读书报告_机械瓣膜置换术后孕产妇的处理

ManagementofPregnantWomanwithMechanicalHeartValves--ACaseBasedDiscussionDepartmentofAnesthesiologytheFirstAffiliatedHospitalofSoochowUniversityJINXINKeywordsG3P2孕3产2gravidaI或primigravidagravidaII或secundigravidagravidaIII或tertigravidaparaO未产妇paraⅠ初产妇paraⅡ、Ⅲ、Ⅳ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CaseIntroduction25years,G3P2gestation6weeks,2children,S.V.Delivery.1stpregnancy:Dyspnoea(30weeks),MitralRegurgitation,Diuretic-Rest-Observation,MVR,Anticoagulation(warfarin).2ndpregnancy:2yearslater,uneventful,S.V.Delivery.….tobecontinuedRiskofProstheticValveThrombosisTissuevalve:wearingoutandnecessitatingreplacement.Mechanicalvalve:longevitybutlife-longanticoagulation.prostheticvalvethrombosis(PVT):0.7~6.0%perpatientperyear(1.3%-obstruction)VS25%withnoanticoagulation.Thromboembolisminpregnantwomenwithprostheticheartvalve:7~23%perptperyear.FactorsincreasingtheriskofPVTMechanicalValveTissueValveRightHeartLeftHeartMitralValveAorticValveHypercoagulablestateofpregnancyInterruptiontoAnticoagulationConsiderationsduringAnticoagulationAnticoagulationdrugs:1.Warfarin2.Unfractionatedheparin(UFH)3.lowmolecularweightheparin(LMWH)Balanceoftworisks:1.Valvethrombosis2-1.Directharmtofetus2-2.HaemorrhagetobothmotherandfetusWarfarinBestprotectioninmother,bestinterestofunbornchild.Crossingtheplacenta:fetalloss,embryopathy.Fetalandneonatalhaemorrhage.WarfarinEmbryopathy:skeletalabnormality,takingwarfarininthefirsttrimester(esp.6th~12thwks),indefiniteincidence(1.6%oflivebirths),skeletaldeformityandnasalhypoplasia-10%ofbabiesexposedtowarfarin.HeparinNeitherUFHnorLMWHcrosstheplacenta,nodirectharmtofetus,butlessprotectionagainstPVT.LMWHUFH:thrombocytopeniaandosteoporosis,subcutaneousabsorption,longT1/2,dose-responseeffect.Valvethrombosisrate:8.6%.-81pregnancyin75womenwithmechanicalprostheticheartvalvestreatedwithLMWH.AnticoagulationManagementUFH:17500~20000units,sc.,Bid,throughoutpregnancy.a.APTT(6hourpostdosing):twicethecontrollevel.b.anti-Ⅹalevel(6hourpostdosing):0.35~0.70IU/ml.LMWH:dalterpain100units/kg,sc.,throughoutpregnancy.anti-Ⅹalevel(4hourpostdosing):1.0IU/ml.UFHorLMWHtherapy:asaboveuntil13thweek,Warfarin:tillthemiddleofthe3rdtrimester,UFHorLMWHtherapy:restartuntildelivery.NB:warfarinusedalone-anembryopathyrateof6.4%,completelyeliminatedbyuseofheparinpriorto13weeksofgestation.(AMeta-Analysis)ThrombosisRateWarfarinthroughoutpregnancy-3.9%Heparinthroughoutpregnancy-33%Heparinein1sttrimesterthenwarfarinthereafter-9.2%Aspirin150mgQd.isstronglyadvised.Warfarin:offeringthebestprotectionagainstthrombosisHeparin(1sttrimester):protectingtheunbornbabyfromteratogeniceffectofwarfarinAssoonasherpregnancyisconfirmed:LMWH(tinzaparin):7500unitsBid.,andstoppingwarfarin.Warfarin:recommencedat16wksandstoppedat36wks.LMWH(enoxaparin):90mgBid.Aspirin:150mg,Qd,togetherwithLMWH.CaseIntroduction….tobecontinuedMonitoringLMWHTherapyUFH:InteractingwithAT-Ⅲ:intrinsicpathwayofcoagulationLMWH:BlockingonlyFactorⅩa:1.notrequiredformonitoringofanticoagulationtherapy.2.Dosage:basedonBW,adjustedaspregnancyprocessduetoGFR↑,Vd↑,andplacentalheparinase.3.anti-Ⅹalevel≌1IU/ml(4hourspostdosing).At38weeks:aplannedinductionoflabor.HeamatologyDepartment:joinedforassistance.Fullbloodcountandanti-Ⅹalevel1.2IU/mlAnalgesiainlabor:opioids,N2O+O2(Entonox).Epiduralanalgesia≧24hrsafterlastLMWHRecommenceLMWH≧2hrsafterEpi.CatheterremovalEpiduralheamotoma:riskreducedbutstillinexistenceUneventfullabor(SVD),healthyboy,dischargedhomelater.AnticoagulationtherapyWarfarin:restartedfollowingdelivery,INR2.0~3.0.Enoxaparin:usedinpregnacy.CaseIntroduction….tobecontinued10dayslater:vaginalbleeding,lightheaded.Vitalsignsandbloodtests:withinnormallimits.HR:64bpm,BP:110/72mmHg,RR:14/min.Hb:112g/L,WBC:5.8E9/L,Plt:195E9/LAPTTratio:1.2,Fibinogen:2.8g/dl,anti-Ⅹalevel:1.32IU/mlPost-PartumHaemorrhage(PPH)Post-partumhaemorrhage(PPH):a.﹥500mlafterV.deliveryor﹥1000mlafterC.section.b.Bloodlossthatmakesthepatientssymptomatic(dizzy,tachycardia,oliguricetc),primarily(24hrs)orsecondarily(24h~6wkspostpartum).CausesofPPH1.Tone–uterineatony:anover-distendeduterus(multiplepregnancy,fetalmacrosomia,polyhydramnios),fatigueuterus(prolongedlabor/augmentedlabor,administrationoftocolytics),andanobstructeduterus(retainedplacenta,retainedproductsofconception).2.Trauma–sustainedinjuriesduringdelivery3.Tissue–retainedproductsofconception:preventinguterusfromadequatecontraction,asourceofinfection.4.Thrombin–coagulationdisorder,eitheracquiredorinherited.CauseandManagementNobirthtrauma,nosepsis,INR2.0Clinicalexamination:poorcontracteduterusUSexamination:retainedproductsofconceptionStoppingwarfarin,commencingLMWH(enoxaparin70mgBid.)Removalofproductsofconceptionundergeneralanesthesia.Continuingbleeding(Hb6.5g/dl)andbloodtransfusion4units.INR1.1atpresentOnesurgicaloptionavailable--placementofanintrauterineballoonSevereorrefractoryPPHsecondarytouterineatonySeverePPHduetoretainedproducts,con