Heart Disease in Pregnancy
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Transcript Heart Disease in Pregnancy
Max Brinsmead MB BS PhD
May 2015
In the UK this has increased over time
Deaths in 1982 – 85
in 2003 – 05
7.3 per million births
22.7 per million births
Due mainly to increasing maternal age
and ↑ incidence of coronary artery disease
In PNG there were 4 admissions to the
antenatal ward for heart disease in 2010
amongst 12,109 deliveries
Myocardial ischaemia/Infarction
33%
Cardiomyopathy
33%
Rheumatic heart disease
10%
Congenital heart disease
10%
In developing countries there is more rheumatic
heart disease and less coronary artery disease
Pregnancy increases the risk 3 – 4 fold
But age >40 increases the risk 30 fold
When infarction occurs 33% women will die
Associated risk factors...
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Hypertension
Pre eclampsia
Diabetes
Smoking
Obesity
Hyperlipidaema
A high index of suspicion in patients at risk
If they develop chest pain then early recourse
to...
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ECG
Serum tropinins
CT or MRI
Angiography if required
Unknown aetiology and no known risk factors
25% will be associated with hypertension
Sometimes due to viral myocarditis
Can occur any time in the antenatal period and
up to 6 months postpartum
A patient who complains of increasing
dyspnoea
Especially nocturnal orthopnoea
Investigate by...
▪ ECG
▪ CXR
▪ Echocardiography
Mitral stenosis is the most common
And most serious
But it is difficult to detect
So early referral and echocardiography is
recommended when...
Any diastolic murmur is detected
There is any history suggestive of rheumatic fever
Usually associated with systolic hypertension
So keep this controlled
Also a complication of Marfan’s Sydrome
The spider people
With dislocated lens
May be a family history
But 30% are spontaneous mutations
Risk of aortic dissection is low if the aortic root
diam is <40 mm
Survival after corrective or palliative surgery
now more common
Cyanotic CHD carries the poorest prognosis
And any degree of pulmonary hypertension is
worrying
In terms of frequency the problems are:
Left ventricular outflow obstruction ± Bicuspid aortic valve
Coarctation of the aorta
Tetralogy of Fallot
Right ventricular outflow obstruction
Ebstein’s anomaly (<1%)
Start Preconception
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Complete diagnostic work up
Multidisciplinary care
Patient education
Family Planning
Contraception
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COC’s are only relatively contraindicated for most
But Progestin-only contraception may be better
IUCD insertion may require resuscitation backup
Mirena may be better than copper IUDs
Antenatal Care
▪ Multidisciplinary care
▪ Preferably seen by same person for each visit
Cardiac evaluation at each visit
▪ Know what to ask for (based on knowledge of the patient)
▪ Know what to look for (based on what was found before)
▪ Rising pulse rate at rest may be first sign of trouble
Low threshold for admission
▪ Fetal echocardiography for those with CHD
Delivery Planning
▪ Multidisciplinary meeting at 32 – 34 w
▪ Decide on timing, place and type of delivery
▪ Labour & Delivery in ICU may be the best option
Intrapartum Care
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Multidisciplinary team
Minimise cardiovascular stress
Analgesia – best by epidural
Caesarean only for the usual obstetric indications
But this may include high risk of failed induction
Assisted delivery
2 units Syntocinon IV or low dose Syntocinon infusion the
safest option for the 3rd stage
▪ The greatest risk of CCF is immediately postpartum
Postpartum Care
▪ Consider thromboprophylaxis
Family Planning
The New York Heart Association (NYHA) Classification
Class I
▪ No symptoms and no limitation to ordinary physical
activity
Class II
▪ Mild symptoms (dyspnoea or angina) with slight limitation
to physical activity
Class III
▪ Marked limitation of activity due to symptoms
Class IV
▪ Symptoms at rest
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