Transcript Cardiac Diseases in Pregnancy

Scenario:

Hx.:
A 30-year-old multigravida at the 20 weeks’ gestation.
 Has a mild SOB with activity.
 She has no symptoms at rest.
 Had a childhood history of rheumatic fever.


P/E:


Diastolic murmur.
Investigations:

Echocardiography:
Mitral stenosis.
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Signs & Symptoms of Cardiac Diseases.
Special Types of Cardiac diseases
Management and Counseling.
Contraception in Cardiac Diseases.
Normal Hemodynamic Changes in Pregnancy:

Plasma volume

Cardiac Output

Heart rate

Left Ventricular Work index
Normal Hemodynamic Changes in Pregnancy:



Systemic Vascular
Resistance SVR
Pulmonary Vascular
Resistance PVR
BP
Normal Hemodynamic Changes in Pregnancy:

Murmur!!??
A systolic ejection murmur along the left sternal border is
normal in pregnancy owing to increased COP.
“Hyperdynamic Circulation”
Diastolic murmurs are never normal in pregnancy and must
be investigated.
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Special Types of Cardiac diseases
Signs & Symptoms of Cardiac Diseases.
Management and Counseling.
Contraception in Cardiac Diseases.
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Special Types of Cardiac diseases
Signs & Symptoms of Cardiac Diseases.
Management and Counseling.
Contraception in Cardiac Diseases.
Classification of Cardiac Diseases:
Structural Classification:
Heart
Diseases
Congenital
Acquired
Structural Classification:
Heart Diseases
Congenital
Non-Cyanotic
ASD
VSD
Cyanotic
Tetralogy of
Fallot
Acquired
Eisenmenger’s
Syndrome
Marfan’s
Syndrome
Structural Classification:
Heart Diseases
Congenital
Rheumatic
Mitral Stenosis
Acquired
Coronary Heart
Diseases
Rare during child
-bearing ages
Cardiomyopathy
Arrhythmia
Classification of Cardiac Diseases:
New York Heart Association
Classification NYHA:
ClassI
Class II
Class III
Class IV
• No limitation with physical activities.
• Mild limitation with physical activities.
• Marked limitation with physical activities.
• Limitation at rest.
New York Heart Association
Classification NYHA:
Class I and Class II are low risk patients. They have a good
prognosis and do not need invasive monitoring in labour.
Class III and Class IV are High risk patients. They have a poor
prognosis need invasive monitoring in labour.
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Signs & Symptoms of Heart Diseases
Special Cardiac Diseases.
Management and Counseling.
Contraception in Cardiac Diseases.
Signs & Symptoms of Heart Diseases:

Symptoms:
 Severe
progressive dyspnea.
 Orthopnea.
 Paroxysmal Nocturnal Dyspnea PND.
 Hemoptysis.
 Chest pain.
 Syncope.
Signs & Symptoms of Heart Diseases:

Signs:
systolic murmur  3/6 “ with palpable thrill”.
 Diastolic murmur.
 Parasternal heave. “ cardiomegaly “.
 Cyanosis & clubbing.
 Signs of pulmonary HTN.
 Persistent jugular venous distension.
 Severe
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Signs & Symptoms of Heart Diseases
Special Cardiac Diseases.
Management and Counseling.
Contraception in Cardiac Diseases.
Rules:
Valvular Stenosis are NOT well-tolerated in
pregnancy…
Valvular insufficiency as well as ASD & VSD are
well-tolerated in pregnancy…
Rheumatic Heart Diseases
Rheumatic Heart Diseases:

They are the most common etiology.

