Cardiac Diseases in PregnancyAbdullah Matar BadranHasan Arafat

NOTE:To change the image on this slide, select the picture and delete it. Then click the Pictures icon in the placeholder to insert your own image.Heart Failure and PregnancyAlthough the development of Heart Failure in pregnancy is dangerous; treatment principles are the same as in non- pregnant patients2Specific ConditionsTreatment ProtocolAdmission & ConfirmationDrug TherapyArrhythmias CorrectionAssessment of Fetal Well- Being

1- Admission: the patient must be admitted to the hospital to confirm the diagnosis by clinical examination and echocardiography4Ischemic Heart DiseaseRisk: 1 in 10,000Peak incidence: 3rd trimester in parous women older than 35Underlying cause is unknownCoronary artery dissection is the most common cause in the postpartum periodIschemic Heart DiseaseTreatment: PTCAA technique used for inflating stenotic coronary artery/iesInsert a deflated balloon on a catheter through the femoral or inguinal arteryProceed through blood vessels until the stenotic artery is reachedInflate the balloon A stent is often placed at the site of blockade to permanently open the arteryUse X-ray to guide you through out the procedure; contraindicated when the fetus is most vulnerable to radiation (8-15 weeks)Mitral & Aortic StenosisMitral StenosisRheumatic in originOnset of pulmonary edema: 40 weeks of gestationTreatment: bed rest, oxygen, - blockers and diuretics Balloon mitral valvotomy is the treatment of choice after delivery can be considered during pregnancy depending on the clinical condition and gestationAortic StenosisCongenital in originUsually well tolerated throughout pregnancyExcept for severe aortic stenosis: 17% maternal mortality, 30% fetalTreatment: bed rest, drug therapysurgical intervention such as balloon or surgical aortic valvotomy can be considered if feasible and the condition of the patient deterioratesObstructive lesions impair the heart ability to increase its output to meet the demands of pregnancyCO increases by 50% by the 20th week of gestationTreatment of MS aims at reducing heart rate7Marfan SyndromeAutosomal dominant connective tissue diseaseCan lead to mitral prolapse, aortic regurgitation, aortic root dilation and aortic dissectionPregnancy increases the risk for aortic rupture by 50%If aortic dilation > 4cm, advise against pregnancyIf aortic dilation < 4cm; small risk for rupture, but unpredictable Echocardiography is the principal investigationOther complications: early pregnancy loss, preterm labor, cervical weakness, uterine inversion and postpartum hemorrhage

Pulmonary HypertensionAn increase in the pulmonary vascular resistance resulting in an increased workload placed on the right side of the heartThe demands of increased CO & blood volume may not be met by an already compromised right ventricleMain symptoms: fatigue, breathlessness, syncopeTreatment: endothelin blockers, phosphodiesterase inhibitors, prostaglandinsDespite the treatment, mortality is high (40-50%)Women with PH should be advised not to get pregnantand any decline in cardiac performance in pregnancy represents a life threatening eventWomen with PH should be strongly advised not to get pregnant with contraceptive useTermination must take place earlyIf they choose to get pregnant, careful monitoring and admission should take placeDelivery according to progression of the condition 9Heart Diseases in PregnancyRheumatic Congenital Arrhythmia Cardiomyopathy10Return to the introduction and write notesRheumatic Heart DiseaseThe most common lesion is mitral stenosisPatients are at high risk for developing heart failure, subacute endocarditis and thromboembolic diseaseIncreased risk for fetal wastageOnset of pulmonary edema: 40 weeks of gestationSevere MS leads to atrial fibrillation, which can lead to CHF

1-Obstructive lesions impair the heart ability to increase its output to meet the demands of pregnancy1-CO increases by 50% by the 20th week of gestation3-Fetal wastage: loss of conception between 20th and 28th weeks, either voluntary or involuntary4-PE is a result of cardiac decompensationTreatment of MS aims at reducing heart rate11Congenital Heart DiseasesInclude atrial and ventricular septal defects, primary pulmonary hypertension and cyanotic heart diseasePatients with complete surgical correction can tolerate pregnancyPatients with persistent septal defect generally tolerate pregnancyPatients with PH (primary or as a result of cyanotic heart disease) should not get pregnantPH can lead to pulmonary congestion, heart failure and hypotension, all of which can lead to sudden deathPPH: Eisenmengers syndromeCyanotic Heart Disease: tetralogy of Fallot or transposition of great arteriesTOF: most common, four conditions, three are always present: Pulmonary Stenosis, Overriding aorta, ventricular septal defect and right ventricular hypertrophyTransposition of the greater arteries means abnormal spatial arrangement of the greater arteries (aorta and pulmonary)If the patient chose to get pregnant, all measures must be taken to avoid decompensation and overloading the circulationDecompensation might lead to pulmonary congestion, heart failure and hypotension

12Cardiac ArrhythmiaSupraventricular tachycardia is the most common typeOccurs as a result of birth defects and changes in heart structureAtrial fibrillation and flatter are more serious forms, associated with underlying cardiac diseasesPeripartum CardiomyopathySpecific to pregnant or postpartum womenPatient has no underlying heart diseaseSymptoms appear in the last week of pregnancy or within 6 months after delivery Dilatational cardiomyopathy, decreased ejection fractionHx of preeclampsia, hypertension or poor nourishment Mortality rate: 20%, persistence: 30%- 50%, recurrence: 20%- 50%Hypertensive cardiomyopathy, ischemic heart disease, viral myocarditis, and valvular heart disease must be excluded in patients with cardiac dysfunction before the diagnosis can be made.14ManagementDepends on two factorsThe New York Heart Association classification of heart diseases is important in determining the optimal managementThe type of defect is important as wellNew 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 activityManagement (Contd)Risk for types I and II is minimalRisk for types III and IV is markedRisk increases if cyanosis is presentManagement (Contd)Risk also depends on the type of defectMitral and aortic stenosis (obstructive diseases) carry a high risk for decompensationRegurgitant diseases carry a lower riskOther high risk conditions: PH, Marfan syndrome, mechanical valve, ventricular ejection fraction less than 40%, or a previous history of cardiac event during pregnancyManagement (Contd)Title and Content Layout with ChartTwo Content Layout with TableFirst bullet point hereSecond bullet point hereThird bullet point hereRisk Factors for Developing Heart FailureRespiratory of Urinary InfectionAnemiaObesityCorticosteroidsTocolyticsMultiple GestationHypertensionPain- Related StressTitle and Content Layout with SmartArt