291.4 📋 章末速記 Summary

291.4.1 🔑 一句話總結

妊娠 CV 生理 → 血量 ↑ 40-50%、CO ↑ 30-50%、SVR ↓ 20%、HR ↑ 10-20，peak stress 28-32 週 + L&D + 產後 2 週；risk stratification mWHO 1-4（4 = 禁懷孕：Eisenmenger、severe PAH、severe AS、single vent、Marfan aorta > 45 mm、EF < 30%、severe MS）；妊娠期重大 CV 疾病：preeclampsia/eclampsia（magnesium + 控壓 + delivery）、peripartum cardiomyopathy (PPCM, HF in last month-5 mo postpartum)、aortic dissection（Marfan + 3rd trimester/postpartum 高發）、SCAD（peripartum, conservative management）；用藥安全: labetalol/methyldopa/nifedipine/hydralazine/digoxin/LMWH/低劑量 ASA 安全；禁忌: ACEi/ARB/MRA/warfarin 1st trimester/DOAC/atenolol/amiodarone/statins/ETAs。

291.4.2 💊 治療精要

• HTN/preeclampsia：labetalol（IV/PO）、nifedipine ER、methyldopa、hydralazine；severe → IV labetalol + magnesium sulfate
• PPCM：標準 HF therapy 改良版（loop + carvedilol/metoprolol + hydralazine/ISDN + LMWH if EF < 35%）；bromocriptine 可選；postpartum 改 ACEi/ARB
• Mechanical valve：LMWH 1st trimester + warfarin 2nd-3rd + UFH/LMWH peripartum
• VTE / PE：LMWH × 6 wk postpartum minimum
• Arrhythmia：vagal + adenosine (SVT)、metoprolol、digoxin；避免 amiodarone

291.4.3 🎯 盧醫師的考前提醒

1. Peak hemodynamic stress = 28-32 wk + L&D + 產後 2 週（高死亡風險時段）
2. mWHO IV 絕對避孕：Eisenmenger、severe PAH、severe AS（symptomatic or not）、single vent、Marfan > 45 mm、BAV > 50 mm、EF < 30%、severe MS、prior PPCM with 不可逆 LV dysfunction
3. PPCM 特徵：late pregnancy-5 mo postpartum + LVEF < 45% + 排除其他原因；African American 4-10x ↑；bromocriptine controversial；recurrence rate 30-80%
4. preeclampsia：BP ≥ 140/90 + proteinuria/end-organ damage after 20 wk；magnesium sulfate for seizure prophylaxis；delivery 才是 definitive treatment
5. aspirin 81-150 mg/d from 12-16 wk 用於 high-risk preeclampsia 預防（ASPRE 2017）
6. mechanical valve anticoag：1st trim LMWH（warfarin embryopathy 5-25%）→ 2nd-3rd trim warfarin（如劑量 ≤ 5 mg/d 風險較低）→ 產期 UFH/LMWH
7. pregnancy SCAD：1-4% of pregnancy MI；conservative > PCI（high re-dissection rate）；avoid stress testing in recovery
8. 絕對禁忌藥：ACEi/ARB/MRA/aliskiren、warfarin 1st trimester、DOACs、atenolol（IUGR）、amiodarone、ETAs（teratogenic）、riociguat、sotatercept
9. 安全藥：labetalol（first-line HTN）、methyldopa、nifedipine ER、hydralazine、digoxin、adenosine、LMWH、low-dose ASA
10. Marfan + 主動脈 > 4.5 mm：pre-pregnancy 修補；不修補的話考慮 cesarean delivery + β-blocker continuation