291.2 🩺 國考版

291.2.1 高頻考點

291.2.1.1 Physiologic Changes

  • ↑ blood volume 40-50%
  • ↑ CO 30-50%
  • ↑ HR 10-20
  • ↓ SVR 20%
  • Peak 28-32 weeks
  • L&D + immediate postpartum highest stress

291.2.1.2 mWHO Risk Class

  • I: no increase
  • II: small increase
  • II-III: moderate
  • III: significantly increased
  • IV: pregnancy contraindicated

291.2.1.3 mWHO IV Conditions (MEMORIZE)

  • Pulmonary HTN any cause
  • Eisenmenger
  • Severe systemic LV dysfunction (EF < 30%)
  • PPCM with persistent LV dysfunction
  • Severe MS (any symptoms)
  • Severe AS symptomatic or asymptomatic
  • Severe coarctation
  • Marfan with aorta > 45 mm
  • BAV with aorta > 50 mm

291.2.1.4 PPCM

  • HF developing 1 month pre to 5 months post-partum
  • 1 in 1,000-4,000 deliveries
  • African American 4-10x higher
  • Pathology: prolactin fragment, sFlt-1, angiogenic imbalance
  • Bromocriptine controversial
  • 50% recover LV; recurrence 30-50% in subsequent pregnancy

291.2.1.5 Preeclampsia / Eclampsia

  • BP ≥ 140/90 + proteinuria or end-organ damage after 20 weeks
  • HELLP variant
  • Magnesium for seizure prophylaxis
  • BP control: labetalol / nifedipine / hydralazine
  • Delivery is definitive
  • Aspirin 81 mg from 12-16 wk in high-risk pregnancies (prevention)

291.2.1.6 Safe Drugs

  • β-blocker: labetalol, metoprolol
  • Methyldopa
  • Nifedipine ER
  • Hydralazine
  • Digoxin
  • Adenosine
  • LMWH
  • Aspirin (low-dose)

291.2.1.7 Contraindicated

  • ACEi/ARB (teratogenic 2nd-3rd trimester)
  • MRA (spironolactone — anti-androgen)
  • Warfarin 1st trimester (embryopathy)
  • DOACs
  • Statins (CDC controversy; avoid)
  • Atenolol (IUGR)
  • Amiodarone
  • ETAs (bosentan, ambrisentan, macitentan)

291.2.1.8 Anticoagulation in Mechanical Valve

  • 1st trimester: LMWH (or carefully managed warfarin if low dose)
  • 2nd-3rd trimester: warfarin (if dose ≀ 5 mg/d, lower risk)
  • Around delivery: switch to UFH/LMWH
  • Lifelong follow-up

291.2.1.9 SCAD in Pregnancy

  • Pregnancy-associated SCAD: 1-4% of all pregnancy MI
  • Conservative > PCI (high re-dissection risk)
  • Avoid stress testing in recovery

291.2.2 易混淆比范

Condition Timing Key Feature Treatment
Preeclampsia > 20 wk BP + proteinuria Mg + BP control + delivery
HELLP > 20 wk Hemolysis + ↑ LFT + ↓ plt Delivery
Eclampsia > 20 wk Seizures Mg, deliver
PPCM Late preg-5 mo PP HF, ↓ EF HF therapy + delivery
SCAD Peripartum MI, dissection Conservative
Aortic dissection Any Severe pain, tear Surgery (Type A)

291.2.3 Special Topics

291.2.3.1 Aspirin for Preeclampsia Prevention

  • 81-150 mg/d from 12-16 weeks until delivery
  • High-risk groups: prior preeclampsia, CKD, autoimmune (SLE/APS), DM, chronic HTN, multiple gestation

291.2.3.2 Cardiomyopathy + Pregnancy

  • HCM: usually well-tolerated; β-blocker continues; vaginal delivery OK
  • DCM (non-PPCM): mWHO 2-3 depending on EF; risk of decompensation
  • RCM (amyloid): high mortality; avoid pregnancy