现代心脏病学2.docVIP

Clinical Findings A. HISTORY The evaluation of heart disease in pregnancy may become difficult due to the normal anatomic and physiologic changes of pregnancy. A careful history taking therefore becomes more important and should include a history of rheumatic fever, valvular disorder, arrhythmia, congenital heart disease, coronary risk factors or established coronary artery disease, and cardiac surgery. Reduced exercise tolerance and fatigue are the most common symptoms reported in pregnant women, probably due to increased body weight and anemia. Dizziness, light-headedness, or even syncopal episodes may occur during the latter part of pregnancy because mechanical compression of the uterus on the inferior vena cava decreases venous return, and thus the cardiac output. Palpitations are also a frequent complaint but usually are not associated with a significant arrhythmia. Dyspnea and orthopnea, probably due to hyperventilation, are also reported. B. PHYSICAL EXAMINATION The physical examination of pregnant patients with normal cardiovascular systems changes because of the increased hemodynamic burden. The evaluation of patients with suspected heart disease during pregnancy requires a thorough knowledge of the normal physiologic changes. A normal pregnant patient has a slightly fast resting heart rate, large pulse, slightly widened pulse pressure, and warm extremities. The jugular venous distention is seen from the twentieth week. Edema of the ankles and legs is commonly encountered in late pregnancy. A prominent but unsustained left ventricular impulse may be palpated in late pregnancy and may simulate the volume overload seen in aortic or mitral regurgitation. The auscultatory findings of normal pregnancy begin late in the first trimester and usually disappear 2–4 weeks after delivery. During cardiac auscultation, the first heart sound is loud and exhibits an exaggerated splitting. The second heart sound during late pregnancy is often increased and may exhibit per