final pregnancy hd
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Heart Diseases in Heart Diseases in PregnancyPregnancy
Faisal Alatawi ,M.DFaisal Alatawi ,M.D
Consultant CardiologistConsultant Cardiologist
PSCCPSCC
OutlineOutline
PhysiologyPhysiology
Incidence& Risk assessment Incidence& Risk assessment
Congenital heart diseaseCongenital heart disease
Acquired heart disease Acquired heart disease
AnticoagulationAnticoagulation
SBE prophylaxisSBE prophylaxis
Basic heamodynamicsBasic heamodynamics
Stroke volume(SV)=amount of blood Stroke volume(SV)=amount of blood ejected per cycleejected per cycle
COP=SV*HRCOP=SV*HR
Blood pressure=COP*SVR Blood pressure=COP*SVR
Starling’s low:increase preload SVStarling’s low:increase preload SV
Systemic vas. resistance(SVR) SVSystemic vas. resistance(SVR) SV
Heamodynamics In pregnancyHeamodynamics In pregnancy
Heamodynamics In pregnancyHeamodynamics In pregnancy
Haemodynamic changesHaemodynamic changes
Supine hypotensive (uterocaval) syndrome Supine hypotensive (uterocaval) syndrome of pregnancy occurs in 11 % of womenof pregnancy occurs in 11 % of women
Decrease HR&BP due to compresion on Decrease HR&BP due to compresion on IVCIVC
Weakness ,nausea and dizziness even Weakness ,nausea and dizziness even syncope avoid by lateral positioningsyncope avoid by lateral positioning
Haemodynamic changesHaemodynamic changes
Changes during labor:Changes during labor:
3 fold increase in oxygen consumption3 fold increase in oxygen consumption
Increase COIncrease CO
Increase in BP mainly in 2Increase in BP mainly in 2ndnd stage stage
Pain reduction, local and epidual Pain reduction, local and epidual anesthesia limit hamodynamic changes anesthesia limit hamodynamic changes and O2 consumption and O2 consumption
The hemodynamic changes during The hemodynamic changes during the the post-partumpost-partum state state
Mainly due to relief of vena caval Mainly due to relief of vena caval compression after delivery.compression after delivery.
Increase in venous return augments Increase in venous return augments cardiac output and causes a brisk diuresis. cardiac output and causes a brisk diuresis.
The hemodynamic changes return to the The hemodynamic changes return to the pre-pregnant baseline within 3 to 4 weeks pre-pregnant baseline within 3 to 4 weeks following deliveryfollowing delivery
Characteristic Characteristic signs and symptomssigns and symptoms of normal of normal pregnancypregnancy
Due to hemodynamic changes associated with pregnancyDue to hemodynamic changes associated with pregnancy
Fatigue, dyspnea, and decreased exercise capacity. Fatigue, dyspnea, and decreased exercise capacity.
Pregnant women usually have peripheral edema and jugular venous Pregnant women usually have peripheral edema and jugular venous distension.distension.
Most pregnant women have Full and collapsing pulseMost pregnant women have Full and collapsing pulse
Displaced and enlarged apex, RV heaveDisplaced and enlarged apex, RV heave
A physiologic third heart sound (S3), reflecting the volume overloaded state, A physiologic third heart sound (S3), reflecting the volume overloaded state, can often be appreciatedcan often be appreciated
Most have audible physiologic systolic murmurs, created by augmented Most have audible physiologic systolic murmurs, created by augmented blood flow.blood flow.
Normal exam can mimic heart disease Normal exam can mimic heart disease
Not normal : S4, Loud SM, DM, Fixed split S2Not normal : S4, Loud SM, DM, Fixed split S2
Cardiac assessmentCardiac assessment
Electrocardiogram:Electrocardiogram: The electrocardiogram may reveal a leftward shift of the electrical axis, especially The electrocardiogram may reveal a leftward shift of the electrical axis, especially during the third trimester when the diaphragm is pushed upwards by the uterusduring the third trimester when the diaphragm is pushed upwards by the uterus
Chest radiograph:Chest radiograph: Routine chest radiographs should be avoided, especially in the first trimester Routine chest radiographs should be avoided, especially in the first trimester
Echocardiography :Echocardiography :Of choice tool for diagnosis and evaluation of suspected cardiac disease in the Of choice tool for diagnosis and evaluation of suspected cardiac disease in the pregnant patient.pregnant patient.
