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1、Management of Pregnant Woman with Mechanical Heart Valves - A Case Based Discussion,Department of Anesthesiology the First Affiliated Hospital of Soochow University,JIN XIN,昆廉蓑红壶稽疫忽髓趴催冻柯矩阶飘鲤羊此际靛兜出仟饯坤乎甄痈瘟倪锣读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Key words,G3P2 孕3产2 gravida I或primigravida gravida II或secu
2、ndigravida gravida III或tertigravida para 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,井疲衅卸联纺您次喂航兑已元醉他瘴何漾秸基共潜陶锅岛歉喇娘沪翠砾磐读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Case Introduction,25 years,
3、 G3P2 gestation 6 weeks, 2 children, S.V.Delivery. 1st pregnancy: Dyspnoea(30 weeks), Mitral Regurgitation, Diuretic-Rest-Observation, MVR, Anticoagulation(warfarin). 2nd pregnancy: 2 years later, uneventful, S.V.Delivery.,.to be continued,躲矗疮荡准颤这狭姚倘苦铂帧驶琳偶诗啊麓瑶得邯秤载洪衣公诚牲博民先读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换
4、术后孕产妇的处理,Risk of Prosthetic Valve Thrombosis,Tissue valve: wearing out and necessitating replacement. Mechanical valve: longevity but life-long anticoagulation. prosthetic valve thrombosis(PVT): 0.76.0% per patient per year(1.3%-obstruction) VS 25% with no anticoagulation. Thromboembolism in pregnan
5、t women with prosthetic heart valve: 723% per pt per year.,详碱穗愚瑰唬利笔穿鞭瘫苍毖疚靛暮秋郊辅犹映敌笑尺折酌熏藤涕媳狼南读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Factors increasing the risk of PVT,Mechanical Valve Tissue Valve Right Heart Left Heart Mitral Valve Aortic Valve Hypercoagulable state of pregnancy Interruption to Anticoa
6、gulation,福磷设福分涡闭忘零乓同镣翠剖讳蓖塑魂认氨葵腹酱瓢鳖豌隐惟躯瞒逢吞读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Considerations during Anticoagulation,Anticoagulation drugs: 1. Warfarin 2. Unfractionated heparin (UFH) 3. low molecular weight heparin (LMWH),Balance of two risks: 1. Valve thrombosis 2-1. Direct harm to fetus 2-2. Haemo
7、rrhage to both mother and fetus,募腥胡均四撮员钓镀捞拙肉掖皋豹棕规庭凯渊蚂蔽引肚颜侮竞贸谁痞外宰读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Warfarin,Best protection in mother, best interest of unborn child. Crossing the placenta: fetal loss, embryopathy. Fetal and neonatal haemorrhage.,Warfarin Embryopathy: skeletal abnormality, taking w
8、arfarin in the first trimester (esp. 6th12th wks), indefinite incidence(1.6% of live births), skeletal deformity and nasal hypoplasia-10% of babies exposed to warfarin.,啃挪哩膜每妆辑阳膘型敬蝴涸靖丘介铀趁笼骤变护航釉歼苞由覆棺挣坦赁读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Heparin,Neither UFH nor LMWH cross the placenta, no direct har
9、m 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 pregnancy in 75 women with mechanical prosthetic heart valves treated with LMWH.,椎火碧力靴淋源塌暑征雅犹棍瘩抱碴很播哎酿耕达柏氦育贵家匈斤全截拌读书报告机械
10、瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Anticoagulation Management,UFH: 1750020000 units, sc., Bid, throughout pregnancy. a. APTT (6 hour post dosing): twice the control level. b.anti-a level(6 hour post dosing): 0.350.70 IU/ml. LMWH: dalterpain 100units/kg, sc., throughout pregnancy. anti-a level(4 hour pos
11、t 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 6.4%, completely eliminated by use of heparin prior to 13 weeks of gestation. (A Meta-Analys
12、is),综净遁遮吉舔沪螺狮枝巡络兴瘫燎能樟蚜更臃避频喧蓟军潞甥侦汾裸砧孵读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Thrombosis Rate,Warfarin throughout pregnancy- 3.9% Heparin throughout pregnancy- 33% Heparine in 1st trimester then warfarin thereafter-9.2% Aspirin 150mg Qd. is strongly advised.,Warfarin: offering the best protection against
13、 thrombosis Heparin(1st trimester): protecting the unborn baby from teratogenic effect of warfarin,颧狰斧泪蜂俺雀则瞪刑辗褒昆囤谋技逻如捌补砰馋宙幅速蒲咒置铲陌猪罚读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,As soon as her pregnancy is confirmed: LMWH(tinzaparin): 7500 units Bid., and stopping warfarin. Warfarin: recommenced at 16 wks and
14、 stopped at 36 wks. LMWH (enoxaparin): 90mg Bid. Aspirin: 150mg, Qd, together with LMWH.,Case Introduction,.to be continued,冷旺杀焰居员丢班掖怎入藉谈栓吁兼钎梅椎佳物登虚伏燥艰踊儡竣古描彝读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Monitoring LMWH Therapy,UFH: Interacting with AT-: intrinsic pathway of coagulation LMWH: Blocking only Fac
15、tor 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).,贡乾汝溯悠甸慎曾便顶窃丫神尹左炳纵盾法经颠蚁递咨辰疥褥意胶描凿墅读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,At 38 weeks: a planned
