Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
1
Cardiac diseases in pregnancy
PYSIOLOGICAL CHANGES DURING
PREGNANCY
CO increases by 40% as SV increases
HR increases by 10 beats/min
– 3
rd
trimester
CO peaks at 18-24 wks then stabilize
CO increase grade 2 systolic flow murmur along
the left sternal border without radiation
Diastolic murmur if present consider pathologic
investigate
Increases VR cardiac fullness and hypertrophy
displacement of heart
Apex beat superiorly and laterally
ECG
Lt axis deviation
Flattened T wave
•
These women should be fully assessed before
pregnancy and the maternal and fetal risks carefully
explained.
•
Cardiologist should be involved in assessment.
•
Concurrent medical problems should be aggressively
treated
•
If pt require surgical correction should be undertaken
before a pregnancy.
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
2
Issues in prepregnancy counselling
•
Risk of maternal death
•
Possible reduction of maternal life expectancy
•
Effects of pregnancy on cardiac disease
•
Mortality associated with high risk conditions
•
Risk of fetus developing congenital heart disease
•
Risk of preterm labour and FGR
•
Need of frequent hospital admission
•
Other options
–contraception,adoption,surrogacy
•
Timing of pregnancy
Antenatal management
•
Experienced physicians and obstetricians should
manage this pt
•
Routine physical examination
•
Echocardiography to serially assess the pt
•
Any signs of deterioating cardiac stutus should be
carefully assess and treated
•
Bed rest
•
Anticoagulation is a complicated issue
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
3
Stages of heart failure new york heart
association classification
•
1 mild no limitation of physical activity
•
2 mild slight limitation.comfortable at rest
•
3 moderate marked limitation
•
4 severe unable to carry out any activity and symptoms
of insufficiency at rest
Risk markers for maternal cardiac events
•
Prior episode of heart failure ,arrhythmia or stroke
•
2 class>2 or cyanosis
•
3 left heart obstruction
•
4 reduced left ventricular function (EF<40 per cent).
High risk conditions
•
Systemic ventricular dysfunction ef <30 % class3-4
•
Pulmonary hypertention
•
Cyanotic congenital heart disease
•
Aortic pathology (marfan syndrom)
•
Ischaemic heart disease
•
Left heart obstructive lesions (aortic, mitral stenosis)
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
4
•
Prosthetic heart valves
•
Previous peripartum cardiomyopathy
Fetal risks of maternal cardiac disease
•
Recurrence (congenital heart disease)
•
Fetal hypoxia
•
Iatrogenic prematurity
•
FGR
•
Effects of drugs
Management of labour
•
Avoid induction of labour
•
Use prophylactic antibiotics
•
Ensure fluid balance
•
Avoid supine position
•
Discuss anaesthesia with senior anasesthetist
•
Keep second stage short
•
Use syntocinon judiciously
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
5
Treatment of heart failure in pregnancy
•
Heart failure in pregnancy is dangerous
•
Treatment are the same as non pregnant
•
Diagnosis by clinical signs and echocardiography
•
Treat:should admitted and give diuretics ,vasodilators
and digoxin ,oxygen and morphine
•
If arrhythmias require selective beta blockade
Risk factors for heart failure
•
Respiratory or urinary infections
•
Anaemia
•
obesity
•
corticosteroids
•
Tocolytics
•
Multiple gestation hypertension
•
arrhythmias
•
Pain related stress
•
Fluid overload
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
6
Specific conditions
ischaemic heart disease
•
The risk of MI during pregnancy is estimated as 1 in 10
000 and the peak incidence is the third trimester , in
parous women older than 35
•
The underlying pathology is not atherosclerotic, and
coronary artery dissection is the primary cause in
postpartum period
•
The diagnosis of MI is often missed and prompt
diagnosis and treatment are necessary to reduce the
high associated maternal and perinatal mortality
Mitral and aortic stenosis
•
Obstructive lesions of the left heart are well recognized
risk factors for maternal morbidity and mortality
•
Aortic stenosis is usually congenital and mitral stenosis
usually rheumatic in origin.
•
For those with known mitral stenosis, 40% experience
worsening symptoms in the pregnancy with the average
time of onset of pulmonary oedema at 30 weeks.
•
The aim of treatment is to reduce the heart rate,
achieved through bed rest, oxygen,beta blockade and
diuretic.
•
Maternal mortality is reported at 2 per cent and the risk
of an adverse fetal outcome is directly related to the
severity of mitral stenosis
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
7
•
The risk of maternal death in those with severe aortic
stenosis is reported as 17per cent , with fetal mortality of
30per cent
•
If the woman`s condition deteriorates before delivery is
feasible , surgical intervention such as balloon or surgical
aortic valvotomy can be considered , although there is
less experience and success than with mitral stenosis
Marfan syndrome
•
Is an autosomal dominant connective tissue abnormality
that may lead to mitral valve prolapse and aortic
regurgitation , aortic root dilatation and aortic rupture or
dissection .
•
Pregnancy increases the risk of aortic rupture or
dissection and has been associated with maternal
mortality of up to 50per cent
•
Echocardiography is the principal investigation
•
Women with an aortic root <4 cm should be reassured
that their risks are lower , and the risk of an adverse
cardiac event is around 1 per cent
•
A number of obstetric complications have also been
described : early pregnancy loss , preterm labour ,
cervical weakness , uterine inversion and postpartum
haemorrhage .
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
8
Pulmonary hypertension
•
Is characterized by an increase in the pulmonary
vascular resistance resulting in an increased workload
placed on the right side of the heart
•
The main symptoms are fatigue , breathlessness and
syncope , and clinical signs are those of right heart
failure .
•
Pregnancy is associated with a high risk of maternal
death
•
Close monitoring by a multidisciplinary team is crucial .
•
The mortality of the condition remains high at 30-50 per
cent .
•
Pt should be strongly advised against pregnancy and
given clear contraceptive advice , with early termination
advased in the event of pregnancy .
Classification of PH
•
Idiopathic
– sporadic or familial
•
Persistent PH of the newborn
•
Associated with :
•
Collagen vascular disease
•
Congenital pulmonary to systemic shunts
•
Drugs or toxins
Cardiac diseases in pregnancy Dr
.Yussra 3/3/2016
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•
Portal hypertension
•
PH with left heart disease
•
PH with lung disease
•
PH due to thrombosis and / or embolic disease .
PERIPARTUM AND POSTPARTUM
CARDIOMYOPATHY
Rare
No etiological factor found
No underlying cardiac disease
Symptoms of cardiac decompensation appear during
last weeks of pregnancy or (2-20wks)postpartum
.
Women prone to this condition give us history of :
Pre-eclampsia
Hypertension
Malnutrition
GUIDELINES FOR MANAGEMENT
Avoid excessive weight gain and edema
Avoid strenuous activity
Avoid anemia
Early detection of a problem
THE END
BY:
Taher ali TAHER