cardiac disease in pregnency

7/29/2019 Cardiac Disease in Pregnency

1/35

By

PROF. AZRA SAEED AWANPROF OBG UNIT IIIIMC RAILWAY HOSPITAL RAWALPINDI


2/35

Incidence 3 3.5 %3rd most common non-obst cause of

maternal death

Maternal mortality

0.5 %Most women with cardiac

abnormality do well if they areasymptomatic or only mildlysymptomatic before preg.


3/35

In addition to gestationalHTN,previously healthy women may

develop life threatening

complication of cardiomyopathy,MI & Thromboembolism,Particularly in the peripartum & post

partum period.


4/35

Cardiac output Stroke vol Heart rate BP Central VenousPressure Pul. Capillary Wedgepressure Systemic vascularresistance

40 %

10-20 bpm1st & 2nd Trimester

25 30 %


5/35

Pulmonary vascularresistance

Serum colloid

osmotic pressure Mean arterial

pressure

25 30 %10 15 %

15 mmHg


6/35

Heart rate,BP & cardiac output areinfluenced by anxiety & pain, posture,analgesia & anesthesia & mode ofdelivery

Rise in stroke vol with each contraction isattenuated by good pain relief & furtherreduced by epidural analgesia & supineposition.

G/A is associated with a rise in BP & heartrate


7/35

One litre of blood may be return tocirculation if there is no postpartum

loss.

All the changes revert rapidly during thefirst week & more slowly over the followingsix weeks but even at a year significancechanges still persist and a enhance by a

subsequent preg


8/35

Venous dilation & increase blood flow Venous pressure rises upto 5 cm Blood pressure is reduce First heart sound - loud Second heart sound

splitting

Physiological third heart sound Systolic ejection murmur Venous hums & mammary souffles


9/35

Axis shift superiorly in late preg T Wave inversion in the right precordial

ECOCARDIOGRAPHY

Enables any suspected cardiac abnormality tobe recognized


10/35

Class I

Class II

Class III

Class IV

No breathlessness /Uncompromise

Breathlessness on severe

exertion/ slightly compromisedBreathlessness on mild

exertion/moderatelycompromised

Breathlessness at rest/severecompromised


11/35

Congenital Acquired

AcynoticCynotic

Cardiomyopathy


12/35

PRENATAL MATERNAL SURVILLANCE

Detail Hx &Ex Regular cardiology consultation

/echocardiography Assess functional class of heart dis

(NYHA) Routinely examine every wk / visit

B.P, pulse, chest, cough, sore thoart,dental caries, wt gain.


13/35

Cyanotic heart disease DCM with CCF

Pulmonary HTN

Marfan syndrome Heart lung transplant

IHD with persistent Angina or CCF


14/35

Restrict physical activity / adequate rest/ avoid undue strain or stress especiallyin late preg

Iron &Folic acid supplementation-treat

anaemia vigorouslyCompetent dental care and oral hygienemandatory /tooth extraction coveredwith antibiotic

Prompt T/M of respiratory infection


15/35

Avoid diuretic & do not restrict sodium Avoid supine position & abdominal

compression

Elastic stocking / tights (Prosthetic valve,Cardiomyopathy, Fallot,& Eisenmenger)

Hospital admission if Any deterioration of condition

Acute complication Few days before term for rest & assessment


16/35

Avoid complete immobilization (danger ofvenous thrombosis)

IOL for obstetric indication

FETAL SURVILLANCE IUGR

Congenital anomaly scan 18-20 wks

Fetal echo 20-22 wks

Fetal growth charting charting & umbilical arteryDoppler wkly after 32 wks if IUGR suspected thenearlier 24 wks monthly size


17/35

IST STAGE OF LABOUR Prop up

Left lateral position

Oxygen administration intermittently or

continuously if any dyspnoea or cyanosis Restrict I/V fluid /prevent dehydration

Oxytocin with extreme caution Cardiomyopathy

Fallot Eisenmenger S


18/35

Endocarditis prophylaxis Prosthetic valve / bioprosthetic homograft Previous SBE Surgically corrected systemic-pulmonary shunts

HCM / Cardiomyopathy

Structural heart defect except repaired PDA, MV prolapsewithout regurgitation, ASD ,>6 months after Repair of VSD& ligation of PDA

AMOXYCILLIN 1 GM I/V OR I/M PLUS GENTAMYCIN 120MGI/V OR I/M at the onset of labour or rupture of membrane

Allergy to PENCILLIN then ERYTHROMYCIN / VANCOMYCIN1GM and if RFTS derranged then KENAMYCIN


19/35

Adequate analgesia Morphine derivatives

Moderately / severe disease EPIDURALANAESTHESIA

CTG 2 hrly with intermittent fetal heartascultation


20/35

Do not allow forceful bearing down for morethan a few contraction

Routine prophylactic instrumental deliveryunnecessary

C-SEC for obst. Indication with low thresholdin dysfunctional labour under epidural orspinal anaesthesia preferably by experienced

anaesthetic


21/35

Regional

small serial boluses G / A Benzodiazepine & Narcotics

Inhaled only low dose

NO EPIDURAL ANAESTHESIA IN EISENMENGERSYNDROME


22/35

Use I/V bolous inj syntocinon 5 units orinfusion (careful in CCF )

ERGOMETRINE I/V OR I/M ISCONTRAINDICATED


23/35

Counsel for contraception (6 wk postpartum).Encourage to limit family size with optimalsparing. Sterilization

Oral contraception

POP Barrier Contraception

IUCD is no preferred

Reassess cardiac status after 6 wks


24/35


25/35

Off these, 70% are familial with autosomaldominant inheritance.

