XU TRI BENH VAN TIM o PHU NU CO THAI

XỬ TRÍ BỆNH VAN TIM
Ở PHỤ NỮ CÓ THAI
PGS.TS. PHẠM MẠNH HÙNG
Tổng thư ký - Hội Tim Mạch Học Việt Nam


Trường hợp lâm sàng 1

BN nữ 27 tuổi, không biết bị bệnh tim
BN đang mang thai tuần 20

Khó thở  vào viện phát hiện HHL khít,
Câu hỏi:

Xử trí thế nào? Biện pháp gì?


Trường hợp lâm sàng 2
BN nữ 32 tuổi

Van nhân tạo cơ học
Hoạt động tốt

Mong muốn mang thai?
Câu hỏi:

Có được không?
Thuốc chống đông thế nào?


Tỷ lệ tử vong liên quan thai nghén đã được cải

thiện đáng kể (1)
Maternal mortality ratio
(per 100 000 live births)
1990

2003

2013

Number of maternal deaths
1990

2003

2013

Annualised rate of change in
maternal mortality ratio (%)
1990–2003

2003–13

1990–2013

Worldwide

283·2
(258·6 to
306·9)

273·4
(251·1 to
296·6)

209·1
(186·3 to
233·9)

376 034
361 706
292 982
(343 483 to (332 230 to (261 017 to
407 574)
392 393)
327 792)

−0·3%
(−1·1 to
0·6)

−2·7%
(−3·9 to
−1·5)

−1·3%
(−1·9 to
−0·8)

Developed
countries

24·5 (23·0
to 26·1)

16·0 (14·9
to 17·0)

12·1
(10·4 to
13·7)

3827 (3596 2341 (2178 1811 (1560
to 4076)
to 2490)
to 2053)

−3·3%
(−3·8 to
−2·8)

−2·9%
(−4·2 to
−1·5)

−3·1%
(−3·7 to
−2·5)

Southern subSaharan Africa

150·8
(115·9 to
182·6)

490·4
(367·8 to
626·1)

279·8
(202·6 to
381·5)

2455 (1886 8406 (6305 4898 (3547 9·1% (6·5
to 11·8)
to 2973) to 10 733)
to 6679)

−5·6%
(−8·1 to
−3·0)

2·7% (1·2
to 4·4)

South Africa

134·0
(93·3 to
175·2)

341·8
(227·8 to
481·0)

174·1
(96·3 to
274·9)

1403 (977 3739 (2492 1925 (1065 7·2% (3·3
to 11·1)
to 1835)
to 5262)
to 3041)

−6·9%
(−11·1 to
−2·7)

1·0%
(−1·6 to
3·8)

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, …Sliwa K…, Lozano R, et al. Global, regional, and national levels and
causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.
Lancet. 2014
201


Tỷ lệ tử vong liên quan thai nghén đã được cải
thiện đáng kể (2)

Cause of death

Southern
subSaharan
Africa
Tropical
Latin
America

Western
Europe

Timing of death

Abort

Haem

HPT

Obs
Lab

Sepsis

Other
direct

Indir*

HIV

AnteP

IntraP

Post-P

Late

718
(488–
1026)

517
(360–
714)

624
(428–
868)

298
(197–
437)

627
(430–
914)

463
(313–
662)

657
(435–
942)

381
(217–
563)

1059
(660–
1542)

1014
(571–
1662)

2221
(1471–
3256)

604
(376–
914)

225
(171–

287)

196
(147–
253)

341
(259–
435)

69 (51
–92)

249
(192–
317)

279
(214–
356)

332
(253–
426)

1
(1–2)

295
(191–

418)

544
(349–
776)

858 (6
23
–1158)

272
(178–
378)

55 (45
–62)

35 (29
–41)

34 (28
–39)

23 (19
–27)

24 (20
–29)

60 (50

–68)

34 (28
–40)

0
(0–0)

65 (52
–78)

