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