What Causes Palpitations in Pregnancy?

Heart disease during pregnancy can be divided into two categories. The first category is heart diseases that existed before pregnancy. The majority are rheumatic and congenital heart diseases. Hypertensive heart disease, mitral valve prolapse, and hypertrophic heart disease are rare. ; The second category is pregnancy-induced heart disease, such as hypertension heart disease during pregnancy, perinatal heart disease.

Basic Information

English name: heart disease in pregnancy
Visiting department: Obstetrics and Gynecology
Multiple groups: Pregnant woman

Common causes: Pre-pregnancy heart disease; pregnancy-induced heart disease
Common symptoms: Shortness of breath, more tiredness, can not lie flat, cough, foamy sputum or blood, cyanosis, etc.

Clinical manifestations of heart disease during pregnancy

Heart failure heart disease

If the patient's original heart function has been impaired or barely compensated, the heart function can be further decompensated due to pregnancy. Cardiac insufficiency manifested in pregnant women with rheumatic heart disease:

(1) Pulmonary congestion is more common in mitral valve disease. Patients are short of breath and even more tired after exhaustion, and there are fine wet rales at the base of both lungs. X-ray examination showed interstitial edema.

(2) Acute pulmonary edema is more common in severe mitral stenosis. Due to high blood volume caused by increased pulmonary arterial pressure. The patient was suddenly short of breath, unable to lie flat, coughing, foaming sputum or blood, and wheezing or moaning sounds scattered in both lungs.

(3) Right heart failure is common in older people, who have a larger heart enlargement, and who have atrial fibrillation. They usually have a reduced labor force or have a history of heart failure. In pregnant women with congenital heart disease, arterial ducts, atrial septal defects, and ventricular septal defects are associated with pulmonary hypertension, often leading to right heart failure, pulmonary valve stenosis, and tetralogy of Fallot. Because the right ventricular pressure is too heavy, it also manifests as right heart failure. Aortic stenosis can manifest left heart failure due to left ventricular pressure overload.

2. Infective endocarditis

Regardless of rheumatic heart disease or congenital heart disease, infective endocarditis can be complicated by bacteremia. If not controlled in time, it can cause heart failure and cause death.

3. Hypoxia and cyanosis

Patients with cyanotic congenital heart disease usually have hypoxia and cyanosis, low peripheral resistance during pregnancy, and increased cyanosis. Non-cyanogenic, left-to-right shunting pregnant women with congenital heart disease, if blood pressure drops due to blood loss and other reasons, can cause temporary reverse shunting, that is, right-to-left shunting, causing cyanosis and hypoxia.

4. Embolism

During pregnancy, the blood is in a hypercoagulable state, coupled with increased venous pressure and venous blood stasis associated with heart disease, which is prone to embolism. Thrombosis may come from the pelvic cavity, causing pulmonary embolism, increasing pulmonary circulation pressure, which triggers pulmonary edema, or reverses left-to-right shunt to right-to-left shunt. In the case of congenital heart disease that affects left and right ventricular cavity, the thrombus may cause embolism of the surrounding arteries through the defect.

Heart disease during pregnancy

1. Routine ECG examination helps diagnosis.

2. Echocardiography helps to diagnose the type of pulmonary hypertension and congenital heart disease.

Heart disease diagnosis during pregnancy

If the following abnormalities are found, organic heart disease should be considered.

1. Grade III or higher, rough systolic murmur.

2. Diastolic murmur.

3. Severe arrhythmia, such as atrial fibrillation or flutter, atrioventricular block and so on.

4. X-rays showed a significant enlargement of heart shadows, especially individual atria or ventricles.

5. Echocardiography showed heart valve, atrial and ventricular lesions.

Heart disease treatment during pregnancy

1. indications for termination of pregnancy

Whether women with pre-existing heart disease can tolerate pregnancy depends on many factors, such as the type of heart disease, the degree of disease, the state of heart function, and the presence of complications. When assessing the ability of pregnant women with heart disease to tolerate pregnancy, careful consideration must be given to the possibility that pregnancy may increase the heart burden and be life-threatening, as well as avoiding excessive concerns that could result in the loss of fertility opportunities for competent individuals. In the following cases, pregnancy is generally unsuitable and should be terminated early.