Normal changes attributable to pregnancy include increased left ventricularNormal changes attributable to pregnancy include increased left ventricular mass and mass and dimensionsdimensions
27 years female 27 years female
,pregnant,pregnant
C/O SOBC/O SOB
EchocardiographyEchocardiography
Heart disease in pregnancyHeart disease in pregnancy
1-4% of pregnancies involve maternal CV 1-4% of pregnancies involve maternal CV diseasesdiseases
CV disease does not preclude pregnancy CV disease does not preclude pregnancy but poses increased risk to mother and but poses increased risk to mother and fetusfetus
RISK ASSESSMENT RISK ASSESSMENT
Preconception counselingPreconception counseling
Discussion of contraception,Discussion of contraception,
Maternal and fetal risks during pregnancy,Maternal and fetal risks during pregnancy,
Potential long-term maternal morbidity and Potential long-term maternal morbidity and mortality.mortality.
The New York Heart Association(NYHA) The New York Heart Association(NYHA) functional class is often used as a predictor of functional class is often used as a predictor of outcome.outcome.
RISK ASSESSMENTRISK ASSESSMENT
Women with NYHA class III and IV Women with NYHA class III and IV face a mortality rate upwards of 7% face a mortality rate upwards of 7% and a morbidity rate of over 30%. and a morbidity rate of over 30%.
These women should be strongly These women should be strongly cautioned against pregnancy.cautioned against pregnancy.
In a study of 252 completed pregnancies in In a study of 252 completed pregnancies in women with cardiac disease, five factors were women with cardiac disease, five factors were found to be predictive of maternal cardiac found to be predictive of maternal cardiac complicationscomplications
Prior CHF, TIA, stroke or arrhythmiaPrior CHF, TIA, stroke or arrhythmia
Baseline NYHA class >II or cyanosisBaseline NYHA class >II or cyanosis
Left heart obstructionLeft heart obstructionMVA <2 cmMVA <2 cm22, AVA <1.5cm, AVA <1.5cm
LVOT gradient >30 mm Hg by echoLVOT gradient >30 mm Hg by echo
systemic vent dysfunction (EF <40%)systemic vent dysfunction (EF <40%)
RISK ASSESSMENTRISK ASSESSMENT
Low RiskLow Risk
Ventricular septal defect Ventricular septal defect
Atrial septal defectAtrial septal defect
Patent ductus arteriosus Patent ductus arteriosus
Asymptomatic AS with low mean gradient and normal LV function Asymptomatic AS with low mean gradient and normal LV function (EF>50%) (EF>50%)
AR with normal LV function and NYHA class I or II AR with normal LV function and NYHA class I or II
MVP (isolated or with mild/moderate MR and normal LV function) MVP (isolated or with mild/moderate MR and normal LV function)
MR with normal LV function and NYHA class I or II MR with normal LV function and NYHA class I or II
Mild/moderate MS (MVA >1.5 cmMild/moderate MS (MVA >1.5 cm22, mean gradient <5 mm Hg) without , mean gradient <5 mm Hg) without severe pulmonary hypertension severe pulmonary hypertension
Mild/moderate PS Mild/moderate PS
Repaired acyanotic congenital heart disease without residual cardiac Repaired acyanotic congenital heart disease without residual cardiac dysfunctiondysfunction
Intermediate RiskIntermediate Risk
Large left to right shunt Large left to right shunt
Coarctation of the aorta Coarctation of the aorta
Marfan's syndrome with a normal aortic root Marfan's syndrome with a normal aortic root
Moderate/severe MS Moderate/severe MS
Mild/moderate AS Mild/moderate AS
Severe PS Severe PS
History of prior peripartum cardiomyopathy with History of prior peripartum cardiomyopathy with no residual ventricular dysfunction no residual ventricular dysfunction
High risk High risk
Eisenmenger's syndrome Eisenmenger's syndrome
Severe pulmonary hypertension Severe pulmonary hypertension
Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, tricuspid atresia) tricuspid atresia)
Marfan's syndrome with aortic root or valve involvement Marfan's syndrome with aortic root or valve involvement
Severe AS with or without symptoms Severe AS with or without symptoms
Aortic and/or mitral valve disease with moderate/severe LV dysfunction Aortic and/or mitral valve disease with moderate/severe LV dysfunction (EF<40%) (EF<40%)
NYHA class III to IV symptoms associated with any valvular disease or NYHA class III to IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology with cardiomyopathy of any etiology
History of peripartum cardiomyopathy with persistent LV dysfunctionHistory of peripartum cardiomyopathy with persistent LV dysfunction
AS = aortic stenosis, LV = left ventricle, EF = ejection fraction, AR = aortic regurgitation, NYHA = New York Heart Association, MVP = mitral valve prolapse, MS = mitral stenosis, MVA = mitral valve area, PS = pulmonary stenosis, TOF = tetralogy of Falot, TA = Truncus arteriosus, TGA = transposition of the great arteries Adapted from reference 3.
