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CardiacDiseaseinPregnancy
HuixiaYang
CardiacDiseaseinPregnancyMaternaldeathinChina(2010)Maternaldeathin21stcentury(USA)MaternaldeathinChina(2010Cardiacdiseasewithpregnancyisseriouscomplicationinobstetrics,alsothemajorcauseleadingtomaternaldeathIncidence：1%~4%Includepreexistingdiseaseaswellasconditionsthatdevelopduringpregnancyorinthepostpartumperiod
CardiacdiseasewithpregnancyThepatternofcardiacdiseaseinpregnancyhaschangedgreatlyinrecentdecades：Congenitalheartdisease
RheumaticheartdiseaseCardiacarrhythmiasPIHinducedcardiacdiseasePeripartumcardiomyopathy.
Theshiftawayfromrheumaticheartdiseasetosurgicallycorrectedcongenitalheartdisease!!Thepatternofcardiacdisease先心种类非紫绀型左向右分流
右心腔和肺循环血流明显增加
房室间隔缺损、动脉导管未闭紫绀型
右向左分流，动脉血氧饱和度法四、艾森曼格氏综合征先心种类非紫绀型无分流型先心肺动脉瓣口狭窄主动脉狭窄Marfan综合症（动脉瘤）三尖瓣下移畸形（Ebstein）无分流型先心Atpresent,congenitalheartdiseaseismorethanrheumaticdisaese.Peripartumcardiomyopathy--Rarebutwithhighermaternalmortality(25~50%)Atpresent,congenitalheartNormalphysicologicchangesCardiacreserveisreducedinpregnancyPlasmavolume：Beginninginearlypregnancy6~8weeks，Asteadyriseininplasmavolumewithaplateauatapproximately32~34GWs(singletonpregnancyatterm30~45%)NormalphysicologicchangesCarChangesintotalbloodvolumeChangesintotalbloodvolume
Cardiacoutput(CO)
COstartstoincreasefrom10~20weeksandreachesaplateaunear32~34weeksatlevels30%~50%abovenon-pregnantvalues
Cardiacoutput(CO)CardiacOutputindifferentpositionCardiacOutputindifferentp
O2consumptionincreasedColloidoncoticpressure,COP
(Bothplasmaandinterstitial)
CardiacSystemchangeduringpregnancy
HR:heartrate;MAP:meanarterialpressure;SVR:systemicvascularresistance;BV:bloodvolume
CardiacSystemchangeduriChangeincardiacoutlineChangeincardiacoutlineEffectsofPregnancyuponCardiacDiseaseHeartFailure:32~34weeks’gestation
Labor&DeliveryandPostpartumperiod
SignificantfluidshiftsoccurandcanleadtocongestiveheartfailureinthecardiacpatientAnemia、infection、hypertension&arrhythmiasmayaggravateheartdiseaseEffectsofPregnancyuponCardEffectsofcardiacdiseaseonfetusFetaldistress、FetalGrowthRestriction(FGR）andpretermlaborThefetusisatincreasedriskofdevelopingcongenitalheartdiseasewhenmaternalheartdiseaseiscongenital
Theincidencerangesfrom5~10%，whenthefetusisaffected,onlyabout50%willhavethesameanomalyasthemotherEffectsofcardiacdiseaseonDiagnosisSignificanthistoryorSymptoms&SignECGEchocardiographyX-rayBloodgasanalysisifnecessary(LackofimprovementinSao2withoxygensuggestsfurtherincreasedmaternalrisk)Cardiacfailure
DiagnosisSignificanthistoryoCardiacdiseasewillalwaysbeaseriousconcern,however,inviewofthemagnitudeofchangeincardiovascularstatusinpregnancy,relatingtoinincreasedintravascularvolume.Therearecertainprinciplesinrelationtocareofcardiacdiseaseinpregnancy
CardiacdiseasewillalwaysbeManangementPre-pregnancyObstetrician&cardiologistincollaborationPreconceptualevaluationandcounselingCoexistentconditionsshouldbeappropriatelytreatedandcontrolledAnynecessarycardiacsurgeryshouldbecarriedoutpriortoconceptionManangementPre-pregnancyGroup1–Mortality<1%AtrialseptaldefectVentricularseptaldefectPatentductusarteriosusMitralstenosis-NYHAclassI&IIPulmonic/TricuspidvalvediseaseCorrectedTetralogyofFallotBioprostheticvalveGroup2–Mortality5-15%2A
2BMitralstenosis-NYHAclassIII&IV Mitralstenosiswithatrialfibrillation
Aorticstenosis
MechanicalValveCoarctationofAortawithoutvalvularinvolvement
UncorrectedTetralogyofFallot Previousmyocardialinfarction Marfansyndromewithnormalaorta
Group3-Mortality25-50%Pulmonaryhypertension(Primary,EisenmengerSyndrome)CoarctationofaortawithvalvularinvolvementSevereAorticstenosis
MarfansyndromewithaorticinvolvementPeripartumcardiomyopathywithpersistentleftventriculardysfunctionGroup1–Mortality<1%ThegreatestconcerncentersonpatientswhohavepulmonaryhypertensionsuchaswithEisenmenger’ssyndromeRiskofreversaloftherighttoleftshuntandsuddencollapse.Maternalmortality:a30%riskofmortalityinpregnancyatleast.Patientsmustbecounselledpriortoconception!!