(1) Heart disease becomes severe, heart function is above Grade III, or has a history of heart failure.

(2) Rheumatic heart disease is associated with pulmonary hypertension, chronic atrial fibrillation, high atrioventricular block, or recent bacterial endocarditis.

(3) Congenital heart disease has obvious cyanosis or pulmonary hypertension.

(4) Combined with other more serious diseases, such as nephritis, severe hypertension, and tuberculosis. However, if the pregnancy has been over 3 months, termination of pregnancy is generally not considered, because for a sick heart, termination of pregnancy at this time is no less dangerous than continuing pregnancy. If heart failure has occurred, it is still advisable to terminate the pregnancy in a timely manner.

2. Continue the monitoring of pregnancy

Heart failure is a fatal injury to pregnant women with heart disease. Therefore, the purpose of strengthening the monitoring during pregnancy is to prevent heart failure, and the specific measures can be summarized as reducing the burden on the heart and improving the function of cardiac compensation.

(1) To reduce the burden on the heart, attention should be paid to the following aspects: Limit physical activity, increase rest time, and ensure at least 10 to 12 hours of sleep per day. Try to take the left lying position to increase the stroke volume and keep the return blood volume stable. Maintain mental pleasure and avoid emotional excitement. Enter a high-protein, low-fat, multi-vitamin diet, limit sodium intake, and 3 to 5 grams of daily salt to prevent swelling. Reasonable nutrition, control the rate of weight gain, no more than 0.5 kg per week, and no more than 10 kg during pregnancy. Eliminate various factors that impair heart function, such as anemia, hypoproteinemia, vitamin (especially B ₁ ) deficiency, infection, pregnancy-induced hypertension syndrome. If blood transfusion is needed, a small amount (150 200ml) is needed repeatedly; if fluid replacement is needed, the limit is 500 1000ml / d, and the drip rate is <10 15 drops / min.

(2) Improving cardiac compensatory function includes the following aspects: Cardiovascular surgery: Patients with severe disease, cardiac function III to IV, uncomplicated surgery, and low anesthesia requirements can be performed at 3 to 4 months of pregnancy. Emergency mitral valve dissection (acute pulmonary edema caused by mitral stenosis alone) can be performed prenatally. When heart failure occurs during an open arterial catheter, or if there is an arterial catheter infection, surgery is indicated. Digitalis If pregnant women with heart disease do not have the symptoms and signs of heart failure, digitalis treatment is generally not needed, because digitalis application does not work at this time. Moreover, the application of digitalis during pregnancy cannot guarantee that heart failure does not occur during delivery. Once a reaction occurs, it is difficult to add drugs at that time. In addition, rapid digitalis can exert its effects within a few minutes, such as closely monitoring changes in the condition, and it is not difficult to control early heart failure in a timely manner. Therefore, digitalis is usually only applied at 28 to 32 weeks of gestation (that is, before the peak of hemodynamic load during pregnancy) in those with pre-existing heart failure or early heart failure and Grade III cardiac function. Because pregnant women have poor tolerance to digitalis and are susceptible to poisoning, they should choose rapid preparations, such as deacetyllanolin (Cedrocetin) or strophanthin K poisoning (Poisonin). Digoxin, which is excreted faster, is used for maintenance treatment, and is generally used until the blood circulation returns to normal 4 to 6 weeks after delivery.

In addition, pregnant women with cardiac function and should increase the number of prenatal examinations. At least every 2 weeks before 20 weeks, they should be checked by cardiology and obstetricians, and once a week thereafter, if necessary, follow-up at home. In addition to obstetrics, he mainly understands the function of cardiac compensation and various symptoms, and regularly conducts electrocardiogram and echocardiogram examinations in order to make a comprehensive estimation of the condition and find abnormalities. If there is a threat of heart failure, immediately hospitalize. Admitted to the hospital for delivery 2 weeks before the expected date of birth, both ample rest and easy inspection and observation. Those with heart function grade III or with heart failure should be hospitalized and kept in hospital for delivery.

