CARDIAC DISEASE IN PREGNANCY

Olufemi Aworinde

Consultant Obstetrician and Gynaecologist,

Bowen University, Iwo

OUTLINE• Introduction

• CVS changes in pregnancy

• Clinical classification of cardiac disease

• Management of cardiac disease

- Preconceptional counselling

- Antenatal care

- Intrapartum care

- Postpartum care

• Peripartum cardiomyopathy

• Conclusion

INTRODUCTION• Cardiac disease is a significant indirect

cause of maternal mortality in theWestern world.

• Its incidence is increasing and it isattributable to acquired heart diseases;

- myocardial infarction

- ischaemic heart disease

- peripartum cardiomyopathy

• In the developing world, cardiac disease is relativelyuncommon.

• There is a decline in rheumatic fever and rheumaticheart disease

• There is an increase in number of girls maturing intoreproductive age group due to cardiac centres

• Thus, congenital heart diseases are becomingrelatively commoner

• Decompensation can occur as pregnancy advances orduring labour

INTRODUCTION

• Preconceptional counselling and early recognitionof problems during pregnancy will preventmorbidity and mortality to the mother and her baby

• Complicates about 1% of all pregnancy

• Marked haemodynamic changes stimulated by pregnancy has profound effect on underlying HD.

INTRODUCTION

CVS CHANGES IN PREGNANCY

parameterChanges at various times (weeks)

5 12 20 24 32 38

HR ↑ ↑↑↑ ↑↑↑ ↑↑↑ ↑↑↑↑ ↑↑↑↑

SBP ↔ ↓ ↓ ↔ ↑ ↑↑

DBP ↔ ↓ ↓↓ ↓ ↔ ↑↑

SV↑

↑↑↑↑↑ ↑↑↑↑↑↑ ↑↑↑↑↑↑ ↑↑↑↑↑↑↑↑↑↑

CO ↑↑ ↑↑↑↑↑↑ ↑↑↑↑↑↑↑ ↑↑↑↑↑↑↑ ↑↑↑↑↑↑↑ ↑↑↑↑↑↑↑

SVR ↓↓ ↓↓↓↓↓ ↓↓↓↓↓↓ ↓↓↓↓↓↓ ↓↓↓↓↓↓ ↓↓↓↓↓

LV EF ↑ ↑↑ ↑↑ ↑↑ ↑ ↑

↑ ≤ 5%; ↑↑ 6-10%; ↑↑↑ 11-15%; ↑↑↑↑ 16-20%; ↑↑↑↑↑ 21-30%; ↑↑↑↑↑↑ > 30%, ↑↑↑↑↑↑↑ > 40%.

CARDIOVASCULAR PHYSIOLOGY OF PREGNANCY

• Because significant hemodynamic alterations areapparent early in pregnancy,

• Women with severe cardiac dysfunction mayexperience worsening of heart failure before midpregnancy.

• Majority of HF also develop peripartum and duringthe puerperium.

CLINICAL CLASSIFICATION OF HEART DISEASE (NYHA)

NYHA- 1st published in 1928

• Class I (Asymptomatic);

- Uncompromised

- No limitation to physical activity

- No symptoms of cardiac insufficiency or angina pain

• Class II (Symptoms with > Normal activity)

- Slight limitation to physical activity

- Comfortable at rest

- Discomfort results in the form of excessive fatigue, palpitation, dyspnoea with > ordinary physical activity

• Class III (Symptoms with Normal activity);

– Marked limitation of physical activity

– Comfortable at rest, but less than ordinary activity causes symptoms

• Class IV (Symptoms at bed rest);

– Severely compromised

– Inability to perform any physical activity

– Symptoms of cardiac insufficiency and/or angina pain at rest

CLINICAL CLASSIFICATIONS OF HEART DISEASE (NYHA)

• DISADVANTAGES OF THE NYHA CLASSIFICATION;