ThegreatestconcerncentersoPrenatalcareTheevaluationandcounselingatthefirstvisitTerminationisanoptionwithafewconditionswithhighermaternalmortalityAssessfunctionalclassofheartdisease(vitalsignsandweightgain)JointmanagementwithcardiologistPrenatalcareTheevaluationan
OptimizemedicalmanagementAvoid/minimizeaggravatingfactorsAvoidheartfailure
OptimizemedicalmanageFetalsurveillanceFetalGrowth(especiallywithR
LshuntsasPO2
)NST/umbilicalarteryDoppler
(especially，ifleft-rightshunt)Detailedfetalcardiacultra-ifmaternalcongenitalheartdisease
increasedriskoffetalmalformationsifmaternalcongenitaldisease.FetalsurveillanceFetalGrowth
Labor/deliveryInformanaesthetistinadvanceofdeliveryVaginaldeliveryforthepatientswithheartfunctionclassI-IIElectiveinductionmaybenecessaryformaternaland/orfetalindicationsProphylacticantibioticsasappropriateAvoidmentalandphysicalstress(epidural)Labor/deliveryInformanaestheLabor/deliveryLaborinleftlateraloruprightpositionMonitorelectrocardiogramAdministerextraoxygenContinuousfetalheartratemonitoringOperativevaginaldeliverytoshortenthesecondstageAvoidergometrine/ivpitocineforthirdstageLabor/deliveryLaborinleftla
CesareandeliveryHeartfunctionClassIII~IVPulmonaryhypertensionCyanoticheartdiseaseCesareandeliveryHeartfunc
PostnatalVigilanceforcardiacfailureintheimmediatepostpartumperiod(
circulatoryvolumefollowinguterinecontraction)AvoidfluidoverloadContinuedhigh-dependencycareAvoidbreastfeedingforheartfailureDiscusseffective/safecontraceptionPostnatalVigilanceforcardiCongenitalCardiacLesionswithHighestRisk:Mortality25-50%
Eisenmenger’sSyndromeSevereleftoutflowobstructionAorticstenosisMarfan’ssyndromewithaorticrootinvolvementCongenitalCardiacLesionswitCARPregStudy
(Circulation2001–Siu,etal)Firstprospectivestudytoestablishapredictivescore562consecutivepatientswithheartdiseaseinpregnancyIncludedpatientswithacquired,congenital……Overallrateofcardiacevent(PulmonaryEdema,Arrhythmia,Stroke,Death)=13%FetalMortalityRate=2%PretermDeliveryrate=10%Hypertensioninpregnancy=4%(increasedwithcoarctation)MayoverestimateriskCARPregStudy
(Circulation2004PredictorsofaCardiacEvent
(definedas:Pulm.Edema,Arrhythmia,Stroke,orDeath)N
-NYHA>IIO
-ObstructionLeftHeart(MV<2cm;AV<1.5cm;LVOTGrad>30peak)P
-Priorcardiaceventbeforepreg.(Failure,Arrhyth.,TIAorStroke)E
-EF< 40%Adaptedfrom:Siu,Circulation2001.NumberofriskfactorsRiskofadverseevent05%127%2ormore75%Mostcommonadverseevents:pulmonaryedemaarrhythmias4PredictorsofaCardiacEvenEisenmenger’sSyndromeIntra-cardiacconnectionsallowmixingofoxygenated(leftside)andlessoxygenated(rightside)bloodOnly10%ofASD’sleadtoESBUT50%ofVSD’sleadtoESSecondarypulmonaryhypertensionfromchronicleft-to-right(systemic-to-pulmonary)shuntingIfpulmonarypressure>systemicpressure,flowacrosstheshuntreversestoright-to-leftDecreasedpulmonaryperfusion,hypoxemiaandworseningpulmonaryhypertensionEisenmenger’sSyndromeIntra-caEisenmengerSyndromeIntracardiacshunt+pulmonaryvasculardisease+cyanosis(reversalofshunt)Reproducedwithpermissionfrom:Brickneretal.NEJM2000EisenmengerSyndromeIntracardiEisenmenger’sSyndromeDeathusuallyinthefirstweekpostpartumMostcommoncausesofdeath:worseningandintractablehypoxemiavolumedepletionpreeclampsiathromboembolism–consideranticoagulationpulmonaryarteryrupture19%riskofmortalitywithsurgeryEisenmenger’sSyndromeDeathusEisenmenger’sSyndromeAvoidsAvoidhypotensiondecreaseinSVRcausesincreasedright-to-leftshunting,severehypoxemiaandworseningpulmonaryhypertensionAvoidheavybloodloss+volumedepletionAvoidincreaseinpulmonaryvascularresistancehypoxemia,hypercarbia,metabolicacidosis,excesscatecholamines,highaltitudeAvoidirondeficiencyandanemiaAvoidexerciseEisenmenger’sSyndromeAvoidsAAorticStenosisFixedcardiacoutputstateMilddisease:valvearea>2cm2
peakgradient<36mmHgSeveredisease:valvearea<1cm2peakgradient>75mmHgMeangradient>35mmHgejectionfractionlessthan55%AorticStenosisFixedcardiacoAorticStenosis:ComplicationsObstructedFlowHighpressurepulmonaryedema–“SOB”Underperfusion/lowcardiacoutputAngina:duetodecreasedcoronaryperfusionSyncope:duetopoorcerebralperfusionSuddendeath:duetoarrhythmiasAorticStenosis:ComplicationsAorticStenosis:AvoidsAvoidhypotension:coronaryperfusionandanginaAvoidhypovolemiaanddecreasedLVFilling:bloodloss,aorto-cavalsyndrome,dehydrationAvoiddecreasedSVR:drugs,valsalvaAvoidbradycardiaandtachycardiaAvoidhypervolemia:mayleadtopulmonaryedemaAorticStenosis:AvoidsAvoidhSomeMx“specifics”forSevereASConsiderplacingaPAcatheterpriortolabor:
Maxgradient>50mmHg,meangradient>35mmHgMaintain“preloadedge”
PCWP~16-18mmHgArteriallineforABGandclosemonitoringofBPOxygen,FowlerspositionDelivery:Assist
2ndstage,modifiedlithotomy
(kneesdown)SomeMx“specifics”forSevereMarfan’sSyndromeandTheAortaAneurysmaldilationanddissectionofaortaaccountforthemajorityofthemorbidityandmortalityRuptureriskinpregnancyincreaseswithdilationnormalaorticdimension:rupturerisk<1%aorticrootdiameter>4cm:rupturerisk~10%Aorticrootdiameter>4.5cmisanindicationforpreconceptionrepairifpatientdesirespregnancyTheriskfordissectionisdecreasedbutnoteliminatedfollowingsurgicalcorrection50%willrequirerepairofaneurysminanotherlocationSerialevaluationofaorticrootisrecommendedevenifinitialdiameterisnormalMarfan’sSyndromeandTheAortMarfan’sSyndrome–MxAvoidhypertensionAvoidtachycardiaGoalHR<70bpmatrest(metoprolol)AvoidvalsalvaAssistedsecondstage,painmanagementwithepidural
Cesareanmaybenefitpatientswithaorticrootdiameter>4cm,aorticrootdissectionorheartfailureMarfan’sSyndrome–MxAvoidhypHypertensiveCardiomyopathy
Desaietal.BrJObstetGynaecol1996;103:523-8(LevelIII)Pulmonaryedemaandseverehypertensioninpreeclampsia:25%(4/16)hadimpairedsystolicfunction(?PPCM)75%(12/16)hadimpaireddiastolicfunctionDiastolicdysfunction:increasedLVEDPisanimportantcauseoffulminant(flash)pulmonaryedema,CCF,andsuddendeath:
Morecommoninchronichypertensionandsuperimposedpreeclampsia(Mabieetal)Older,diabetic,obeseHypertensiveCardiomyopathy
DePeripartumversusHypertensiveCardiomyopathyBewarelabelingthepatientwithpreeclampsiaanddiastolicdysfunctionasperipartumcardiomyopathy(systolicdysfunction)Suggestion:Getanecho,BNP(markedlyelevatedinPPCM)andworkwithacardiologistPPCM:左室扩张伴中重度左室收缩功能下降PeripartumversusHypertensiveperipartumcardiomyopathyperipartumcardiomyopathy
