现代心脏病学3.doc

Treatment A. DRUG TREATMENT IN PREGNANCY Treatment of the pregnant patient with cardiac disease requires the collaborative consultation of the obstetrician and cardiologist at regular intervals during gestation and careful planning for delivery with the anesthesiologist. All cardiovascular drugs during pregnancy should be avoided, if possible, especially in the first trimester. Most cardiovascular drugs cross the placenta and are secreted into the breast milk, mandating a detailed evaluation of risk-to-benefit ratio (Table 31–7). Table 31–7. Alphabetical list of the commonly used cardiovascular medications, their potential side effects, and overall safety. 1. Heart failure—Treatment of heart failure is more challenging in pregnant patients than in nonpregnant women. Salt restriction and activity limitation are extremely important. In patients with pulmonary congestion, medical therapy should begin with digoxin. Although digoxin has been safely used during pregnancy for many years, blood levels should be monitored to avoid toxicity. Diuretics, although not teratogenic may cause impaired uterine blood flow and placental perfusion, and hence should only be used in severely symptomatic patients. Thiazide diuretics have been associated with neonatal thrombocytopenia, jaundice, hyponatremia, and bradycardia. Afterload is already reduced during pregnancy, hence further reduction in afterload may only be beneficial in selected cases. Hydralazine, the most frequently used afterload-reducing agent during pregnancy, is a direct arteriolar dilator and has not been associated with adverse fetal effects. ACE inhibitors are contraindicated in pregnancy due to their associated increased risk of premature delivery, low birth weight, fetal hypotension, renal failure, bony malformations, persistent patent ductus arteriosus, respiratory distress syndrome, and even death. Angiotensin II receptor blockers have similar adverse reactions and are thus rendered unsafe. Data on nitrates are