- Inability to indicate the structural severity of thecardiac condition at the time of classification

- Class may change as pregnancy advances

- Not useful in prognosis

CLINICAL CLASSIFICATIONS OF HEART DISEASE (NYHA)

MANAGEMENT OF CARDIAC DISEASE IN PREGNANCY

• Pre-conceptional counselling

• Antenatal management

• Intrapartum management

• Postpartum management

PRE-CONCEPTIONAL COUNSELLING

• Heart disease should be diagnosed prior topregnancy for optimum result

• Management should be in collaboration with acardiologist

• Aim is to assess the nature & severity of the heartlesion and control before pregnancy is embarkedupon.

• Life - threatening cardiac disease can be reversed bycorrective surgery making subsequent pregnancyless dangerous

• Patients will fall into three groups after assessment;

- Group I : no evidence of lesion, no follow up required

- Group II : mild lesion with no haemodynamicproblems e.g congenital mitral valve prolapse. Theyusually need no follow up

- Group III : real or potential haemodynamicimplications and need careful assessment andsubsequent management

• Maternal mortality varies directly with functionalclassification at pregnancy onset.

PRE-CONCEPTIONAL COUNSELLING

RISK OF MATERNAL MORTALITY CAUSED BY VARIOUS TYPES OF HEART DISEASE

• Group I (Minimum risk - 0.1%)

NYHA I & II, Mitral stenosis, ASD, VSD, PDA, Correctedbioprosthetic valves

• Group 2 (Moderate risk- 5 -15%)

Mitral stenosis + NYHA III, IV OR atrial fibrillation,Aortic stenosis, Fallot tetralogy (uncorrected), Aorticcoarctation without valvular involvement, PreviousMI, Marfan syndrome with normal aorta, Artificialvalve etc

•Group 3 (Major risk - 25 - 50%)

– Pulmonary hypertension

– Aortic coarctation + valvular involvement

– Marfan syndome with aortic involvement

RISK OF MATERNAL MORTALITY CAUSED BY VARIOUS TYPES OF HEART DISEASE

ANTENATAL CARE

• Team approach - Obstetrician, Neonatologist,Cardiologist, Anaesthesiologist

• Assess for need for termination of pregnancy e.gPrimary pulmonary hypertension, Eisenmenger’ssyndrome.

Symptoms of heart disease duringpregnancy;

– Progressive dyspnoea

– Orthopnoea

– Paroxysmal nocturnal dyspnoea - nocturnal cough

– Hemoptysis

– Chest pain

– Easy fatiguability

– Palpitations

– Syncope

– dizziness

– Leg swelling

ANTENATAL CARE

• SIGNS THAT MAY SUGGEST HEARTDISEASE IN PREGNANCY INCLUDE;

- Cyanosis

- Finger clubbing

- Raised JVP

- Systolic murmur > grade 3

- Persistent splitting 2nd heart sound

- Diastolic murmur

ANTENATAL CARE

• SIGNS THAT MAY SUGGEST HEART DISEASEIN PREGNANCY INCLUDE;

- Pedal oedema

- Cardiomegaly

- Coarse crepitations

- abnormal characteristics of peripheral pulses

- Tachycardia

Diastolic murmur heard during pregnancy requiresfurther investigation with echocardiography andDoppler ultrasound.

ANTENATAL CARE

DIAGNOSIS OF HEART FAILURE

• Many of the physiological adaptations of normalpregnancy alter physical findings.

• This makes diagnosis more difficult.

E.g in normal pregnancy:

- Functional systolic murmurs are common

- Respiratory effort may be accentuated as dyspnoea

- Oedema of the leg is common after mid-pregnancy.

• Important not to diagnose HF when non exists andnot to miss the diagnosis when it does exist.

MANAGEMENT OF CLASS I & II• Most advance through pregnancy without difficulty

• CCF of gradual onset.

• 1st warning sign - basal rales and nocturnal cough

• Attention directed toward prevention and earlydetection of heart failure.

