291.3 🏥 內科專科考前版

291.3.1 Mechanistic Deep Dive

291.3.1.1 Hormones + CV

  • Estrogen: vasodilation, ↑ HDL, ↑ procoagulant
  • Progesterone: smooth muscle relaxation
  • Relaxin: vascular remodeling
  • hCG, hPL: metabolic
  • ANP/BNP: salt/water regulation

291.3.1.2 PPCM Pathophysiology

  • Imbalance angiogenic factors (sFlt-1 ↑)
  • 16-kDa prolactin fragment (cleaved by cathepsin D) → endothelial damage
  • Bromocriptine inhibits prolactin → may protect
  • STAT3 deficiency (mouse model)
  • Genetic predisposition (TTN, others)

291.3.1.3 Preeclampsia Pathology

  • Abnormal placentation → ischemia → release of antiangiogenic factors (sFlt-1, sEng)
  • Endothelial dysfunction throughout maternal vasculature
  • Vasoconstriction, microvascular injury
  • AKI, hepatic injury, neurologic, pulmonary edema

291.3.2 Recent Trials & Updates

291.3.2.1 Bromocriptine for PPCM (BO ARDER 2017)

  • 2.5 mg BID × 1-2 weeks
  • Improved LV recovery in some trials
  • 2024 ESC: Class IIb consideration

291.3.2.2 Aspirin for Preeclampsia (FASTER 2017, ASPRE 2017)

  • 150 mg/d at night from 12-16 wk
  • ↓ preeclampsia 60% in high-risk

291.3.2.3 Magpie Trial (2002) — Magnesium

  • Magnesium sulfate gold standard for eclampsia prophylaxis + treatment
  • Confirmed in subsequent meta-analyses

291.3.2.4 Pregnancy Following PPCM Recovery

  • Recurrence risk 30-50% if recovered EF; 80% if persistent dysfunction
  • Multidisciplinary planning, close monitoring

291.3.2.5 Sotatercept in PAH (STELLAR)

  • PAH-CHD subgroup encouraging
  • Pregnancy still contraindicated for PAH

291.3.3 High-Yield Specialist Points

291.3.3.1 Marfan in Pregnancy

  • Aortic dilation risk ↑ during pregnancy
  • Aortic root > 4.5 mm pre-pregnancy: consider repair

  • 4.0-4.5 mm: consider cesarean

  • β-blocker continuation
  • Lifelong follow-up

291.3.3.2 Mechanical Valve Pearls

  • INR target same as non-pregnant
  • Warfarin embryopathy 5-25% in 1st trimester (dose-dependent)
  • LMWH alternative — strict anti-Xa monitoring (peak 0.8-1.2 IU/mL)
  • Aspirin 75-100 mg/d may be added
  • Multidisciplinary management

291.3.3.3 Cesarean Cardiac Indications

  • Aortic root > 4.0-4.5 mm Marfan
  • Severe pulmonary HTN
  • Mechanical valve at risk
  • Severe AS
  • Active aortic dissection
  • Failed labor with hemodynamic instability

291.3.3.4 Postpartum Monitoring

  • 2 weeks + 6 weeks: highest CV risk window
  • Continue HF therapy (re-introduce ACEi/ARB after delivery)
  • Anticoagulation continuation per indication
  • Cardiology follow-up

291.3.3.5 Lactation Considerations

  • ACEi safe with lactation (enalapril, captopril)
  • ARB: less data; OK
  • β-blocker: metoprolol, labetalol safe; atenolol caution
  • Diuretics: OK
  • Statins: hold during lactation
  • Amiodarone: hold

291.3.3.6 Future Pregnancy Counseling

  • Recurrence risk: aortic dissection (50% same pregnancy), PPCM (30-80%)
  • Genetic recurrence: TOF 3-5%, BAV 6-10%, Marfan AD (50%)
  • Pre-pregnancy optimization
  • ART (assisted reproductive tech) cardiac risks

291.3.3.7 COVID-19 + Pregnancy

  • ↑ severity in pregnancy
  • ↑ thromboembolism
  • ↑ preeclampsia
  • COVID-19 vaccine recommended
  • Maternal-fetal outcomes worse with severe COVID

291.3.3.8 Cardio-Oncology + Pregnancy

  • Chemotherapy cardiotoxicity emerges over time
  • Pregnancy stresses already-damaged heart
  • Special consideration in cancer survivors

291.3.4 Pearls

  • Pregnancy physiology: blood volume + CO ↑ 30-50%, peak 28-32 wk + L&D + first 2 wk postpartum
  • mWHO IV (pregnancy contraindicated): Eisenmenger, severe PAH, severe AS, single vent, Marfan > 45 mm, EF < 30%, severe MS
  • PPCM: HF late preg-5 mo postpartum; bromocriptine controversial; recurrence high
  • Preeclampsia: BP + proteinuria after 20 wk; magnesium for seizure prophylaxis; delivery is definitive
  • Aspirin 81-150 mg from 12-16 wk in high-risk for preeclampsia prevention
  • Mechanical valve: LMWH 1st trimester, warfarin 2nd-3rd, UFH/LMWH peripartum
  • SCAD in pregnancy: conservative management, do NOT PCI routinely
  • Avoid: ACEi/ARB/MRA, warfarin 1st trimester, DOACs, atenolol, amiodarone, statins, ETAs