heart failure in pregnancy ramon m. gonzalez, md professor ust medicine and surgery

Heart Failurein

Pregnancy

Ramon M. Gonzalez, MDProfessor

UST Medicine and Surgery

• AB a 22y/o married, bank teller• Visited for the 1st time an obstetrician• 5 months PTC she had a (+) pregnancy test• Felt perfectly well prior to consult• Few days ago started to have shortness of

breath on climbing 2 flights of stairs, easy fatigability on walking 2 blocks and had palpitations

• Bp-100/60mmHg CR-89/min RR=21cycles/min

• Heart- AB at 5th ICS LMCL, no thrills, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex

• Referred by the obstetrician to a cardiologist

Cardiovascular changes in pregnancy

Parameter Percentage of change_______________________________________________

Cardiac output 40-50% IncreaseIntravascular volume 45% IncreaseHeart rate 15-25% IncreaseSystemic vascular resistance 20% DecreaseStroke volume 30% IncreaseSystolic BP MinimalDiastolic BP 20% Decrease at mid-pregnancyO2 consumption 30-40% Increase

Periods of increase cardiac output

• 28-32 weeks gestation

• Labor and Delivery

• Immediately postpartum

Hemodynamics during labor

Parameter Stage of Labor Percentage of change____________________________________________________Cardiac output Latent phase 10% Increase Active phase 25% Increase Expulsive phase 40% Increase Immediate postpartum 70-80% Increase

Heart rate All stages Increase

CVP All stages Increase

Hemodynamics during puerperium

Parameter Postpartum Percentage of change_______________________________________________________________Cardiac output W/in 1hr 30% above pre-labor values 24-48 hr Just below pre-labor values 2 weeks 10% above pre-pregnant values 12-24 weeks Baseline pre-pregnancy valuesHeart rate Immediate Decrease

2 weeks Pre-pregnant values

Stroke volume 48 hr Remains above pre-labor values 24 weeks 10% above pre-pregnant

values

What is the effect of pregnancy on heart disease?

Change in New York Heart Association (NYHA) functional class between first visit and follow-up during pregnancy in patients

with predominant mitral valve disease.

Maternal outcome in patients with mitral stenosis

• Congestive heart failure– 43% vs 0% p<0.0001

• Arrhythmias– 20% vs 0% p<0.0001

• Hospitalization– 43% vs 2 p 0.001

• Mortality – 0% vs 0% p 1.0

Conclusion

• Women with VHD had a high rate of clinical deterioration

• Marked increase in morbid events during pregnancy, including CHF, arrhythmias and need to either initiate or increase cardiovascular drug therapy or to hospitalize patients during pregnancy.

What is the effect of heart disease on fetal outcome?

Fetal outcome in patients with mitral stenosis

• Preterm delivery– 35±7 vs 39±2wks p <0.0002

• IUGR– 24% vs 0% p <0.001

• Stillbirth– 4% vs 0% p 0.5

• Birth weight– 2845g vs 3372g p 0.02

Offspring risk for congenital heart defects

Defect Mother affected Father affected

(%) (%)Aortic stenosis 13–18 3 Atrial septal defect 4–4.5 1.5Atrioventricular canal 14 1Coarctation of the aorta 4 2Patent ductus arteriosus 3.5–4 2.5Pulmonic stenosis 4–6.5 2Tetralogy of Fallot 2.5 1.5Ventricular septal defect 6–10 2

Main Aims of Management

• To optimize the mother’s condition during pregnancy

• To monitor for deteriorations

• Minimize any additional load on the cardiovascular system

Management of Cardiac Disease in Pregnancy: General Principles of Management

• Women in NYHA class I and II proceed to pregnancy without morbidity.

• All women with heart disease should be managed by a multidisciplinary team.

• Antenatal management is directed towards avoiding cardiac decompensation.

• Special attention should be directed toward both prevention and early recognition of heart failure.

Warning signs of heart failure

• Persistent basilar rales, frequently accompanied by a nocturnal cough

• A sudden diminution in ability to carry out usual duties

• Increasing dyspnea on exertion• Clinical findings may include hemoptysis,

progressive edema and tachycardia

Management of Cardiac Disease in Pregnancy: General Principles of Management

• Even when pregnancy is well tolerated, infection, anemia, pain and anxiety, often result in clinical deterioration and require aggressive management.

• A clear plan for the management of labor and delivery should be established in advance

Management during Pregnancy

• In symptomatic patients, medical treatment should be the first line of management.

• Cardiac drugs commonly used during pregnancy includes β blockers, hydralazine, diuretics and digoxin.

• Advice bed rest and oxygen.

• Fetal assessment to monitor the potential problems arising from heart disease and pharmacologic treatment of the mother.

Management during Pregnancy

• Vaginal delivery is the preferred mode of delivery

• A short and pain free labor and delivery - minimize hemodynamic fluctuation

• Hemodynamic monitoring including O2 saturation, ECG, arterial pressure, pulmonary artery and wedge pressures and cardiac output especially in class III and IV patients

Management: Labor and Delivery

• Epidural analgesia – produces good analgesia without major

hemodynamic changes– It is administered in incremental doses– Slower onset of anesthesia, allows maternal CVS

to compensate for occurrence of sympathetic blockade, resulting in lower risk of hypotension and decreased uteroplacental blood flow.

Management: Labor and Delivery

Management: Labor and Delivery• Epidural analgesia – spares the lower extremity “muscle pump,” aiding

in venous return and also decreases the incidence of thromboembolic events.

• During the 2nd stage – prevent maternal effort in “pushing”

• Shorten the 2nd stage – vacuum or forceps delivery

• Fetal heart rate monitoring during labor• Induction of labor – to optimize the timing of delivery in relation to

anticoagulation and availability of medical staff• Cesarean section – obstetrics indication, specific cardiac lesions and

deterioration of cardiac performance

Management: Labor and Delivery

• Oxytocin – administered by infusion and not by bolus

• Methyergonovine and Carboprost – Produces severe hypertension, tachycardia and

increased pulmonary vascular resistance

Management: Postpartum

• High level maternal surveillance is required until the main hemodynamic changes after delivery have resolved.

• Postpartum hemorrhage, infection, anemia and thromboembolism are much more serious complications in those with heart disease.

Management: Postpartum

Management: Postpartum

• Recent review of parturients with heart disease found that the worst cardiac compromise did not always occur at the time of delivery.

Thank You