Mitral Stenosis:



The most common acquired heart disease in pregnancy.
Dx.: Echocardiography.
Complications:



Slow diastolic follow.
Diastolic Murmur.
Left Atrial Enlargement:


Atrial fibrillation  emboli.
Subacute bacterial endocarditis SBE.
Rheumatic Heart Diseases:

Complications:

Pulmonary edema develops early.
Rheumatic Heart Diseases:

Mitral Insufficiency (Regurgitation):




Well tolerated in pregnancy…
In the past, rheumatic fever was the commonest etiology.
However, nowadays, the commonest cause is congenital mitral valve
Prolapse.
Usually, not complicated by SBE. (No need for prophylaxis).
Rheumatic Heart Diseases:

Aortic Stenosis:

If severe:



Mortality is high.
The pregnancy should be terminated.
Correction: surgical



Surgical correction is ideal to be done before pregnancy.
If it is necessary to be done during pregnancy, it is done in the 2nd trimester.
2 types:


Closed surgery: can also be done in 1st trimester.
Open: is NEVER done during pregnancy.
Congenital Heart Diseases
Congenital Heart Diseases:

Acyanotic:



VSD and ASD are the most common
congenital heart diseases.
They are well-tolerated in pregnancy.
Cyanotic:


Tetralogy of Fallot is the most common.
Should be repaired surgically.
Congenital Heart Diseases:
Congenital Heart Diseases:

Eisenmenger’s Syndrome:
Congenital Heart Diseases:

Eisenmenger’s Syndrome:

Characterized by pulmonary HTN and bidirectional shunt.

If the pulmonary pressure exceeds the systemic pressure, the shunt
reverses  Mortality is high.

During pregnancy, decrease in systemic vascular resistance SVR places
the patient at risk of mortality.

The mortality rate of Eisenmenger’s syndrome during pregnancy is about
50%
Congenital Heart Diseases:

Eisenmenger’s Syndrome:
 Management:

Avoid Hypotension….
Marfan’s Syndrome
Congenital Heart Diseases:

Marfan’s Syndrome:

An autosomal dominant CT disease.

Defect on fibrillin gene on chromosome 15.

Fibrillin is an important components in the media layer of blood vessels
wall.
Congenital Heart Diseases:

Marfan’s Syndrome:
Congenital Heart Diseases:

Marfan’s Syndrome:

If the aortic root is diameter is  40mm, the maternal mortality rate is
high (about 50%).
Peripartum Cardiomyopathy
Peripartum Cardiomyopathy:
Peripartum Cardiomyopathy:


Occurs in last few weeks of pregnancy and first few months post
partum.
Enlargement and weakness of ventricles:
 Biventricular Failure

Idiopathic.

Occurs more in multipara.

Maternal mortality is high 75%.

High risk for recurrence.
Maternal Mortality Risk:

Low Maternal Mortality:  1%
 VSD,
ASD, PDA
 Minimal Mitral Stenosis.
 Corrected Tetralogy of Fallot.
 Porcine Heart Valve.
Maternal Mortality Risk:

Intermediate Maternal Mortality: 5-15%
 Mitral
stenosis with atrial fibrillation.
 Uncorrected Tetralogy of Fallot.
 Marfan’s syndrome (aortic root  40mm).
 Artificial (Metalic) heart valve.
Maternal Mortality Risk:

High Maternal Mortality: 25-50%
 Pulmonary
HTN.
 Eisenmenger’s syndrome.
 Marfan’s syndrome (aortic root 40mm).
 Aoric Coarctation.
 Peripartum cardiomyopathy.
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Signs & Symptoms of Heart Diseases
Special Cardiac Diseases.
Management and Counseling.
Contraception in Cardiac Diseases.
Management:
Remember….
- Two major issues should be considered during management:
Intravascular
volume
Tachycardia
-They are normal physiologic changes of pregnancy.
-But, they increase stress on diseased heart.
Management:
Remember….
so, management always seeks:
Control
Intravascular
volume
-The aim of management is to:
- Control the vascular volume
-Control tachycardia.
Control
Tachycardia
Management:
Antepartum Management:
Control intravascular volume:
Low salt intake.
 Diuretics if needed.

Control tachycardia:
Avoid strenuous activities.
 Control anemia.
 Digitalis or -blockers if indicated.

Feta echocardiogram:

Done after the 20th week of gestation if the mother has congenital
heart diseases.
Intrapartum Management:
Intrapartum Management:
Control intravascular volume:
During labour, bleeding is going on  prevent hypotension.
 Monitor intravenous fluid volume.
 Use areterial line and pulmonary artery catheter, specially with
classes NYHA III and IV.

