Pregnancy with ventricular septal defect
Introduction
Introduction to pregnancy complicated with ventricular septal defect Ventricular septal defect is one of the most common congenital heart malformations. The incidence of ventricular septal defect is 2%, accounting for 30% of congenital heart disease, accounting for about 10% of adult congenital heart disease. Physiological changes during pregnancy can aggravate the condition of patients with ventricular septal defect and threaten the life and health of pregnant women and fetuses. Severe ventricular septal defect should not be pregnant, and should be terminated once pregnancy. Therefore, patients should consult a doctor before pregnancy. Those who are not pregnant should terminate their pregnancy early. Continued pregnancy increased pregnancy complications, should strengthen supervision and strengthen perinatal care. basic knowledge The proportion of illness: 0.001% Susceptible people: children Mode of infection: non-infectious Complications: atrial septal defect, patent ductus arteriosus, aortic valve insufficiency, arrhythmia, infective endocarditis
Cause
Pregnancy complicated with ventricular septal defect
(1) Causes of the disease
In the first 3 months of pregnancy, rubella virus infection (which may also include cytomegalovirus, coxsackie virus, herpes virus, etc.) affects fetal cardiovascular development. During pregnancy, the mother takes a teratogenic drug, and the plateau region has low oxygen partial pressure. Environment, premature birth, so that the fetus does not have enough time to complete development is an environmental factor that causes congenital heart disease. Others such as pregnant women (over 35 years old), malnutrition, alcohol abuse, early threatened abortion, exposure to radiation, etc. may also be pathogenic factors.
(two) pathogenesis
Since the left ventricular pressure is higher than the right ventricle, a left-to-right shunt is generated at the defect. The fractional flow depends on the size of the defect, the compliance of the right ventricle and the resistance of the pulmonary circulation, such as the diameter of the ventricular septal defect <0.5 cm. High resistance, small flow rate, pulmonary circulation slightly larger than the systemic circulation, pregnant women can better tolerate.
Large defect, left to right divided flow, pulmonary circulation blood flow can reach 3 to 5 times of systemic circulation, into the left atrium, left ventricle and then shunted to the right ventricle, so left and right ventricular load increased, pulmonary circulation increased blood flow Pulmonary arterial pressure rises. When the pulmonary artery pressure is equal to or higher than the systemic circulation pressure, bidirectional or right-to-left shunt occurs to produce cyanosis, which forms Eisenmenger syndrome.
According to the location of the defect can be divided into 5 types:
1. The supraventricular sacral defect is located in the right ventricular outflow tract, above the upper iliac crest and the main, under the pulmonary valve, may be associated with aortic regurgitation, this type is less common.
2. The supraorbital sacral defect is located in the ventricular septal membrane, also known as the membrane defect. This type is most common, accounting for 60% to 70% of the total number of ventricular septal defects.
3. The defect after the septum is located in the right ventricular inflow tract, and the rear of the tricuspid valve is about 20%.
4. The muscle defect is trabecular bone defect, and the defect is smaller when the myocardial contraction occurs, so the left-to-right sub-flow is less.
5. The common ventricular septal membrane and muscle are neither developed or multiple defects, which are rare.
The diameter of the defect is 0.1-3.0 cm, which is larger in the membrane and smaller in the muscle. The small defect is mainly due to the increase of the right ventricle, and the left ventricle is the largest.
The effect of ventricular septal defect on pregnancy is that pregnant women with small defects have no heart-to-left shunt, and generally have less heart failure. They can successfully pass pregnancy and childbirth. Patients with large defects often have pulmonary hypertension symptoms and may appear. Right to left shunt and heart failure, pulmonary hypertension can be aggravated after labor, leading to blood right to left shunt and cyanosis.
Prevention
Pregnancy with ventricular septal defect prevention
1, the disease is a congenital disease, no effective preventive measures, should be early detection and early diagnosis and early treatment.
2, timely inspection, such as electrocardiogram, cardiac ultrasound examination, etc., to prevent heart failure, pulmonary hypertension. Serious cases consider termination of pregnancy.
3, it is necessary to do a good pregnancy check, such as Down's screening, ultrasound monitoring, blood HCG examination, blood routine examination.
Complication
Complications of pregnancy complicated with ventricular septal defect Complications, atrial septal defect, patent ductus arteriosus, aortic valve, insufficiency, arrhythmia, infective endocarditis
Ventricular septal defect may be associated with atrial septal defect, patent ductus arteriosus, large vessel dislocation, aortic valve insufficiency, etc.
High-level defects often associated with other cardiovascular abnormalities, such as uncorrected surgery before pregnancy, can significantly increase the incidence of heart failure, arrhythmia and infective endocarditis after pregnancy.
Symptom
Symptoms of pregnancy complicated with ventricular septal defect Common symptoms Fatigue heart failure systolic murmur ventricular septal defect systolic reflux murmur wheeze palpitations tremor
Symptom
Patients with small defects and small flow rate can be asymptomatic, have a good prognosis, and often reach the growth period. Because of this type of pregnancy, the type is more common, the defect is large and the flow is large, and there is no surgery, dysplasia After exertion, there are symptoms such as heart palpitations, asthma, cough, fatigue, lung infection, etc. The prognosis is poor. A few patients can reach the growth period, and often cause death after complications such as heart failure after pregnancy.