• Prevent infection –sepsis may precipitate cardiacdisease

• Pneumococcal and influenza vaccine recommended

• Life style modifications- Smoking prohibited

• DURING LABOUR AND DELIVERY

–In general, vaginal delivery is preferredunless obstetrical indication for C/S

–Induction of labour is generally safe andshould be for obstetric indication

–Antibiotics may be administered

–Fluid balance – should be carefullymaintained to avoid pulmonary oedema

MANAGEMENT OF CLASS I & II

• DURING LABOUR AND DELIVERY

– Pain relief : - epidural is ideal.

– Oxygen administration is essential throughout labour

– Nurse in semi- recumbent position with lateral tilt

– Prophylactic antibiotics

– Vitals checked frequently in between contraction.

• PR > 100 and RR > 24 may suggest an impendingventricular failure

- Short second stage - 2nd stage may be shortened withforceps or vacuum extraction.

MANAGEMENT OF CLASS I & II

• DURING LABOUR AND DELIVERY

Third stage of labour : -

- Active management of the 3rd stage to preventPPH

- Oxytocin is used instead of ergometrine to avoidrisk of precipitating heart failure

- In established heart failure, the patient should benursed in cardiac position, oxygen and I.Vfrusemide are added.

MANAGEMENT OF CLASS I & II

PUERPERIUM

• Client who have shown little or no evidence of cardiacdisease during pregnancy, labour & delivery may stilldecompensate postpartum

• Close monitoring

• Correct anaemia, prevent infection and thrombo-embolism

MANAGEMENT OF CLASS III & IV• Uncommon in modern obstetric practice

• If woman chooses to get pregnant;

– Made to understand the risk involved

– Must cooperate fully with planned care

– If seen early should be offered pregnancy interruption

– If woman insists on carrying the pregnancy then prolongedhospitalisation with bed rest recommended

– Epidural analgesics for labour and delivery

– Vaginal delivery preferred

– C/S limited to obstetrical indication as they tend to toleratesurgical procedures poorly.

PERIPARTUM CARDIOMYOPATHY

• Peripartum cardiomyopathy is defined asthe onset of acute heart failure withoutdemonstrable cause in the last trimesterof pregnancy or within the first 6 monthsafter delivery.

• It is a diagnosis of exclusion

PERIPARTUM CARDIOMYOPATHY

• A form of Dilated Cardiomyopathy

• Left ventricular systolic dysfunction

• Results in signs and symptoms of heart failure

• Often unrecognized, as symptoms of normal pregnancy commonly mimic those of mild heart failure.

Criteria for Peripartum Cardiomyopathy

1.Development of Cardiac failure in the last month of pregnancy or within 5 month after delivery

2. Absence of an identifiable cause for the cardiac failure.

3.Absence of recognizable heart disease prior to the last month of pregnancy.

4.Left ventricular systolic dysfunction demonstrated by classic echocardiographic criteria such as depressed ejection fraction.

The National Heart, Lung and Blood Institute and the Office of rare diseases (1997)

Incidence

The incidence in the west ranges from 1 in 4000 deliveries

Sixty percent present within the first 2 months postpartum

Up to 7% may present in the last trimester of pregnancy.

Geographic variations exist with a higher incidence reported in areas of Africa because of malnutrition and local customs in the puerperium

Commoner in Northern Nigeria compared to other zones

Etiology

Still unknown. Associations include: -nutritional deficiencies- selenium -small vessel coronary artery abnormality -hormonal effects -toxemia -maternal immunologic response to fetal

antigen or -myocarditis Wakan Jeko- A cultural practice in Northern Nigeria

which composes of a triad of hot baths, ingestion of pap (kunun kanwa) which is made with lake salt that has high levels of sodium (Na + )

Predisposing factors

• -maternal age greater than 30 yr

• -multiparous or eclamptic patients

• - twinning

• - racial origin (black)

• - hypertension and

• - nutritional deficiencies

• In majority of cases there is no family history

Symptoms

Symptoms of worsening cardiac failure like: -dyspnoea on exertion -fatigue -ankle oedema -embolic phenomena -atypical chest pains and -haemoptysis. Many of above symptoms may occur even in

normal pregnancy and can be mistaken for a diseased state.

