读书报告机械瓣膜置换术后孕产妇的处理课件

1、Management of Pregnant Woman with Mechanical Heart Valves - A Case Based DiscussionDepartment of Anesthesiology the First Affiliated Hospital of Soochow UniversityJIN XIN读书报告机械瓣膜置换术后孕产妇的处理1Management of Pregnant Woman Key wordsG3P2 孕3产2gravida I或primigravidagravida II或secundigravidagravida III或terti

2、gravidapara O 未产妇 para 初产妇para 、 Peripartum 围产期 Gestation 怀孕, 酝酿, 妊娠Thrombosis 血栓形成Thromboembolism 血栓栓塞Embryopathy 胚胎病 Osteoporosis 骨质疏松症Teratogenic 畸形形成的hypoplasia 发育不全 读书报告机械瓣膜置换术后孕产妇的处理2Key wordsG3P2 孕3产2Peripartum 围Case Introduction 25 years, G3P2 gestation 6 weeks, 2 children, S.V.Delivery.1st

3、pregnancy: Dyspnoea(30 weeks), Mitral Regurgitation, Diuretic-Rest-Observation, MVR, Anticoagulation(warfarin).2nd pregnancy: 2 years later, uneventful, S.V.Delivery. .to be continued读书报告机械瓣膜置换术后孕产妇的处理3Case Introduction 25 years, GRisk of Prosthetic Valve ThrombosisTissue valve: wearing out and nece

4、ssitating replacement.Mechanical valve: longevity but life-long sthetic valve thrombosis(PVT): 0.76.0% per patient per year(1.3%-obstruction) VS 25% with no anticoagulation.Thromboembolism in pregnant women with prosthetic heart valve: 723% per pt per year.读书报告机械瓣膜置换术后孕产妇的处理4Risk

5、of Prosthetic Valve ThromFactors increasing the risk of PVTMechanical Valve Tissue ValveRight Heart Left HeartMitral Valve Aortic ValveHypercoagulable state of pregnancyInterruption to Anticoagulation读书报告机械瓣膜置换术后孕产妇的处理5Factors increasing the risk ofConsiderations during AnticoagulationAnticoagulatio

6、n drugs:1. Warfarin2. Unfractionated heparin (UFH)3. low molecular weight heparin (LMWH) Balance of two risks:1. Valve thrombosis2-1. Direct harm to fetus2-2. Haemorrhage to both mother and fetus读书报告机械瓣膜置换术后孕产妇的处理6Considerations during AnticoagWarfarinBest protection in mother, best interest of unbo

7、rn child.Crossing the placenta: fetal loss, embryopathy.Fetal and neonatal haemorrhage. Warfarin Embryopathy: skeletal abnormality, taking warfarin in the first trimester (esp. 6th12th wks), indefinite incidence(1.6% of live births), skeletal deformity and nasal hypoplasia-10% of babies exposed to w

8、arfarin.读书报告机械瓣膜置换术后孕产妇的处理7WarfarinBest protection in motHeparinNeither UFH nor LMWH cross the placenta, no direct harm to fetus, but less protection against PVT.LMWH UFH: thrombocytopenia and osteoporosis, subcutaneous absorption, long T1/2, dose-response effect.Valve thrombosis rate: 8.6%.- 81 pre

9、gnancy in 75 women with mechanical prosthetic heart valves treated with LMWH.读书报告机械瓣膜置换术后孕产妇的处理8HeparinNeither UFH nor LMWH crAnticoagulation ManagementUFH: 1750020000 units, sc., Bid, throughout pregnancy. a. APTT (6 hour post dosing): twice the control level. b.anti-a level(6 hour post dosing): 0.

10、350.70 IU/ml.LMWH: dalterpain 100units/kg, sc., throughout pregnancy. anti-a level(4 hour post dosing): 1.0IU/ml.UFH or LMWH therapy: as above until 13th week, Warfarin: till the middle of the 3rd trimester, UFH or LMWH therapy: restart until delivery. NB: warfarin used alone-an embryopathy rate of

11、6.4%, completelyeliminated by use of heparin prior to 13 weeks of gestation. (A Meta-Analysis)读书报告机械瓣膜置换术后孕产妇的处理9Anticoagulation ManagementUFH:Thrombosis RateWarfarin throughout pregnancy- 3.9%Heparin throughout pregnancy- 33%Heparine in 1st trimester then warfarin thereafter-9.2% Aspirin 150mg Qd.

