Fetomaternal Division

Obstetrics & Gynecology Department

Dr. Soetomo General Hospital

S U R A B A Y A

CARDIOVASCULAR DISEASES

ON

PREGNANCY

dr. Aditiawarman,SpOG

Incidence• 1% of all pregnancies

• Rate of maternal death 4-5% among class

III-IV

• Rate of perinatal death 6-31%

• Atrial Fibrilation increase maternal death to

15%

• AF increase perinatal death to 17%

• History:– Congenital - Repair

– Acquired - Not repair

• Cardiac disease in pregnancy complicates a

small percentage of all pregnancies in

developed countries (eg, only 1 to 4 percent

of pregnancies in the United States

• Congenital heart disease the most

common form of heart disease complicating

pregnancy in the United States

advances in the treatment of congenital

heart disease more affected children to

reach adulthood and attempt pregnancy

• Rheumatic heart disease was the most

common form of cardiac disease in pregnant

women predominates in developing

countries and in immigrant populations in the

United States

0

5

10

15

20

25 24

7

12

2

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PENYEBAB KEMATIAN OBSTETRI DI RSUD DR SOETOMO

2013

PEB

HPP

Jantung

Tumor otak

AIDS

TBC

Jaundice

Liver

DM

Sepsis

Asma

Ginjal kronis

sistematic lupus

Kelainan anemia

10

15

5

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PENYEBAB KEMATIAN IBU DI RSUD DR SOETOMO

TAHUN 2014

JANTUNG PE HPP LUPUS GINJAL

DM TUMOR SEPSIS HIV RUPTURA UTERI

CEDERA OTAK KANKER SUFOKASI LIVER PARU

Gunawan,2008. Laporan penelitian

Causes of Heart disease in pregnancy in Dr. Soetomo

Surabaya

from 1998 through 2002.

46.90%

4.70%

12.50%

3.10%

3.10%

3.20%

9.40%

4.70%

1.60%

3.10%

7.80%

0.0% 100.0%

MS

MI

MSI

MSI-AR

AR

PS

ASD

ES

FT

PDA

VSD

R

H

D

VSD : Ventricular Septal Defects, PDA : Patent Ductus Arteriosus, FT : Fallot’s Tetralogy, ES :

Eisenmenger’s Syndrome, ASD : Atrial Septal Defects, PS : Pulmonary Stenosis, AR : Aorta

Regurgitation, MSI-AR : Mitral Stenosis Insufficiency- Aorta Regurgitation, MSI : Mitral Stenosis

Insufficiency, MI : Mitral Insufficiency,MS : Mitral Stenosis

( 64 cases per 18262 live birth 0.35%)

Hemodynamic changes

maternal neonatal survival• Premarital counseling

• Pre conceptional counseling

• Antenatal care

• Family planning

START

Pregnancy stimulate the marked

hemodynamic changes have profound

effect on underlying heart disease.

1.Increased cardiac out put 30 to 50%

2.Increased resting pulse

3.Increased diastolic filling

PHYSIOLOGICAL

CONSIDERATION

Cardiac disease

• Congenital heart disease

–Acyanotic

–Cyanotic

• Acquired

–RHD

• Others:

–Coronary heart disease

Symptoms

Progressive dyspnea or orthopnea

Nocturnal cough

Hemoptysis

Syncope

Chest pain

Some Clinical Indicators of Heart

Disease During Pregnancy

Clinical Findings

– Cyanosis

– Clubbing of fingers

– Persistent neck vein distention

– Systolic murmur grade 3/6 or greater

– Diastolic murmur

– Cardiomegaly

– Persistent arrhythmia

– Persistent split-second sound

– Criteria for pulmonary hypertension

PRECAUTION

INCREASED PRELOAD OF NORMAL

PREGNANCY

INCREASED CARDIAC OUTPUT

MITRAL STENOSIS

IN

PREGNANCY

CARDIAC FAILURE WITH

PULMONARY EDEMA

ANY TACHYCARDIA

PROPHILACTICALLY

β BLOCKING AGENTS

VENTRICULAR

DIASTOLIC

FILLING TIME

ATRIAL TACHY

ARRHYTHMIAS

LEFT ATRIAL &

PULMONARY

VENOUS &

CAPILLARY

PRESS.