High riskHigh risk
The high-risk conditions are associated The high-risk conditions are associated with increased maternal and fetal with increased maternal and fetal mortality. Pregnancy is not advised.mortality. Pregnancy is not advised.
If pregnancy should occur, therapeutic If pregnancy should occur, therapeutic abortion to be considered . abortion to be considered .
These patients are best managed with the These patients are best managed with the assistance of a cardiologistassistance of a cardiologist
Women with congenital heart Women with congenital heart disease outcome of pregnancydisease outcome of pregnancy
Good outcome is expected in Good outcome is expected in presence of acyanotic CHDpresence of acyanotic CHD– Disease natureDisease nature– Surgical repairSurgical repair– PAP, LV dysfunction,PAP, LV dysfunction,– Functional capacity Functional capacity – LV obstructionLV obstruction– ArrhythmiaArrhythmia
Fetal wastage in 45 % of cyanotic mothers Fetal wastage in 45 % of cyanotic mothers compared tocompared to 20 % in non cyanotic20 % in non cyanoticLow birth weightLow birth weight Prematuritey Prematuritey Risk of Cong.HD (4 to 8 %) Risk of Cong.HD (4 to 8 %)
Women with congenital heart Women with congenital heart disease outcome of pregnancydisease outcome of pregnancy
Women with congenital heart Women with congenital heart disease :disease :Labor and deliveryLabor and delivery
Elective induction of labor when maturity is Elective induction of labor when maturity is confirmedconfirmed
Vaginal delivery is recommendedVaginal delivery is recommended
Oxygen, pain control, fluid loss Oxygen, pain control, fluid loss management, Antibiotic prophylaxis management, Antibiotic prophylaxis
ASDASD– Well tolerated even with large shunts. No Well tolerated even with large shunts. No
need for AB prophylaxis( if no association)need for AB prophylaxis( if no association)
VSDVSD– Usually tolerated. CHF, arrhythmia are Usually tolerated. CHF, arrhythmia are
reported. Hypotension and fluid loss can reported. Hypotension and fluid loss can enhance shunt reversal in those with enhance shunt reversal in those with pulmonary HTNpulmonary HTN
PDAPDA– Shunt reversal need to be avoided. CHF has Shunt reversal need to be avoided. CHF has
been reportedbeen reported
Congenital Aortic StenosisCongenital Aortic Stenosis– Moderate and severe AS has been associates Moderate and severe AS has been associates
with maternal morbidity and mortalitywith maternal morbidity and mortality– Symptoms include SOB, chest pain and Symptoms include SOB, chest pain and
syncopesyncope– Severe AS managed by abortion followed by Severe AS managed by abortion followed by
AVR, or continuation of pregnancy with AVR, or AVR, or continuation of pregnancy with AVR, or AVB in case of clinical deteriorationAVB in case of clinical deterioration
AO CoarctationAO Coarctation– HTN, CHF, Aortic dissection have been HTN, CHF, Aortic dissection have been
reported. Avoid exertion, control BP reported. Avoid exertion, control BP
Pulmonary StenosisPulmonary Stenosis– Well tolerated. Balloon valvoplasty is Well tolerated. Balloon valvoplasty is
considered in case of progressive R considered in case of progressive R ventricular failure, increased cyanosis due to ventricular failure, increased cyanosis due to associated shuntsassociated shunts
Tetrology Of FallotTetrology Of Fallot– Repaired ( do well)Repaired ( do well)– Un repaired or those with residual lesions Un repaired or those with residual lesions
have increase risk mainly due to deterioration have increase risk mainly due to deterioration of cyanosisof cyanosis
Eisenmenger SyndromeEisenmenger Syndrome
High risk of maternal morbidity and mortality (40 %)High risk of maternal morbidity and mortality (40 %)
Pregnancy is not allowed, and abortion is recommended.Pregnancy is not allowed, and abortion is recommended.