CLINICAL FEATURES Chest pain or syncope, caused by left

ventricular outflow tract obstruction Double apical pulsation(palpable fourth

heart sound) Ejection systolic murmur (left ventricular

outflow obstruction) Pan-systolic murmur (mirtal regurgitaion) Arrhythmias Heart failure.


26/35

Some women may be asymptomatic, thediagnosis having been made because ofscreening following a diagnosis of HOCM in afirst-degree relative or echocardiography toinvestigate a heart murmur detected inpregnancy.

Effect of pregnancy on HOCM Mostly well tolerated in pregnancy and the

stroke volume is usually able to increase.

B-blockers should be continued or started inpregnancy for those women with symptoms.

Epidural anaesthesia/analgesia carries therisk of hypotension with consequentincreased left ventricular outflow tractobstruction.

Any hypovolaemia will have the same effectand should be rapidly and adequately


27/35

This rare condition is specific to preg.It is

defined as the development of heartfailure in the absence of a known causeand without any heart disease prior tothe last month of pregnancy.Onset isusually in the first month after

delivery,but may occur in the last monthof pregnancy and up to 5 monthspostparlum.

Risk factors include:

Multiple pregnancy Preg complicated by hypertension Multiparity Advanced maternal age

Afro-Caribbean race.


28/35

Dyspnoea Reduced exercise tolerance Palpitations Pulmonary and/or peripheral oedema Symptoms relating to peripheral or cerebral

emboli.Signs Tachycardia Pulmonary oedema Congestive cardiac failure

Dysrhythmias Signs of pulmonary,carebral and systemic

embolisation Systemic embolism occurs in 21-40% of those

affected by peri-partum cardiomyopathy, and

ischaemic stroke in about 5%


29/35

Unknown Myocarditis AutoantibodiesDiagnosis Requires ECHO Diagnostic Criteria are

Left vent ejection fraction


30/35

Thromboprophylaxis Mandatory if Severly impaired left vent dysfunction Intracardiac thrombus Arrhythmias

T/ M for heart failure

Diuretics,vasodilators, digoxin, inotropes &after delevery ACE inhibitors

Immunosupprissive Therapy Myocarditis documented by endomyocardial

biopsy Myocarditis fail to improve with in to 2 wks of

initiation of standard heart failure therapy

Cardiac Transplantation Severe cases unresponsive to conventional

and full supportive management Elective Delever If dia nosed antenatal


31/35

Maternal mortality rate-25-50% About 50% pts make a spontaneous & full

recovery Prognosis depends on normalisation of left

vent size and function with in 6 months afterdelivery.Mortality is increased with persistent

left vent dysfunction Women should be counselled against further

preg if left vent size or function does notreturn to normal because of recurrencetherefore, puerperial cardiomyopathy should

not be casually diagnose and should besupported by echocardiography at least. For those whose cardiomyopathy resolves,

the recurrence is not non (0-25%) Subsequent preg require high risk

collaborative care.


32/35

Anticoagulation through preg The interests of the mother & fetus are in

conflict.Continuation of Warfarin affords themother the risk of thrombosis, where for thefetus, WARFARIN IS ASSOCIATED WITHINCREASE RISK OF Teratogenesis, Miscarriage,

Stillbirth & intracerebral bleeding. LMWH is safe The choice of anticoagulant regimen will

depend on Position of prothesis

Types of valve replacement Pt choice

Counselling thoroughly prior to pregregarding potential risk to herself and herfetus


33/35

WARFERIN throughout preg HEPARIN b/ t 6 & 12 wks gestation followed by WARFARIN HEPARIN throughout

WARFERIN should discontinue for 10 days to 2 wksprior to delivery to allow clerance of warfarin by

fetus. While awaiting delivery , full anticoagulant doses of

either s.c heparin or LMWH or I/V heparin shouldbe used

S.C heparin should be discontinued for labour &delivery.Dose of I/V is reduced to prophylatic level-1000 units / hr


34/35

Full anticoagulant doses of heparin should beresumed a/f delivery

Warfarin may be restarted 3 5 daysfollowing de\livery

In the event of an urgent need to deliver afully anticoagulated pt, Warfarin may bereversed with FFP & vit K, & heparin andLMWH with PROTAMINE SULPHATE


35/35

Pulm oedema & heart failure-Diuretic Tachycardia Beta Blocker Atrial fibrillation Digoxin &B-blocker SURGERY

Ballon valvectomy &Closed mitral valvotomy Surgical valvectomy-risk with fetal mortalityrates 5-

15% for close & open 15-33%

cardiac disease in pregnency

Documents