89 (74
–104)

112
(92–
132)

23 (18
–28)

Abort = abortion; Haem = Haemorrhage; HPT = hypertension; Obs Lab = obstructed labour; Sep = Sepsis; Indir = Indirect; Anti-P =
Antipartum; Intra-P = Intrapartum; Post-P = postpartum

* Indirect causes include: Rheumatic heart disease, cardiomyopathy, congenital heart disease
Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, …Sliwa K…, Lozano R, et al. Global, regional, and national levels and
causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.
Lancet. 2014

Tiếp cận bệnh nhân bị bệnh van tim có thai

Ảnh hưởng
đến thai?

Trước có thai
(bệnh van tim)

Thai giai đoạn sớm

Thai giai đoạn sau

Sau khi sinh


Thay đổi sinh lý ở phụ nữ có thai

 Thay

đổi sinh lý tuần hoàn ở phụ nữ có thai bình
thường cũng rất đáng kể:
Tăng

Thể tích tuần hoàn - V

Tăng

Tần số tim - f

Tăng

Chỉ số tim - SV (tăng 40-50%)

Tăng

Cung lượng tim - CO (tăng 30-50%)

2


Thay đổi sinh lý ở phụ nữ có thai
Pre-preg

rd

BloodVol(L)

4.2

PlasmaVol(L)

Labour

Post-delivery

48%

NC

10-20%

2.4

40-50%

NC

10%byD5

CO(L/min)

4.9

27-50%

11%

Pre-labour1hr
Pre-preg10-14d

SV(ml/beat)

65

21-30%

11%

Pre-labour1hr
pre-preg3-12m

HR(beats/min)

75

16-30%

20%

Pre-labour1hr
Pre-preg6-12weeks

20%

NC

Pre-preg3-12m

SVR
(Dyn/sec/cm)

800-1200

3trimester

PVR

220

25%

ND

ND

CVPmmHG

2-6

NC

ND

ND


Thay đổi huyết động ở bệnh nhân HHL
có thai
•

•

The circulatory changes
represent an additional
burden on the
cardiovascular system of
women with rheumatic
mitral stenosis (MS) ->
pulmonary oedema
Mortality(*):

• < 1%: NYHA 1-2
• 15 – 30%: NYHA 34

(*)Barbosa P, Lopes A, Feotpsa G, et al. Prognostic factors of rheumatic mitral stenosis during
pregnancy and puerperium. Arq Bras Cardiol 2000;75:220-24.


PHÂN TẦNG NGUY CƠ


PHÂN TẦNG NGUY CƠ CHO MẸ VÀ THAI NHI

n engl j med 349;www.nejm.org july 3, 2003


Phân tầng nguy cơ theo vị trí và mức độ tổn
thương van (1)

European Heart Journal Advance Access published March 2, 2015


Phân tầng nguy cơ theo vị trí và mức độ tổn
thương van (2)

European Heart Journal Advance Access published March 2, 2015


Quyết định điều trị dựa trên Phân tầng nguy
cơ theo vị trí và mức độ tổn thương van (1)

European Heart Journal Advance Access published March 2, 2015


Quyết định điều trị dựa trên Phân tầng nguy
cơ theo vị trí và mức độ tổn thương van (2)

European Heart Journal Advance Access published March 2, 2015


Nguy cơ tử vong cho mẹ và con
khi phải phẫu thuật

Weiss BM, etal. Am J Obstet Gynecol.1998;179:1643–53


Các thuốc điều trị khi phụ nữ có thai bị
bệnh van tim (AHA/ACC 2014)
Recommendations
Anticoagulation should be given to pregnant
patients with MS and AF unless contraindicated
Use of beta blockers as required for rate control
is reasonable for pregnant patients with MS in
the absence of contraindication if tolerated

COR

LOE

I

C

IIa

C

Use of diuretics may be reasonable for
pregnant patients with MS and HF symptoms
IIb
(stage D)
ACE inhibitors and ARBs should not be given to
III:
pregnant patients with valve stenosis
Harm

