such as pulmonary hypertension or right ventricular hypertension, reopening, can cause right to left shunt, unless the defect is very small, the heart is enlarged when the atrial septal defect, mainly right ventricle and right atrium, often hypertrophy With the expansion and coexistence, the left atrium and the left ventricle do not expand. When the primary hole is not closed and the mitral regurgitation is accompanied, the left ventricle also increases.
2. Pathophysiology
Since the pressure in the left atrium is usually higher than that in the right atrium, the normal left atrial pressure is 0.53 to 1.07 kPa (4 to 8 mmHg), and the right atrial pressure is 0 to 0.66 kPa (0 to 5 mmHg). Therefore, the shunt of the atrial septal defect is generally left. To the right, the size of the sub-flow varies with the size of the defect and the pressure difference between the two atriums, but in the large atrial septal defect, the left and right atrial pressures are nearly equal, but there is a significant left-to-right shunt, at which point the atrial horizontal shunt is determined. The main factors of the direction and the size of the flow are the compliance of the left and right ventricles. When the ventricle is dilated, the left atrial blood flows into the left ventricle and also enters the right ventricle through the defect. Since the right ventricle is thinner than the left ventricular wall, the compliance is better than the left. Therefore, more left atrial blood flows through the defect into the right heart with lower resistance, thus forming a left to right shunt of the atrial level. When the ventricle is dilated, the right atrial blood flow can enter the right ventricle or enter the left heart through the defect. But in reality, all right atrial blood has entered the right ventricle with good compliance.
Increased pulmonary circulation blood flow, even up to 4 times of systemic blood flow, increased right ventricular workload, normal or slightly reduced systemic blood flow, pulmonary artery pressure and right ventricular pressure may be normal or increased, pulmonary artery resistance may increase due to pulmonary arterioles Significant pulmonary hypertension caused by increased resistance can occur in advanced cases.
Significant pulmonary stenosis, tricuspid atresia or down-transfer malformation, significant pulmonary hypertension, or right heart failure, right atrial pressure is higher than the left atrium, when the shunt turns right to left and cyanosis occurs.
Prevention
Pregnancy with atrial septal defect prevention
Pre-pregnancy should be carefully identified whether there is supraventricular arrhythmia or pulmonary hypertension, especially if there is obvious pulmonary hypertension is not suitable for pregnancy, effective contraceptive measures should be taken, but the preoperative defect has been surgically corrected, the prognosis of mother and child is good, 1973~ In 1987, there were 7 cases of atrial septal defect in preoperative cardiac function level 3. After operation and during pregnancy, the heart function was good, ranging from 1 to 2, and the patients were given full-term delivery and lived infants.
Complication
Complications of pregnancy complicated with atrial septal defect Complications, ventricular septal defect, patent ductus arteriosus
Atrial septal defect often associated with other congenital malformations, such as pulmonary venous malformation into the right atrium, pulmonary stenosis, ventricular septal defect, patent ductus arteriosus, etc., atrial septal defect and pregnant women without surgical correction, severe heart failure The rate is high, often due to heart failure, embolism, lung infection, sepsis, etc., leading to maternal death.
Symptom
Symptoms of pregnancy with atrial septal defect Common symptoms Chest tightness, shortness of breath, arrhythmia, nausea, palpitations, tremors
Symptom
The severity of symptoms depends mainly on the size of the defect. The defect is small and can be asymptomatic. It is often diagnosed by heart murmur due to other diseases or physical examination. The defect is large, and the right heart volume load is slow and progressively aggravated at 30 years old. In the past, it was generally better tolerated. After 30 to 40 years old, nausea, shortness of breath, chest tightness, fatigue, etc. occurred frequently. In severe cases, respiratory infections occurred frequently from infants and young children, and even poor development, patients without cyanosis, but pulmonary hypertension Bleeding can occur when the right to left shunt reaches a certain level, and the disease may have paroxysmal supraventricular tachycardia, atrial fibrillation and other arrhythmias.
2. Signs
The larger the defect, the poorer development, the smaller body, the anterior region of the heart, the heart beats, the heart sounds widened, and the second rib of the left sternal border can hear the systolic murmur of 3/6 or so. Increased flow and relative pulmonary stenosis, mostly without tremor, second heart sounds in the pulmonary valve area, accompanied by fixed division, pulmonary artery pressure may increase when the relative pulmonary valve regurgitation may be heard A murmur, the tricuspid valve area may hear a rumbling-like mid-diastolic murmur caused by relative tricuspid stenosis.
Examine
Examination of pregnancy with atrial septal defect
1. X-ray examination of lung field congestion, pulmonary artery thickening, common pulmonary artery bulge, lung vascular shadow thick and strong pulsation, forming a so-called hilar dance sign, right atrium and right ventricle increased, aortic arch shadow is reduced.
2. ECG examination ECG changes have three main manifestations: complete right bundle branch block, incomplete right bundle branch block and right ventricular hypertrophy, with right axis of the ECG axis, in addition, P wave may increase, showing right The atrial enlargement may increase the P and R intervals.
3. The heart vector diagram checks that the water level QRS ring starts from the front to the back and then turns to the left and right and then clocks to the front and turns to the right. Before the centroid is supported, the main part of the QRS ring is almost in front, and the terminal is at the end. The department is located in the right front or right rear, and runs slowly. This change reflects the right ventricular hypertrophy with blockade of conduction in the supraventricular sac, and some patients have right bundle branch block or right ventricular hypertrophy.
4. Echocardiography
(1) M-type findings: the right ventricle is obviously enlarged, the right ventricle outflow tract is widened; the right atrium and the left atrium are also enlarged; the tricuspid valve is increased in amplitude, and the opening and closing is accelerated; the interventricular septum is in the same direction as the posterior wall of the left ventricle motion.
(2) Type B: the right ventricle is large, the outflow tract is widened; the ventricular septum is in the same direction as the posterior wall of the left ventricle, and the left ventricle is changed from a normal circular shape to an elliptical shape or even a half moon shape; the interatrial septum is continuously interrupted.
Diagnosis
Diagnosis and diagnosis of pregnancy complicated with atrial septal defect
According to the typical signs of the patient, ECG, X-ray and echocardiography are not difficult to make a diagnosis. Some small defects can only hear 2/6 systolic murmurs in the second intercostal space on the left sternal border. In addition to the electrocardiogram, X-ray and echocardiography, the right heart catheterization can be further performed.
Atrial septal defect must be differentiated from large ventricular septal defect, simple pulmonary stenosis, primary pulmonary hypertension, partial pulmonary venous malformation and right atrium.