2. Signs
Typical signs are loud and rough systolic reflux murmurs between the 3rd and 4th ribs on the left sternal border. They often reach level 4 or higher with tremors. The murmurs occupy the entire systolic phase and often submerge the heart sound. It is widely transmitted in the anterior region of the heart and may be heard on the back. The typical systolic murmur is reduced when the pulmonary artery is significantly elevated, but there may be diastolic murmurs in the pulmonary valve area due to relative pulmonary insufficiency.
Patients with large ventricular septal defect are generally poorly developed and are relatively small; patients with right-to-left shunt have cyanosis and clubbing (toe); when heart failure occurs, there is a corresponding sign of heart failure.
Examine
Examination of pregnancy with ventricular septal defect
1. X-ray examination of small defects can be found without abnormalities, large lesions with pulmonary congestion, pulmonary vascular shadow thickening, pulmonary total dry arc bulging and left and right ventricle enlargement, significant pulmonary hypertension, significant right ventricle Increase.
2. Electrocardiogram examination of small ECG with normal defect, large defect can show left ventricular hypertrophy, left and right ventricle with hypertrophy, right bundle branch block and other changes, when the pulmonary artery is significantly high pressure, ECG shows right ventricular hypertrophy with strain.
3. Echocardiographic examination showed continuous interruption of ventricular septal echo, while left ventricular internal diameter increased, there was fashion left atrial enlargement, right ventricular outflow tract and pulmonary artery widened, contrast-enhanced ultrasound can further confirm the existence of defects, huge defects In the case of a single ventricle, the reflected waves of the ventricular septum are not detected at all (Fig. 1). Color Doppler flow imaging is valuable for detecting small defects and for locating and typing defects.
4. Magnetic resonance computed tomography transverse magnetic resonance computed tomography can be displayed from the ventricular septum to the membrane, helping to locate and quantify defects.
5. Cardiac catheterization and selective indicator dilution curve determination Right heart catheterization found that from the right ventricle to the pulmonary artery, blood oxygen content is higher, that is, there is left to right shunt at the right ventricular level, pulmonary artery and right ventricular pressure can be increased Patients with small defects who do blood oxygen levels may not be able to find the existence of a shunt, which can be found by measuring the hydrogen dilution curve.
6. Selective Cardioangiography Selective left ventricular angiography shows that the right ventricle is also developed during left ventricular development.
Diagnosis
Diagnosis and diagnosis of pregnancy complicated with ventricular septal defect
diagnosis
According to the typical murmur, X-ray examination, electrocardiogram, echocardiography, diagnosis of this disease is not too difficult, such as pre-pregnancy cardiology and cardiac catheterization can mostly be diagnosed.
Differential diagnosis
Atrial septal defect
Large ventricular septal defect, especially in children, must be differentiated from atrial septal defect, ventricular septal defect murmur is lower, often between the 3rd and 4th ribs of the left sternal border, and more often with tremor, left ventricular often increased Significant identification, echocardiography, right heart catheterization, etc. can help to determine the diagnosis.
2. Pulmonary stenosis
The funnel-shaped pulmonary stenosis is narrow, and the murmur is often heard in the third and fourth intercostal space on the left sternal border. It is easy to be confused with the murmur of the ventricular septal defect, but the lung circulation is not congested, the lung texture is scarce, and the right heart catheter can be found right. The systolic pressure gradient between the ventricle and the pulmonary artery, without the left-to-right shunt performance, can establish the diagnosis of the former, but the ventricular septal defect and the funnel-shaped pulmonary stenosis can be combined to form the so-called "atypical Farrow Quadruple syndrome, and there is no worry, so pay attention.
3. Aortic stenosis
In the aortic stenosis, the subaortic stenosis type can detect systolic murmur in the third and fourth intercostals of the left sternal border, may not be transmitted to the carotid artery, and must be differentiated from the murmur of the ventricular septal defect.
4. Hypertrophic obstruction primary
Cardiac hypertrophic primary cardiomyopathy with left ventricular outflow tract obstruction can hear systolic murmur at the lower left sternal border, its location and nature are similar to those of ventricular septal defect, but the disease murmur is reduced in the lower jaw, half of the patients There is a reflux systolic murmur at the apex of the apex, the pulse is bimodal, X-ray shows no active hyperemia of the lung, ECG shows left ventricular hypertrophy and strain with abnormally deep Q waves, and echocardiography shows a significant increase in ventricular septum Thick, mitral anterior leaflet systolic advancement (SAM), no left-to-right shunt in cardiac catheterization, and systolic pressure gradient between left ventricle and outflow tract, selective left ventricular angiography showing small ventricular lumen The thick ventricular septum protrudes into the heart chamber.
5. Ventricular septal defect with aortic regurgitation
Must be distinguished from patent ductus arteriosus or aortic-pulmonary septal defect, supraventricular supraventricular ventricular septal defect, such as just under the aortic valve, may pull a leaf of the aortic valve down, or due to the lower part of the valve Lack of tissue support by the blood flow into the left ventricle and other reasons, resulting in aortic regurgitation, systolic murmur caused by ventricular septal defect itself, plus diastolic murmur caused by aortic regurgitation, can be The third and fourth intercostal spaces on the left sternal border produce vocal murmurs, similar to the patent ductus arteriosus or aortic-pulmonary septal defect, but the disease has a lack of typical continuity, and the ECG and X-ray examinations are obvious. Left ventricular hypertrophy, echocardiography and right heart catheterization can help identify.
