perinatal cardiomyopathy
Introduction
Introduction to perinatal cardiomyopathy Perinatal cardiomyopathy refers to a cardiomyopathy involving the heart muscle in the last 3 months of pregnancy or 6 months after birth. The main cause of death in perinatal cardiomyopathy is thromboembolism caused by left ventricular wall thrombosis, so anticoagulant therapy should be part of the treatment of perinatal cardiomyopathy. Warfarin or heparin anticoagulant therapy is available. basic knowledge Sickness ratio: 0.0001% Susceptible population: pregnant women Mode of infection: non-infectious Complications: arrhythmia, arterial embolism
Cause
Causes of perinatal cardiomyopathy
Pregnancy (35%):
The incidence of twin or multiple pregnancies is higher, the incidence of multiple maternal or multiple pregnancies is higher than that of primiparas, and the incidence of twin pregnancies is reported to be 7% to 10%. Demaki reported that a group of patients with pregnancy-induced hypertension syndrome accounted for 22 %, domestic Xu Zengxiang reported that pregnancy-induced hypertension syndrome also accounted for 22% to 50%, the incidence of which is 5 to 7 times higher than normal pregnant women.
Virus infection (25%):
Perinatal cardiomyopathy is associated with some viral infections of myocarditis, especially with Coxsackie B virus-induced myocarditis. Patients with serum coxsackie virus neutralizing antibody titers are elevated, complement fixation test single serum The titer is >1:32.
Autoimmune factors (15%):
Most scholars believe that the occurrence of perinatal cardiomyopathy is related to the body's autoimmune factors, and the ratio of helper T cells to induced T cells in patients with this disease is measured by monoclonal antibody technology.
Other causes (10%):
Low selenium, malnutrition, metabolism and changes in hormone levels in the body are all risk factors for perinatal cardiomyopathy.
Pathogenesis
In the 1980s, intensive lymphocyte infiltration was found in PPCM endocardial biopsy specimens, and myocardial cell edema, necrosis and fibrosis were observed. After treatment with glucocorticoids and immunosuppressive drugs, clinical symptoms improved. And the improvement of clinical symptoms is highly consistent with the pathological improvement of repeated endocardial myocardial biopsy. Therefore, the disease may be caused by myocarditis, and similar reports have been made thereafter. Animal experiments have found that mice are pregnant. Antiviral activity is weakened, and it returns to normal after delivery. Therefore, some scholars believe that PPCM is caused by increased susceptibility of pregnant women to the virus, or may increase cardiac load due to pregnancy and childbirth, aggravating myocardial damage caused by potential viral myocarditis. In addition, the immune function changes during pregnancy, causing the cardiomyocytes to produce an abnormal immune response to viral infection.
Some people think that this disease is related to malnutrition. Because of the increased metabolism during pregnancy, the resistance is low. If the intake is insufficient at this time, especially protein and vitamin deficiency, plus anemia and postpartum breastfeeding during pregnancy, the body will be infected and poisoned. Increased sensitivity, PPCM occurs in areas with poor economic conditions, the incidence of rural areas in China is relatively high, may be related to nutritional deficiencies, but some patients have no obvious history of nutritional deficiencies, so it is currently believed that malnutrition may induce or aggravate Role, one of the dangers or susceptibility factors of PPCM.
In addition, it has been proposed that metabolic endocrine changes during pregnancy, immune response between maternal and infant, drug allergy and other factors are the cause of PPCM, but have not been confirmed, currently considered age factors (> 30 years old), prolific, malnourished, double Fetus, multiple births, pregnancy-induced hypertension, postpartum hypertension, etc. are not the cause of PPCM, but may be a risk or predisposition factor.
Prevention
Perinatal cardiomyopathy prevention
Rest
According to the heart function, bed rest, it is reported that 50% of patients with long-term bed rest can return to normal heart size, if you have heart failure, you can rest in bed for about half a year, in order to facilitate the return of the heart to normal size after childbirth, perinatal cardiomyopathy is prone to thrombosis Embolism complications, clinical manifestations of thromboembolism have been reported in 53% of patients with this disease, platelet adhesion increased due to increased blood coagulation factors II, VII, VIII, X and plasma fibrinogen in late pregnancy, and this change can continue 4 to 6 weeks postpartum, combined with left ventricular dysfunction caused by congestion and long-term bed rest in the past is prone to deep venous thrombosis of the lower extremities, can cause pulmonary embolism and death, so long-term bed rest is not recommended, and appropriate passive attention should be noted Sexual or active physical activity to prevent the occurrence of thromboembolism, if necessary, should consider the use of anticoagulants.
2. Correct the cause and cause
Such as nutritional deficiency should be corrected, because the disease has a tendency to relapse during pregnancy, so should prevent re-pregnancy, especially in the postpartum still have heart enlargement, should be advised to contraception or sterilization, because oral contraceptives have increased risk of thromboembolism Therefore, it should be banned. When the contraceptive failure occurs, it should be artificial abortion in the early pregnancy. For pregnant women who have heart failure after salt control, the intermittent application of diuretics may cause less electrolyte imbalance.
Complication
Perinatal myocardial complications Complications, arrhythmia, arterial embolism
Often combined with arrhythmia and thromboembolism.
1. Arterial embolism: a common complication, the incidence of up to 40%, mainly renal artery embolism and pulmonary embolism, and some patients with embolism as the first symptom.