Control tachycardia:
Provide reassurance.
** (not anesthesia) to control pain.
 Use sedatives and epidural analgesia
 Avoid second stage pushing (bearing down).
 Forceps to shorten the 2nd stage.

** Epidural anesthesia are not used because they cause peripheral pooling of blood.
Intrapartum Management:
Antibiotics prophylaxis:
For subacute bacterial endocarditis SBE.
 Indications:

Vaginal delivery (specially with previous SBE).
 Prosthetic heart valve.
 Complex congenital heat diseases.


They are NOT recommended for any C/S delivery.

Recommended agents:
Ampicillin (2g) IV + Gentamicin (250)mg IV or vancomycin (1g) IV.
Management:
Intrapartum Management:
Control intravascular volume:
Monitor closely for postpartum intravascular volume overload.
 After placental delivery, sudden  intravascular volume.

   Uterine contraction
Sudden emptying of uterine
venous sinuses
postpartum intravascular
overload
Counseling….
NYHA I & NYHA II classes can get pregnant and continue without
any major complications.
NYHA III, NYHA IV and high risk groups are advised not to get
pregnant.
Counseling….
Left lateral rest
is helpful to prevent
hemodynamic fluctuation
during pregnancy as well
as during labour.
Counseling….
-Avoid supine position.
-Gravid uterus compresses inferior vena cava  syncope.
-This condition is called:
Supine Hypotension Syndrome..
Counseling….
Minimize the use of diagnostic studies with radiation
Reduce unnecessary cardiac work by ensuring regular rest and
avoid excess exertion.
Provide prophylaxis against SBE
Counseling….
A patient receiving anticoagulants containing warfarin should
shift to heparin
-N.B:
-Metalic Valve:
-A patient with metallic valve , subcutaneous heparin is NOT
effective.
-Warfarin is better.
-If the patient is pregnant, she should receive IV heparin in
therapeutic range frequently through the pregnancy.
-In the last trimester, shift heparin to warfarin.
Outlines:
Review Hemodynamic Changes During Pregnancy
Classification of Cardiac Diseases.
Signs & Symptoms of Heart Diseases
Special Cardiac Diseases.
Management and Counseling.
Contraception in Cardiac Diseases.
Contraception:


OCP are not ideal as they increase thromboembolic activity.
IUCD can cause infection-  endocarditis.



Barrier contraceptives – Have high failure rates.
Progestin only is better:


It can be used but with SBE prophylaxis.
pills or Long acting injectable progesterone.
Irreversible methods of contraception:

Are the best specially those with high risk, but usually is not
acceptable by patients.
DISCUSSION….
Problem:
Patient Snapshot I:
She has unrepaired VSD. Her
perinatal course is uncomplicated.
She had worked throughout the
pregnancy without any limitation.
What is the appropriate intervention?
a. No need for invasive monitoring.
b. She should have IV fluid infusion with close
monitoring of hydration status.
c. Consider emergency C/S with invasive monitor.
d. Give her tocolytic agents and ask her to come
after 1 week.
Problem:
Patient Snapshot II:
She has unrepaired Tetralogy of
Fallot. Prenatally she had severe
dyspnea with activity and has to be
hospitalized at ICU. She now has
bilateral basal crackle.
What is the appropriate intervention?
a. She is NYHA class III, needs induction of labour
with invasive monitoring at cardiac ICU.
b. Give her bronchodilator and O2 and discharge
her and ask her to take rest at left lateral
position.
c. She can continues labour without any
complication so no intervention is needed.
d. Order serum BNP to confirm cardiac limitation.
Problem:
Patient Snapshot III:
She has Eisenmenger’s syndrome. She
is having bright red vaginal bleeding
and locaalized uterine tenderness.
Her heart rate is 145pbm with BP of
90/60mmHg.
What is the appropriate intervention?
a. Let her continue labour with careful monitoring
of volume status.
b. Give her diuretics and digitalis.
c. Give her analgesia, epidural anesthesia and use
forceps for delivery.
d. Consider emergency C/S since there is a
maternal distress, monitor her invasively.
Thanks…