预后左室功能：左室功能恢复多于6个月内
（n=40，follow-up30±29月）6个月时，LVEF≥50%：45-78%
（n=300，publicationsinUS）预后
预后影响预后的因素：
LVEF
（n=55）NYHA分级QRSduaration
发病时间预后再次妊娠风险Elkayam：60subsequentpregnanciesin44patients28recoveryvs16LVdysfunction再次妊娠风险Elkayam：60subsequentp高危妊娠逐渐增加早识别，多学科合作，正确处理医患间及时沟通改善母儿结局，降低医疗风险48高危妊娠逐渐增加48LearingobjectivesTounderstandwhycardiacreserveisreducedinpregnancyTounderstandtheprinciplesofmanagementofcardiacdiseaseduringpregnancyLearingobjectivesTounderstan谢谢大家！WelcometojoininDepartmentofObstetricsandGynecology谢谢大家！WelcometojoininDepart
CardiacDiseaseinPregnancy
HuixiaYang
CardiacDiseaseinPregnancyMaternaldeathinChina(2010)Maternaldeathin21stcentury(USA)MaternaldeathinChina(2010Cardiacdiseasewithpregnancyisseriouscomplicationinobstetrics,alsothemajorcauseleadingtomaternaldeathIncidence：1%~4%Includepreexistingdiseaseaswellasconditionsthatdevelopduringpregnancyorinthepostpartumperiod
CardiacdiseasewithpregnancyThepatternofcardiacdiseaseinpregnancyhaschangedgreatlyinrecentdecades：Congenitalheartdisease
RheumaticheartdiseaseCardiacarrhythmiasPIHinducedcardiacdiseasePeripartumcardiomyopathy.
Theshiftawayfromrheumaticheartdiseasetosurgicallycorrectedcongenitalheartdisease!!Thepatternofcardiacdisease先心种类非紫绀型左向右分流
右心腔和肺循环血流明显增加
房室间隔缺损、动脉导管未闭紫绀型
右向左分流，动脉血氧饱和度法四、艾森曼格氏综合征先心种类非紫绀型无分流型先心肺动脉瓣口狭窄主动脉狭窄Marfan综合症（动脉瘤）三尖瓣下移畸形（Ebstein）无分流型先心Atpresent,congenitalheartdiseaseismorethanrheumaticdisaese.Peripartumcardiomyopathy--Rarebutwithhighermaternalmortality(25~50%)Atpresent,congenitalheartNormalphysicologicchangesCardiacreserveisreducedinpregnancyPlasmavolume：Beginninginearlypregnancy6~8weeks，Asteadyriseininplasmavolumewithaplateauatapproximately32~34GWs(singletonpregnancyatterm30~45%)NormalphysicologicchangesCarChangesintotalbloodvolumeChangesintotalbloodvolume
Cardiacoutput(CO)
COstartstoincreasefrom10~20weeksandreachesaplateaunear32~34weeksatlevels30%~50%abovenon-pregnantvalues
Cardiacoutput(CO)CardiacOutputindifferentpositionCardiacOutputindifferentp
O2consumptionincreasedColloidoncoticpressure,COP
(Bothplasmaandinterstitial)
CardiacSystemchangeduringpregnancy
HR:heartrate;MAP:meanarterialpressure;SVR:systemicvascularresistance;BV:bloodvolume
CardiacSystemchangeduriChangeincardiacoutlineChangeincardiacoutlineEffectsofPregnancyuponCardiacDiseaseHeartFailure:32~34weeks’gestation
Labor&DeliveryandPostpartumperiod
SignificantfluidshiftsoccurandcanleadtocongestiveheartfailureinthecardiacpatientAnemia、infection、hypertension&arrhythmiasmayaggravateheartdiseaseEffectsofPregnancyuponCardEffectsofcardiacdiseaseonfetusFetaldistress、FetalGrowthRestriction(FGR）andpretermlaborThefetusisatincreasedriskofdevelopingcongenitalheartdiseasewhenmaternalheartdiseaseiscongenital
Theincidencerangesfrom5~10%，whenthefetusisaffected,onlyabout50%willhavethesameanomalyasthemotherEffectsofcardiacdiseaseonDiagnosisSignificanthistoryorSymptoms&SignECGEchocardiographyX-rayBloodgasanalysisifnecessary(LackofimprovementinSao2withoxygensuggestsfurtherincreasedmaternalrisk)Cardiacfailure