C
B


Can thiệp trước khi mang thai
Recommendations
COR
Valve intervention is recommended before
pregnancy for symptomatic patients with severe
I
AS (aortic velocity ≥4.0 m per second or mean
pressure gradient ≥40 mm Hg, stage D)
Valve intervention is recommended before
pregnancy for symptomatic patients with severe
I

MS (mitral valve area ≤1.5 cm2, stage D)
Percutaneous mitral balloon commissurotomy is
recommended before pregnancy for asymptomatic
patients with severe MS (mitral valve area ≤1.5
I
2
cm , stage C) who have valve morphology
favorable for percutaneous mitral balloon
commissurotomy

LOE
C

C

C


Không chỉ định phẫu thuật ở bệnh nhân
có thai bị bệnh hẹp van tim mà chưa có
triệu chứng suy tim nặng
Recommendations
Valve operation should not be performed in
pregnant patients with valve stenosis in the
absence of severe HF symptoms

COR

LOE

III: Harm

C


Anticoagulation of Pregnant Patients With Mechanical Valves


Chống đông ở BN có thai mang van
nhân tạo (1)
Recommendations
Therapeutic anticoagulation with frequent
monitoring is recommended for all pregnant
patients with a mechanical prosthesis
Warfarin is recommended in pregnant patients
with a mechanical prosthesis to achieve a
therapeutic INR in the second and third trimesters
Discontinuation of warfarin with initiation of
intravenous UFH (with an activated partial
thromboplastin time [aPTT] >2 times control) is
recommended before planned vaginal delivery in
pregnant patients with a mechanical prosthesis

COR

LOE

I

B

I

B

I

C


Chống đông ở BN có thai mang van
nhân tạo (2)
Recommendations
Low-dose aspirin (75 mg to 100 mg) once per day
is recommended for pregnant patients in the
second and third trimesters with either a
mechanical prosthesis or bioprosthesis
Continuation of warfarin during the first trimester is
reasonable for pregnant patients with a mechanical
prosthesis if the dose of warfarin to achieve a
therapeutic INR is 5 mg per day or less after full
discussion with the patient about risks and benefits

COR LOE
I

C

IIa

B


Chống đông ở BN có thai mang van
nhân tạo (3)
Recommendations
COR LOE
Dose-adjusted LMWH at least 2 times per day (with a
target anti-Xa level of 0.8 U/mL to 1.2 U/mL, 4 to 6
hours postdose) during the first trimester is reasonable
IIa
B
for pregnant patients with a mechanical prosthesis if
the dose of warfarin is greater than 5 mg per day to
achieve a therapeutic INR
Dose-adjusted continuous intravenous UFH (with an
aPTT at least 2 times control) during the first trimester
is reasonable for pregnant patients with a mechanical
IIa
B
prosthesis if the dose of warfarin is greater than 5 mg
per day to achieve a therapeutic INR


Chống đông ở BN có thai mang van
nhân tạo (4)
Recommendations
COR LOE
Dose-adjusted LMWH at least 2 times per day (with
a target anti-Xa level of 0.8 U/mL to 1.2 U/mL, 4 to 6

hours postdose) during the first trimester may be
IIb
B
reasonable for pregnant patients with a mechanical
prosthesis if the dose of warfarin is 5 mg per day or
less to achieve a therapeutic INR
Dose-adjusted continuous infusion of UFH (with
aPTT at least 2 times control) during the first
trimester may be reasonable for pregnant patients
IIb
B
with a mechanical prosthesis if the dose of warfarin
is 5 mg per day or less to achieve a therapeutic INR


Chống đông ở BN có thai mang van
nhân tạo (5)
Recommendations
LMWH should not be administered to pregnant
patients with mechanical prostheses unless antiXa levels are monitored 4 to 6 hours after
administration

COR

LOE

III:
Harm

B