Signs

• -evidence of a raised CVP

• -tachycardia

• -cardiomegaly with a gallop rhythm (S3)

• -mitral regurgitation

• -pulmonary crackles and

• -peripheral oedema.

PERIPARTUM CARDIOMYOPATHY

On auscultation of the heart:

• loud first heart sound

• exaggerated splitting

• mid systolic murmur and

• continuous venous hum

• These physical signs may confuse and there could be mistakes in the form of over diagnosis or disregarding of heart disease.

PERIPARTUM CARDIOMYOPATHY

Chest radiograph:

cardiomegaly with pulmonary oedema

pulmonary venous congestion.

The ElectroCardioGram:

• nonspecific ST and T wave changes

• atrial or ventricular arrhythmias and

• conduction defects.

Echocardiography / Doppler

• may reveal enlargement of all four chambers with marked reduction in left ventricular systolic function

• small to moderate pericardial effusion and

• mitral, tricuspid and pulmonary regurgitation

• Ventricular wall motion, ejection fraction and cardiac output are decreased and

• pulmonary wedge pressure is increased.

PERIPARTUM CARDIOMYOPATHY

• The clinical presentation and hemodynamic features in PPCM are indistinguishable from those of other forms of dilated cardiomyopathy.

• In the absence of any cardiac symptoms, one of the early indications about this condition is revealed during evaluation of the fetus with a fetal monitor and ultrasound

PERIPARTUM CARDIOMYOPATHY

• Fetal growth is dependent on good blood flow to the uterus and placenta

• An insufficient blood flow means decreased oxygenation resulting in slowed growth

• This should prompt further investigation to discover heart disease.

The prognosis

50-60% patients show complete or near complete recovery within the first 6 months postpartum

In others, either continued clinical deterioration leading to early death or

persistent left ventricular dysfunction and chronic heart failure results

There is an initial high risk period with mortality of 25-50% in the first 3 months postpartum.

Patients with persistent cardiomegaly at 6 months have a reported mortality of 85% at 5 years.

The prognosis

• Subsequent pregnancies in women with PPCM are often associated with relapses and high risk for maternal morbidity and mortality.

• should be discouraged in women with PPCM who have persistent cardiac dysfunction.

Management of PPCM

Vigorous treatment of acute heart failure.

• Oxygen, diuretics, digoxin and vasodilators

• Use of ACE inhibitors in early pregnancy should be avoided as it has teratogenic effects on fetus

PERIPARTUM CARDIOMYOPATHY

Anticoagulant therapy is recommended because of high incidence of thromboembolic events in PPCM

Patient on oral anticoagulants require change to parenteral anticoagulants with short half life

Dose adjusted according to the PTTk which may be discontinued before delivery.

After delivery Warfarin may be used

PERIPARTUM CARDIOMYOPATHY

• Since the disease may be reversible, the temporary use of Intra Aortic Balloon Pump or a LV assist device may help to stabilize the patient’s condition pending improvement.

PERIPARTUM CARDIOMYOPATHY

Many patients with PPCM show evidence of myocarditis in biopsy specimens.

Dobutamine stress echocardiography - for evaluating contractile reserve in women with recovered systolic function who are contemplating further pregnancies.

PERIPARTUM CARDIOMYOPATHY

• Autopsy shows cardiac enlargement, often with mural thrombi along with histological evidence of myocardial degeneration and fibrosis.

CONCLUSION

• Cardiac disease in pregnancy requires amultidisciplinary approach

• Preconceptional counselling has a significant role isensuring a favourable outcome

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