2. Arrhythmia: Some patients may have arrhythmia, with ventricular premature contraction being the most common, and bundle branch block, atrial fibrillation, etc.
Symptom
Symptoms of perinatal cardiomyopathy Common symptoms Perinatal myocardial disease Heart failure Atrial premature beats Abdominal pain Arrhythmias dyspnea Right heart failure Heart enlargement Heart sounds Low blunt sitting breathing
The clinical manifestations vary in severity. The lighter ones only have T-wave changes of the electrocardiogram and are asymptomatic. The severe ones are refractory heart failure and even death. Clinical manifestations: most often occur during the puerperium (80% after 3 months postpartum, postpartum 3 After 10 months, 10%), less common in late pregnancy (only 10%), almost no disease before the last 3 months of pregnancy, Du Xujun (1986) reported 125 cases of PPCM, prenatal morbidity 15 cases (12 %), 110 cases (88%) occurred within 5 months after delivery; sudden onset or insidious onset, mainly manifested as symptoms of left ventricular heart failure, Veille statistics of 329 patients, most of them have palpitations, difficulty breathing, cough and Symptoms such as sitting breathing, 1/3 of patients have hemoptysis, chest pain, abdominal pain; sometimes accompanied by arrhythmia, premature atrial contraction, ventricular premature beats, supraventricular tachycardia, and atrioventricular block is extremely rare 25% to 40% of patients have symptoms of corresponding organ infarction, such as pulmonary embolism, sudden chest pain, dyspnea, hemoptysis and cough, hypoxia and other symptoms, large lung infarction can cause acute right heart failure, shock And sudden death, cerebral infarction can cause hemiplegia, coma, physical examination For the general expansion of the heart, the beat is weak and diffuse, the heart sound is low and blunt, and almost every case in the apical area can smell the pathological third heart sound or galloping, which can be enlarged by the heart relative to the mitral and tricuspid regurgitation. Caused by systolic reflux murmur, bilateral lung auscultation with scattered wet voice, jugular vein engorgement, large liver, lower extremity edema, blood pressure can be increased, normal or low, the above signs can be quickly reduced or disappeared with the improvement of heart function.
Examine
Perinatal cardiomyopathy
Blood routine examination showed anemia, small cell hypochromic anemia; no change in white blood cells, biochemical examination of liver, renal function may have mild abnormalities, occasionally hypoproteinemia.
Electrocardiogram examination
There may be a variety of ECG abnormalities, but most of them are non-specific, such as left ventricular hypertrophy, ST-T changes, low voltage, sometimes pathological Q waves and various arrhythmias, such as sinus tachycardia, atrial, ventricular phase Anterior contraction, paroxysmal supraventricular tachycardia, atrial fibrillation, and left or right bundle branch block.
2. X-ray inspection
The heart is generally enlarged, mainly left ventricle, weakened heart beats, often with pulmonary congestion, may be associated with pulmonary interstitial or parenchymal edema and a small amount of pleural effusion, and chest radiographs with corresponding changes in pulmonary embolism.
3. Echocardiography
The four chambers of the heart are enlarged, especially the left ventricle is enlarged, the left ventricular outflow tract is widened, the ventricular septum and left ventricular posterior wall movement are weakened, suggesting that the myocardial contractile function is reduced, and the mitral and aortic valve opening amplitudes become smaller. Sometimes, there are wall thrombus and less to moderate pericardial effusion. Due to dilatation of the heart chamber, the relative regurgitation of the valve may have mild mitral or tricuspid regurgitation.
4. Cardiac catheterization
Left ventricular end-diastolic pressure, left atrial pressure and pulmonary capillary wedge pressure increased, cardiac output, cardiac index decreased.
5. Endomyocardial biopsy
Endocardial myocardial biopsy can be performed when necessary, especially when there is a high degree of suspected myocarditis, but it is easy to get a positive result in the early stage of the disease.
Diagnosis
Diagnosis and identification of perinatal cardiomyopathy
diagnosis
First, the original heart disease before pregnancy should be carefully excluded, such as rheumatic valvular heart disease, congenital heart disease, myocarditis, other types of primary or secondary cardiomyopathy and thrombotic diseases, due to PPCM symptoms, signs and The item is not specific and is usually diagnosed by exclusion.
Some scholars have established diagnostic criteria: 1 no history of heart disease; 2 heart failure occurred during the perinatal period (3 months after pregnancy or 6 months after delivery); 3 no other determinable causes of heart failure; 4 echocardiography Check for left ventricular systolic dysfunction.
Differential diagnosis
Hypertensive heart disease
Perinatal cardiomyopathy has more normal blood pressure, but it needs to be identified when blood pressure is increased. PPCM blood pressure is not high, blood pressure rises for a short time, blood pressure tends to be normal with the condition, and there is no history of essential hypertension before pregnancy. Dynamic observation of blood pressure during pregnancy helps to distinguish between the two.
2. Anemia heart disease
There are many mild anemias during pregnancy. If there is malnutrition or parasitic infection, it should be differentiated from anemia. The latter has a long anemia and a heavy degree. Hemoglobin is below 60g/L. The heart enlargement is not obvious. After anemia is corrected. Symptoms will improve, perinatal cardiomyopathy is less severe, hemoglobin is more than 80g / L, but the heart is significantly increased.
3. Pregnancy-induced hypertension syndrome (PIH)
Both can occur in the second trimester of pregnancy, with malnutrition, especially with significant anemia, and twin or multiple births are prone to occur.