DiagnosisSignificanthistoryoCardiacdiseasewillalwaysbeaseriousconcern,however,inviewofthemagnitudeofchangeincardiovascularstatusinpregnancy,relatingtoinincreasedintravascularvolume.Therearecertainprinciplesinrelationtocareofcardiacdiseaseinpregnancy
CardiacdiseasewillalwaysbeManangementPre-pregnancyObstetrician&cardiologistincollaborationPreconceptualevaluationandcounselingCoexistentconditionsshouldbeappropriatelytreatedandcontrolledAnynecessarycardiacsurgeryshouldbecarriedoutpriortoconceptionManangementPre-pregnancyGroup1–Mortality<1%AtrialseptaldefectVentricularseptaldefectPatentductusarteriosusMitralstenosis-NYHAclassI&IIPulmonic/TricuspidvalvediseaseCorrectedTetralogyofFallotBioprostheticvalveGroup2–Mortality5-15%2A
2BMitralstenosis-NYHAclassIII&IV Mitralstenosiswithatrialfibrillation
Aorticstenosis
MechanicalValveCoarctationofAortawithoutvalvularinvolvement
UncorrectedTetralogyofFallot Previousmyocardialinfarction Marfansyndromewithnormalaorta
Group3-Mortality25-50%Pulmonaryhypertension(Primary,EisenmengerSyndrome)CoarctationofaortawithvalvularinvolvementSevereAorticstenosis
MarfansyndromewithaorticinvolvementPeripartumcardiomyopathywithpersistentleftventriculardysfunctionGroup1–Mortality<1%ThegreatestconcerncentersonpatientswhohavepulmonaryhypertensionsuchaswithEisenmenger’ssyndromeRiskofreversaloftherighttoleftshuntandsuddencollapse.Maternalmortality:a30%riskofmortalityinpregnancyatleast.Patientsmustbecounselledpriortoconception!!
ThegreatestconcerncentersoPrenatalcareTheevaluationandcounselingatthefirstvisitTerminationisanoptionwithafewconditionswithhighermaternalmortalityAssessfunctionalclassofheartdisease(vitalsignsandweightgain)JointmanagementwithcardiologistPrenatalcareTheevaluationan
OptimizemedicalmanagementAvoid/minimizeaggravatingfactorsAvoidheartfailure
OptimizemedicalmanageFetalsurveillanceFetalGrowth(especiallywithR
LshuntsasPO2
)NST/umbilicalarteryDoppler
(especially，ifleft-rightshunt)Detailedfetalcardiacultra-ifmaternalcongenitalheartdisease
increasedriskoffetalmalformationsifmaternalcongenitaldisease.FetalsurveillanceFetalGrowth
Labor/deliveryInformanaesthetistinadvanceofdeliveryVaginaldeliveryforthepatientswithheartfunctionclassI-IIElectiveinductionmaybenecessaryformaternaland/orfetalindicationsProphylacticantibioticsasappropriateAvoidmentalandphysicalstress(epidural)Labor/deliveryInformanaestheLabor/deliveryLaborinleftlateraloruprightpositionMonitorelectrocardiogramAdministerextraoxygenContinuousfetalheartratemonitoringOperativevaginaldeliverytoshortenthesecondstageAvoidergometrine/ivpitocineforthirdstageLabor/deliveryLaborinleftla
CesareandeliveryHeartfunctionClassIII~IVPulmonaryhypertensionCyanoticheartdiseaseCesareandeliveryHeartfunc
PostnatalVigilanceforcardiacfailureintheimmediatepostpartumperiod(
circulatoryvolumefollowinguterinecontraction)AvoidfluidoverloadContinuedhigh-dependencycareAvoidbreastfeedingforheartfailureDiscusseffective/safecontraceptionPostnatalVigilanceforcardiCongenitalCardiacLesionswithHighestRisk:Mortality25-50%
