《现代心脏病学》doc版.doc

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TreatmentA. DRUG TREATMENT IN PREGNANCYTreatment of the pregnant patient with cardiac disease requires the collaborative consultation of the obstetrician and cardiologist at regular intervals during gestation and careful planning for delivery with the anesthesiologist. All cardiovascular drugs during pregnancy should be avoided, if possible, especially in the first trimester. Most cardiovascular drugs cross the placenta and are secreted into the breast milk, mandating a detailed evaluation of risk-to-benefit ratio (Table 317). Table 317. Alphabetical list of the commonly used cardiovascular medications, their potential side effects, and overall safety.1. Heart failureTreatment of heart failure is more challenging in pregnant patients than in nonpregnant women. Salt restriction and activity limitation are extremely important. In patients with pulmonary congestion, medical therapy should begin with digoxin. Although digoxin has been safely used during pregnancy for many years, blood levels should be monitored to avoid toxicity. Diuretics, although not teratogenic may cause impaired uterine blood flow and placental perfusion, and hence should only be used in severely symptomatic patients. Thiazide diuretics have been associated with neonatal thrombocytopenia, jaundice, hyponatremia, and bradycardia.Afterload is already reduced during pregnancy, hence further reduction in afterload may only be beneficial in selected cases. Hydralazine, the most frequently used afterload-reducing agent during pregnancy, is a direct arteriolar dilator and has not been associated with adverse fetal effects. ACE inhibitors are contraindicated in pregnancy due to their associated increased risk of premature delivery, low birth weight, fetal hypotension, renal failure, bony malformations, persistent patent ductus arteriosus, respiratory distress syndrome, and even death. Angiotensin II receptor blockers have similar adverse reactions and are thus rendered unsafe. Data on nitrates are limited and require further evaluation.2. ArrhythmiasDuring pregnancy any precipitating factors of arrhythmia should be avoided or corrected. In general, conservative treatment of cardiac arrhythmias is indicated. DC cardioversion is the treatment of choice in patients with hemodynamic compromise due to arrhythmia. Although no antiarrhythmic is completely safe during pregnancy, most are tolerated well and are relatively safe. Drugs with the longest record of safety should be used as first-line therapy. Digoxin, although one of the safest drugs for treating arrhythmia during gestation, may cause increased risk of prematurity and intrauterine growth retardation. Adenosine has been reported safe and successful in terminating supraventricular tachycardias during pregnancy.Quinidine, with minimal fetal risk, has the longest record of being used safely and effectively in the treatment of both atrial and VT during pregnancy. When quinidine is indicated during pregnancy, blood levels should be closely monitored because of drug interactions with warfarin may develop excessively prolonged prothrombin time, with the potential for hemorrhage. Procainamide has also been used safely and is the drug of choice in the treatment of wide-complex tachycardias.Amiodarone is associated with fetal hypothyroidism, smaller size at birth for date of gestation, and prematurity, and is also secreted in breast milk. Amiodarone is thus reserved only for treating life-threatening arrhythmias or those refractory to other medical therapy. Verapamil, although used during pregnancy, should be discontinued at the onset of labor to avoid dysfunctional labor and postpartum hemorrhage.Beta-adrenergic blocking agents are relatively safe and have frequently been used in pregnant