12、is strongly advised.Warfarin: offering the best protection against thrombosisHeparin(1st trimester): protecting the unborn baby from teratogenic effect of warfarin读书报告机械瓣膜置换术后孕产妇的处理10Thrombosis RateWarfarin throug As soon as her pregnancy is confirmed: LMWH(tinzaparin): 7500 units Bid., and stopping

13、 warfarin.Warfarin: recommenced at 16 wks and stopped at 36 wks.LMWH (enoxaparin): 90mg Bid.Aspirin: 150mg, Qd, together with LMWH.Case Introduction .to be continued读书报告机械瓣膜置换术后孕产妇的处理11 As soon as her pregnancy iMonitoring LMWH TherapyUFH: Interacting with AT-: intrinsic pathway of coagulationLMWH:

14、Blocking only Factor a: 1. not required for monitoring of anticoagulation therapy. 2. Dosage: based on BW, adjusted as pregnancy process due to GFR, Vd , and placental heparinase. 3. anti-a level1 IU/ml (4 hours post dosing).读书报告机械瓣膜置换术后孕产妇的处理12Monitoring LMWH TherapyUFH: InAt 38 weeks: a planned in

15、duction of labor.Heamatology Department: joined for assistance. Full blood count and anti-a level 1.2 IU/mlAnalgesia in labor: opioids, N2O+O2(Entonox). Epidural analgesia24hrs after last LMWH Recommence LMWH 2hrs after Epi. Catheter removal Epidural heamotoma: risk reduced but still in existenceUne

16、ventful labor(SVD), healthy boy, discharged home later.Anticoagulation therapy Warfarin: restarted following delivery, INR2.03.0. Enoxaparin: used in pregnacy.Case Introduction.to be continued读书报告机械瓣膜置换术后孕产妇的处理13At 38 weeks: a planned inducti10 days later: vaginal bleeding, light headed.Vital signs

17、and blood tests: within normal limits. HR: 64bpm, BP:110/72mmHg, RR:14/min. Hb:112g/L, WBC:5.8E9/L, Plt:195E9/L APTT ratio:1.2, Fibinogen:2.8g/dl, anti-a level:1.32 IU/mlPost-Partum Haemorrhage (PPH)Post-partum haemorrhage (PPH): a. 500ml after V. delivery or 1000ml after C. section.b. Blood loss th

18、at makes the patients symptomatic(dizzy, tachycardia, oliguric etc), primarily (24hrs) or secondarily(24h6wks postpartum).读书报告机械瓣膜置换术后孕产妇的处理1410 days later: vaginal bleedinCauses of PPH1. Tone uterine atony: an over-distended uterus(multiple pregnancy, fetal macrosomia, polyhydramnios), fatigue uter

19、us(prolonged labor/augmented labor, administration of tocolytics), and an obstructed uterus(retained placenta, retained products of conception ).2. Trauma sustained injuries during delivery3. Tissue retained products of conception: preventing uterus from adequate contraction, a source of infection.4

20、. Thrombin coagulation disorder, either acquired or inherited.读书报告机械瓣膜置换术后孕产妇的处理15Causes of PPH1. Tone uterineCause and ManagementNo birth trauma, no sepsis, INR 2.0 Clinical examination: poor contracted uterus US examination: retained products of conception Stopping warfarin, commencing LMWH(enoxap

21、arin 70mg Bid.)Removal of products of conception under general anesthesia.Continuing bleeding(Hb 6.5g/dl) and blood transfusion 4 units.INR 1.1 at present读书报告机械瓣膜置换术后孕产妇的处理16Cause and ManagementNo birth tOne surgical option available -placement of an intrauterine balloonSevere or refractory PPH seco

22、ndary to uterine atonySevere PPH due to retained products, continuing to bleed after evacuation.Severe PPH secondary to coagulopathyPPH following Cesarean deliveryProphylaxis if at very high risk of PPHIn this case, a Rusch balloon is applied first, deflated at 24hrs, however reinserted later for bl

23、eeding again.读书报告机械瓣膜置换术后孕产妇的处理17One surgical option available Case Introduction72 hrs after evacuation of retained products of conceptionBlood: Hb:92g/L, Plt:162E9/L, INR:1.1, anti-a:1.1 IU/mlSlow bleeding, reversal of anticoagulation(thrombosis), surgical intervention while anticoagulated.Final de

24、cision: the interventional radiology service for uterine artery embolisation.to be continued读书报告机械瓣膜置换术后孕产妇的处理18Case Introduction72 hrs after Uterine Artery EmbolisationA safe, uterine-sparing procedure.A high success rate(92%) and a low complication - surgical uterine artery ligation, avoiding surg

25、ical access.Local anesthesia, Unilateral/Bilateral femoral A. puncture, Microcatheter, Fluoroscopic guidance, Internal Iliac A., Synthetic compounds.读书报告机械瓣膜置换术后孕产妇的处理19Uterine Artery EmbolisationA sComplications of UAEImmediate: - Groin puncture site problems including haematoma - Contrast reactions - Ut