3. Management of childbirth and puerperium

(1) Choice of delivery method The delivery method of pregnant women with heart disease mainly depends on cardiac function and obstetric conditions. Caesarean section Cesarean section can end childbirth in a short period of time, thereby avoiding the hemodynamic changes caused by long-term uterine contraction and reducing the heart load caused by fatigue and pain. Vaginal delivery For those with cardiac function , unless there are obstetric complications, in principle, vaginal delivery. The average birth process of pregnant women with heart disease is not significantly different from that of normal pregnant women, but they must be under the supervision of a special person.

(2) Essentials of puerperium management Due to strengthened monitoring during pregnancy and puerperium , patients can pass the customs smoothly. However, if the puerperium monitoring is relaxed, it is likely to fail. According to statistics, 75% of maternal deaths due to heart disease occur early in the puerperium. Continue to use antibiotics to prevent infection in order to prevent the occurrence of subacute bacterial endocarditis. Maternal patients who have had heart failure should continue taking heart-strengthening drugs. Pay attention to changes in body temperature, pulse, breathing and blood pressure, as well as uterine contraction and bleeding. Rest in bed for 24 to 72 hours after giving birth. Women with severe heart disease should take a semi-recumbent position to reduce the amount of returning blood and inhale oxygen. If there is no manifestation of heart failure, encourage early wake-up activities. Those with heart failure should stay in bed and exercise their lower limbs more often to prevent thrombophlebitis. Women with cardiac function above Grade III do not lactate after childbirth. Breastfeeding increases the body's metabolism and fluid requirements, which can make the condition worse. Hospitalization and observation for at least 2 weeks after delivery. The patient can be discharged after the cardiac function improves. After leaving the hospital, adequate rest is required to limit the amount of activity. Strict contraception.

4. Diagnosis and treatment of heart failure

Heart disease is the basis of heart failure. From the impact of hemodynamic changes in pregnancy, childbirth and puerperium on the heart, 32 to 34 weeks of gestation, the first 3 days of childbirth and puerperium are the most dangerous periods for heart disease patients, and heart failure is extremely prone to occur.

(1) Early diagnosis The classification of cardiac compensatory function is also the classification of heart failure: heart function grade II = mild heart failure, heart function grade III = moderate heart failure, heart function grade IV = severe heart failure. The early symptoms of heart failure are: burnout without any other explanation, chest tightness, shortness of breath after mild activity, shortness of breath during sleep, wakefulness and / or head uplift, swelling in the liver area, and edema in the lower limbs. Early signs are: at rest, heart rate> 120 beats / min, breathing> 24 beats / min, increased jugular pulsation, wet snoring at the base of the lungs, alternating pulses, diastolic running rhythm, decreased urine output and weight gain. The ECG V1P wave terminal vector was positive. Continuous chest radiographs (upright position) showed thickening of pulmonary veins in Ueno in both lungs.

(2) Principles of treatment The principles of treatment of heart failure during pregnancy with heart failure are similar to those of non-pregnant patients. Strong Heart Apply rapid digitalis preparations to improve myocardial condition. After taking effect, change to the fast excretion of digoxin to maintain. Pregnant women are less tolerant of digitalis-like cardiac drugs and need to be closely monitored for signs of toxicity. Diuretic effect is to reduce circulating blood volume and reduce pulmonary edema. Reusable, but pay attention to electrolyte balance. Vasodilators In heart failure, peripheral vasoconstriction increases, which leads to an increase in the afterload of the heart. Application of vasodilators can play the role of "internal bleeding" . Sedation Intravenous injection after dilution of morphine in small doses not only has the effects of sedation, analgesia, suppression of excessively excited respiratory centers, and expansion of peripheral blood vessels, reducing the pre- and post-cardiac load, but also antiarrhythmia. Commonly used for rescue of acute left heart failure and pulmonary edema. Reduce the amount of blood from the venous heart. Use a tourniquet to pressurize the limbs, and loosen one limb in turn every 5 minutes. A semi-recumbent position with sagging feet can serve the same purpose. Anti-arrhythmia Arrhythmia can be caused by heart failure, and can also induce or aggravate heart failure, and severe cases should be corrected in time.