PULMONARY

EDEMA

FIBRILLATION

THROMBUS

AORTIC

EMBOLLIZATION

IMMEDIATELY POST PARTUM OF MITRAL STENOSIS IN PREGNANCY

LOSS OF THE LOW RESISTANCE PLACENTAL CIRCULATION

AUTOTRANSFUSION :

• LOWER EXTREMITIES

• PELVIC VEINS

INCREASED PCWP

AVOID FLUID OVERLOAD

PULMONARY EDEMA

PRECAUTION

CLINICAL (appearance)

CLASSIFICATION :• CLASS I

Uncompromised : Patient with cardiac disease and no limitation of physical activity.

• CLASS II

Slightly compromised : Patient with cardiac disease and slight limitation of physical activity.

• CLASS III

Markedly compromised : Patients with cardiac disease and marked limitation of physical activity.

• CLASS IV

Severely compromised : Patients with cardiac disease and inability to perform any physical activity without discomfort.

Risks for Maternal Mortality Caused by

Various Heart DiseaseCardiac Disorder Mortality ( % )

Group 1 – Minimal Risk 0 – 1 Atrial septal defectVentricular septal defectPatent ductus arteriosusPulmonic or tricuspid diseaseFallot tetralogy, correctedBioprosthetic valveMitral stenosis, NYHAa classes I and II

Cardiac Disorder Mortality ( % )

Group 2 – Moderate Risk 5 – 15 2A :Mitral stenosis, NYHA classes III and IVAortic stenosisAortic coarctation without valvar involvementFallot tetralogy, uncorrectedPrevious myocardial infractionMarfan syndrome, normal aorta

Risks for Maternal Mortality Caused by Various

Heart Disease

Cardiac Disorder Mortality ( % )

2B :

Mitral stenosis with atrial fibrillation

Artificial valve

Group 3 – Major Risk 25 – 50

Pulmonary hypertension

Aortic coarctation with valvar involvement

Marfan syndrome with aortic involvement

NYHA = New York Heart Association

From the American College of Obstetricians and Gynecologists ( 1992a )

Modified WHO Risk score

CARPREG

Risk of maternal cardiovascular

complication:

Heart failure, arrhythmia, death

0 points 5%

1 point 27%

2 points 75%

Risk of offspring higher with higher

score no percent assigned

ZAHARA

ZAHARA

Management

• Counseling

• Rest

• Team approach

• Infection prevention –

Endocartitis;Rhematoid

• Delivery

• Diet

• Family Planning

PRE CONCEPTIONAL COUNSELING

Preconceptional Counseling :

• Is preventive medicine for obstetrics

• All factors that could potentially affect maternal and perinatal outcome are identified, the woman is advised of her risk, and a strategy is provided to reduce or eliminate the pathological influences made evident by her family, medical, or obstetrical history and/or specific testing.

PRECONCEPTIONAL COUNSELING

• The women with significant heart diseases may benefit from counseling before the decision to become pregnant

• Maternal mortality generally varies directly with functional classification at pregnancy onset

• Wowen with a significant risk of mortality should be advised to reconsider pregnancy

• Evaluation of cardiac function, surgical records are reviewed, all medications evaluated for fetal safety and pedigree should be obtained to define the fetal risk

Normal clinical findings that can

mimic heart disease in pregnancy

• Raised jugular venous pressure .

• Volume-loaded left ventricle; full, sharp and collapsing

pulse

• Warm extremities

• Peripheral edema

• Palpitations

• Tachycardia

• Premature atrial/ventricular beats

• Increased intensity of mitral closure sound

• Third heart sound

• Systolic murmur

• Continuous murmur from venous hum, mammary soufflé

Management

• Multidiscipline approach obstetricians, cardiologist, anesthesist, pediatriacians

• Cardiology:– Medical

– Surgical

• Mode of delivery– Vaginal

– CS

• Anesthesia– Painless labor

Multidiscipline team

Management in pregnancy

• Cardiac disease + pregnancy are managed by a

Multidisciplinary team.

• This includes:

– Cardiologist with expertise in pregnancy or obstetric

physician;

– Obstetrician or fetal medicine specialist;

– Midwives with experience in medical problems;

– Obstetric anaesthetist; and

– Neonatal paediatrician.

Poor Prognosis

• Poor functional class (poor exercise

tolerance);

• Previous cardiac event (arrhythmia,

pulmonary oedema, stroke);

• Left heart obstruction.

Mitral Stenosis and PTMC

• Rheumatoid fever Mitral

stenosis 2 years

• Maternal death

– 75% cardiac failure

– 3rd trimester or early postpartum

Post PTMC experiences dr

Soetomo

• Maternal mortality 2-3%

• IUGR 1 of 7 babies with birth weight

less 2500 gram

• None IUFD

Terima kasih