Eisenmenger’sSyndromeSevereleftoutflowobstructionAorticstenosisMarfan’ssyndromewithaorticrootinvolvementCongenitalCardiacLesionswitCARPregStudy
(Circulation2001–Siu,etal)Firstprospectivestudytoestablishapredictivescore562consecutivepatientswithheartdiseaseinpregnancyIncludedpatientswithacquired,congenital……Overallrateofcardiacevent(PulmonaryEdema,Arrhythmia,Stroke,Death)=13%FetalMortalityRate=2%PretermDeliveryrate=10%Hypertensioninpregnancy=4%(increasedwithcoarctation)MayoverestimateriskCARPregStudy
(Circulation2004PredictorsofaCardiacEvent
(definedas:Pulm.Edema,Arrhythmia,Stroke,orDeath)N
-NYHA>IIO
-ObstructionLeftHeart(MV<2cm;AV<1.5cm;LVOTGrad>30peak)P
-Priorcardiaceventbeforepreg.(Failure,Arrhyth.,TIAorStroke)E
-EF< 40%Adaptedfrom:Siu,Circulation2001.NumberofriskfactorsRiskofadverseevent05%127%2ormore75%Mostcommonadverseevents:pulmonaryedemaarrhythmias4PredictorsofaCardiacEvenEisenmenger’sSyndromeIntra-cardiacconnectionsallowmixingofoxygenated(leftside)andlessoxygenated(rightside)bloodOnly10%ofASD’sleadtoESBUT50%ofVSD’sleadtoESSecondarypulmonaryhypertensionfromchronicleft-to-right(systemic-to-pulmonary)shuntingIfpulmonarypressure>systemicpressure,flowacrosstheshuntreversestoright-to-leftDecreasedpulmonaryperfusion,hypoxemiaandworseningpulmonaryhypertensionEisenmenger’sSyndromeIntra-caEisenmengerSyndromeIntracardiacshunt+pulmonaryvasculardisease+cyanosis(reversalofshunt)Reproducedwithpermissionfrom:Brickneretal.NEJM2000EisenmengerSyndromeIntracardiEisenmenger’sSyndromeDeathusuallyinthefirstweekpostpartumMostcommoncausesofdeath:worseningandintractablehypoxemiavolumedepletionpreeclampsiathromboembolism–consideranticoagulationpulmonaryarteryrupture19%riskofmortalitywithsurgeryEisenmenger’sSyndromeDeathusEisenmenger’sSyndromeAvoidsAvoidhypotensiondecreaseinSVRcausesincreasedright-to-leftshunting,severehypoxemiaandworseningpulmonaryhypertensionAvoidheavybloodloss+volumedepletionAvoidincreaseinpulmonaryvascularresistancehypoxemia,hypercarbia,metabolicacidosis,excesscatecholamines,highaltitudeAvoidirondeficiencyandanemiaAvoidexerciseEisenmenger’sSyndromeAvoidsAAorticStenosisFixedcardiacoutputstateMilddisease:valvearea>2cm2
peakgradient<36mmHgSeveredisease:valvearea<1cm2peakgradient>75mmHgMeangradient>35mmHgejectionfractionlessthan55%AorticStenosisFixedcardiacoAorticStenosis:ComplicationsObstructedFlowHighpressurepulmonaryedema–“SOB”Underperfusion/lowcardiacoutputAngina:duetodecreasedcoronaryperfusionSyncope:duetopoorcerebralperfusionSuddendeath:duetoarrhythmiasAorticStenosis:ComplicationsAorticStenosis:AvoidsAvoidhypotension:coronaryperfusionandanginaAvoidhypovolemiaanddecreasedLVFilling:bloodloss,aorto-cavalsyndrome,dehydrationAvoiddecreasedSVR:drugs,valsalvaAvoidbradycardiaandtachycardiaAvoidhypervolemia:mayleadtopulmonaryedemaAorticStenosis:AvoidsAvoidhSomeMx“specifics”forSevereASConsiderplacingaPAcatheterpriortolabor:
Maxgradient>50mmHg,meangradient>35mmHgMaintain“preloadedge”
PCWP~16-18mmHgArteriallineforABGandclosemonitoringofBPOxygen,FowlerspositionDelivery:Assist
2nd
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