Heart disease prevention during pregnancy

1. Women of childbearing age with organic heart disease when not pregnant should not be pregnant if

(1) Cardiac function grade III or above, severe mitral valve stenosis with pulmonary hypertension, or congenital heart disease with more obvious cyanosis, repair surgery should be performed first, such as those who are unwilling or unable to operate.

(2) Those with rheumatic heart disease associated with atrial fibrillation or those who have difficulty controlling their heart rate.

(3) Patients with significantly enlarged heart (indicating myocardial damage or severe valvular disease) or those with incomplete recovery from cerebral embolism.

(4) Patients with a history of heart failure or severe medical complications such as chronic nephritis and tuberculosis. These patients should be strictly contraceptive.

During pregnancy

(1) Therapeutic abortion Pregnant women with organic heart disease should have an abortion as soon as possible if they have the above indications that they are not suitable for pregnancy. Aspiration surgery is feasible within 3 months of pregnancy. If pregnancy is more than 3 months, appropriate measures for termination of pregnancy should be selected. People with heart failure during pregnancy must wait for heart failure before undergoing an abortion.

(2) Strengthening prenatal examinations Cardiac function class and pregnant women can continue to conceive, and a systematic prenatal checkup should be performed from the first trimester to closely observe the cardiac function. It is best to be jointly monitored by obstetrics and internal medicine. Patients with Grade or Grade cardiac function may experience rapid deterioration to Grade or even heart failure when they are tired during pregnancy or have upper respiratory tract infection.

(3) Prevention of heart failure . Sleep for 10 hours at night and rest for 0.5 to 1 hour during the day. Limit the amount of activity and salt, not more than 4 grams per day. Actively prevent and treat anemia, and give iron, folic acid, vitamins B and C, and calcium. Strengthen nutrition. Weight gain throughout pregnancy should not exceed 11 kg.

(4) Early detection of heart failure When the physical strength suddenly drops, the cough, the heart rate increases, the lungs continue to be wet, and the cough does not disappear after coughing, the edema is exacerbated or the weight gain is too fast, you should be alert.

(5) Treat acute heart failure in a timely manner to take a semi-recumbent position to facilitate breathing and reduce the amount of blood returning to the heart. Immediately inhale oxygen, give sedatives, diuretics (usually by rapid injection or oral administration), and intravenously inject cardiac medicament. Or poisonous trichoside K. After the symptoms are improved, digoxin can be taken orally, as appropriate.

(6) Timely admission Even if asymptomatic, you should be admitted 2 weeks before the due date. Patients with worsening cardiac function during pregnancy or grade III or infected should be hospitalized in time.

(7) The treatment of those with a history of heart surgery still depends on the cardiac function after the operation.

3. Childbirth

(1) Antibiotics should be given at the beginning of the labor process to actively prevent infection. Measure body temperature, pulse and breath 4 times a day.

(2) Give the mother a quiet rest, give a small amount of sedatives, intermittent oxygen inhalation, and prevent heart failure and intrauterine distress.

(3) If there is no indication for cesarean section, vaginal delivery can be performed, but the labor process should be shortened as much as possible. Perineal resection and forceps surgery are available. Observe heart function closely. Because prolonged labor can increase the burden on the heart, the indications for cesarean section can be appropriately relaxed. Epidural anesthesia is appropriate. If heart failure occurs, cesarean section must be actively controlled after heart failure.

(4) After the fetus is delivered, a sandbag is placed on the abdomen to pressurize it to prevent a sudden decrease in abdominal pressure and heart failure. Immediate intramuscular injection of morphine or phenobarbital sodium. If postpartum hemorrhage exceeds 300 ml, intramuscular injection of oxytocin. When blood transfusion is needed, care should be taken not to go too fast.

4. The puerperium

The mother is well rested. Observe body temperature, pulse, heart rate, blood pressure, and vaginal bleeding, watch for heart failure and infection, and continue to use antibiotics. If heart function is poor, women who are unsuitable for another pregnancy can take long-acting contraception.