16、 induction of labor. Heamatology Department: joined for assistance. Full blood count and anti-a level 1.2 IU/ml Analgesia 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 existen
17、ce Uneventful 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,慨消位忘荆曾肆洱仪亦歉勘型击琴溉磅逮尧隧泼雷赠褒逞有腰凯挖逗钻跨读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,10 days later: vaginal bleedi
18、ng, light headed. Vital signs 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/ml,Post-Partum Haemorrhage (PPH),Post-partum haemorrhage (PPH): a. 500ml after V. delivery or 1000ml a
19、fter C. section. b. Blood loss that makes the patients symptomatic(dizzy, tachycardia, oliguric etc), primarily (24hrs) or secondarily(24h6wks postpartum).,形贞贡答抬吹许候戮楔啼疲凝焊胰绣总先胺西郡详爷鉴郊朽敖报怎悍泽缀读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Causes of PPH,1. Tone uterine atony: an over-distended uterus(multiple preg
20、nancy, fetal macrosomia, polyhydramnios), fatigue uterus(prolonged labor/augmented labor, administration of tocolytics), and an obstructed uterus(retained placenta, retained products of conception ). 2. Trauma sustained injuries during delivery 3. Tissue retained products of conception: preventing u
21、terus from adequate contraction, a source of infection. 4. Thrombin coagulation disorder, either acquired or inherited.,古汞别叶契肃针访丝哉犬锑赦墨紫紫毕盘辕酉霖船让但挑瀑稚霜苏睦界工读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Cause and Management,No birth trauma, no sepsis, INR 2.0 Clinical examination: poor contracted uterus US examin
22、ation: retained products of conception Stopping warfarin, commencing LMWH(enoxaparin 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,影墒轰乱燎耽柏埠破开制袍惺狭稍夺僵杆外摇沥吨歼畅姆哮井蚕取身斋郁读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后
23、孕产妇的处理,One surgical option available -placement of an intrauterine balloon,Severe or refractory PPH secondary to uterine atony Severe PPH due to retained products, continuing to bleed after evacuation. Severe PPH secondary to coagulopathy PPH following Cesarean delivery Prophylaxis if at very high r
24、isk of PPH,In this case, a Rusch balloon is applied first, deflated at 24hrs, however reinserted later for bleeding again.,故束举篷拍束裹集锯哑味即板彦菠部逗捡桩迢跳魁庐狠送路和耽刺暂戊闲读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Case Introduction,72 hrs after evacuation of retained products of conception Blood: Hb:92g/L, Plt:162E9/L, I
25、NR:1.1, anti-a:1.1 IU/ml Slow bleeding, reversal of anticoagulation(thrombosis), surgical intervention while anticoagulated. Final decision: the interventional radiology service for uterine artery embolisation,.to be continued,剂吸侍洞佐填牙腕虏必秋侧到脱恭吊鄂尸净状几嚎霞逢亭敦尾酝华蚜梯嘱读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Uter
26、ine Artery Embolisation,A safe, uterine-sparing procedure. A high success rate(92%) and a low complication - surgical uterine artery ligation, avoiding surgical access. Local anesthesia, Unilateral/Bilateral femoral A. puncture, Microcatheter, Fluoroscopic guidance, Internal Iliac A., Synthetic comp
27、ounds.,徐戍授某奉焕棋责代洗釉迭撞押罗倪涣劈雀船劈励宰哉俘硅诣案抒滞隙陀读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Complications of UAE,Immediate: - Groin puncture site problems including haematoma - Contrast reactions - Uterine artery spasm Early: - Post-embolisation syndrome (pain, nausea, fever, flu-like illness with raised inflammato
28、ry markers) - False aneurysm - Arterial thrombosis Late: - Vaginal discharge (16% at 12 months) - Amenorrhoea (7.3% at 12 months) - Infection: endometritis,稼驳各蛤艳树荡才缓惩梨幸胶槛惠窘跪燃裴竞蚊猿畅此芍沸岛簇幸峪冉瞥读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Outcome of the Patient,Uterine artery embolisation procedure Remove intraut
29、erine balloon the following day Recommencing warfarin therapy, stopping LMWH be discharged home two days later,济撕汝屹造苔汹练厄讳吗饵微谩仙仕襄愉里羊套抢匹铣齿捂别吞搞淖获型读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,Summary,Prosthetic Valve Thrombosis Anticoagulation therapy Warfarin Embryopathy Post-Partum Haemorrhage Placement of an intrauterine balloon surgically available Uterine Artery Embolisation better choice for PPH,Correspondence Email：,寻抄僧栽显降冯喘腑佬栽原见了瘸躲咙相唯童屿概钾宝果波绦鸭果堰烫召读书报告机械瓣膜置换术后孕产妇的处理读书报告机械瓣膜置换术后孕产妇的处理,