Post on 21-Jan-2017
Cardiac Diseases in PregnancyAbdullah Matar BadranHasan Arafat
Subjects
• Introduction• Heart Diseases in Pregnancy• Management
Introduction• Normal Cardiac Changes During
Pregnancy• Pre- Pregnancy Counselling
Normal Cardiac Changes During Pregnancy
• Cardiac output increases up to 50% by 20 weeks ( i.e. Heart Rate , Stroke Volume are both Increased )
• CO is the lowest in supine position • CO is the highest in the left lateral position • CO increases progressively through the three stages of
labor • Systolic Ejection Murmur is present due to increased CO
passing through the aortic and pulmonary valves
Pre-pregnancy Counselling
• Women with heart disease should be aware of their condition prior to pregnancy and they should be also assessed by Cardiologist “ managed or treated according to situation “
• Issues related to that : - Risk of maternal death - Possible reduction of maternal life expectancy - Effects of pregnancy on cardiac diseases - Risk of fetus developing Congenital Heart Disease - Risk of preterm labor & Fetal Growth Restriction - Intensive Maternal and Fetal monitoring during labor
Heart Diseases in Pregnancy• Rheumatic • Congenital • Arrhythmia • Cardiomyopathy
Rheumatic Heart Disease
• The most common lesion is mitral stenosis• Patients are at high risk for developing heart failure,
subacute endocarditis and thromboembolic disease• Increased risk for fetal wastage• Onset of pulmonary edema: 40 weeks of gestation• Severe MS leads to atrial fibrillation, which can lead to CHF
Congenital Heart Diseases
• Include atrial and ventricular septal defects, primary pulmonary hypertension and cyanotic heart disease
• Patients with complete surgical correction can tolerate pregnancy
• Patients with persistent septal defect generally tolerate pregnancy
• Patients with PH (primary or as a result of cyanotic heart disease) should not get pregnant
• PH can lead to pulmonary congestion, heart failure and hypotension, all of which can lead to sudden death
Cardiac Arrhythmia
• Supraventricular tachycardia is the most common type• Occurs as a result of birth defects and changes in heart
structure• Atrial fibrillation and flatter are more serious forms,
associated with underlying cardiac diseases
Peripartum Cardiomyopathy
• Specific to pregnant or postpartum women• Patient has no underlying heart disease• Symptoms appear in the last week of pregnancy or within
6 months after delivery • Dilatational cardiomyopathy, decreased ejection fraction• Hx of preeclampsia, hypertension or poor
nourishment • Mortality rate: 20%, persistence: 30%- 50%, recurrence:
20%- 50%
ManagementDepends on two factors• The NYHA classification of heart • The type of defect is important as
well
New York Heart Association Functional Classification of Heart DiseaseClass I No signs or symptoms of cardiac decompensationClass II No symptoms at risk, but minor limitation on a physical activityClass III No symptoms at rest, but major limitation on o physical activityClass IV Symptoms present at rest, increase with any a kind of physical activity
Management
Management (Cont’d)
• Risk for types I and II is minimal• Risk for types III and IV is marked• Risk increases if cyanosis is present
Management (Cont’d)
• Risk also depends on the type of defect• Mitral and aortic stenosis (obstructive diseases) carry a
high risk for decompensation• Regurgitant diseases carry a lower risk• Other high risk conditions: PH, Marfan syndrome,
mechanical valve, ventricular ejection fraction less than 40%, or a previous history of cardiac event during pregnancy
Management: Antenatal
• Pregnant with significant Heart Disease should be managed in a joint obstetrician/cardiac Clinic .
• Physicians have to distinguish Between Normal Pregnancy changes and impending heart failure
• This is achieved by asking the pregnant woman about breathlessness - esp at night -, changes in heart rate or rhythm, increased tiredness or decreased exercise tolerance .
• Routine Physical examination “ Pulse rate and pressure , BP , JVP , and sacral and ankle edema, presence of basal crackles “
Management: Antenatal (Cont’d)
• These women should be advised to reduce their normal physical activities
• Echocardiography is good to assess Fxn and valves , Echocardiogram is usually done around 28 week - at the booking visit -.
• Avoidance of excessive weight gain and edema • Avoidance of Anemia
Management: Antenatal (Cont’d)
• The use of anticoagulants during pregnancy is a complicated issue .
• This is because Warfarin is teratogenic ‘ 1st trimester’ and linked with fetal intracranial hemorrhage ‘3rd trimester’
• LMWH may be insufficient at preventing thrombosis in women w/ prosthetic heart valves ( risk >10% )
• Anticoagulation is essential in patients w/ congenital heart disease who have pulmonary hypertension or artificial valve replacement , or for those at risk of atrial fibrillation
**
Fetal Risks of Maternal Cardiac Diseases
• Recurrence ( congenital Heart Disease ) • Maternal cyanosis Fetal Hypoxia • Iatrogenic Prematurity • FGR • Effects of Maternal Drugs ( Teratogenesis , Growth
Restrictions , Fetal Loss )
Management: Labor and Delivery
• The aim of management is to await the onset of spontaneous labor
• Induction of labor should be considered for the usual obstetrician Indications and in high risk women
• Epidural anesthesia is often recommended • This regional anesthesia has some risk in some cardiac
conditions as it causes Hypotension • Anesthetist should document an anesthetic management
plan .
Management: Labor and Delivery (Cont’d)
• Prophylactic Antibiotics should be given to any woman with cardiac defects to reduce risk of endocarditis
• Monitoring of Oxygen Saturation and Arterial Blood Pressure is appropriate during labor
• The 2nd stage of normal labor may be intentionally shortened using forceps or vacuum
• CS should only be done for normal obstetrician indications • CS increases the risk of hemorrhage, thrombosis and
infection
Management: Labor and Delivery (Cont’d)
• Postpartum Hemorrhage in particular can lead to major Cardiovascular Instability
• 3rd stage of labor is managed actively by oxytocin ONLY “ not w/ ergometrine “
• As oxytocin is a vasodilator, it should be administrated SLOWLY to patients w/ significant heart disease
( w/ low-dose infusions preferable ) • High-level maternal surveillance is required until the main
hemodynamic changes following delivery have passed
Management: Labor and Delivery (SUMMERY)
• Avoid induction of labor if possible • Use prophylactic Antibiotics • Ensure Fluid Balance • Avoid the supine position • Discuss the type of anesthesia w/ senior anesthetist• Keep the 2nd stage SHORT • Use oxytocin judiciously
Thank You