Close follow-up for those insist to proceed with Close follow-up for those insist to proceed with
pregnancy. hyperviscositey, infection should be pregnancy. hyperviscositey, infection should be
monitored. Anticoagulation is recommended in third monitored. Anticoagulation is recommended in third
trimester.trimester.
Vaginal delivery is preferred with shortening of 2Vaginal delivery is preferred with shortening of 2ndnd stage. stage.
Inhaled NO has been used to reduce PAP and improve Inhaled NO has been used to reduce PAP and improve
oxygenation oxygenation
Women with Rhematic HDWomen with Rhematic HDAcute RF:rare during pregnancyAcute RF:rare during pregnancy
Chronic RHDChronic RHD
Restriction of activity in symptomatic patientsRestriction of activity in symptomatic patients
Antibiotic prophylaxisAntibiotic prophylaxis
Haemodynamic monitoring during labour and 24 Haemodynamic monitoring during labour and 24
hour post partum in patients who hadhour post partum in patients who had– LV FailureLV Failure
– with severe diseasewith severe disease
– pulmonary HTNpulmonary HTN
Rheumatic heart disease in Rheumatic heart disease in pregnancy pregnancy
Stenotic lesions: get worseStenotic lesions: get worse– Because of increase flowBecause of increase flow
Regurgitant Lesions : well tolerated Regurgitant Lesions : well tolerated – Because of decrease vascular resistantBecause of decrease vascular resistant
Rheumatic Mitral stenosis Rheumatic Mitral stenosis
Increase maternal morbidity but no mortalityIncrease maternal morbidity but no mortality
Symptoms in moderate and severe stenosis Symptoms in moderate and severe stenosis worsens by 1, or 2 NYHA classworsens by 1, or 2 NYHA class
Increased blood volume, HR increase MV Increased blood volume, HR increase MV gradient and hence LA pressure and predispose gradient and hence LA pressure and predispose AF and pulmonary edema. AF and pulmonary edema.
Rx: activity restriction, fluid and salt restriction. Rx: activity restriction, fluid and salt restriction. B-blockers, digoxin, diuretics.B-blockers, digoxin, diuretics.
In severe cases unresponsive to medical In severe cases unresponsive to medical therapy Balloon valvoplastey or surgery is therapy Balloon valvoplastey or surgery is recommendedrecommendedMaternal Risk of MV repair or replacement Maternal Risk of MV repair or replacement is comparable to non pregnant women.is comparable to non pregnant women.Foetal daeth during open heart surgery Foetal daeth during open heart surgery (20-30%)(20-30%) Closed commissurotomy is associated Closed commissurotomy is associated with minimal risk to the fetus. with minimal risk to the fetus.
Rheumatic Mitral stenosis Rheumatic Mitral stenosis
Rheumatic heart disease in Rheumatic heart disease in pregnancy pregnancy
MR is well toleratedMR is well toleratedAR well tolerated AR well tolerated
Aortic stenosis : severe disease mandate Aortic stenosis : severe disease mandate termination or valve surgery,Valvoplasty in termination or valve surgery,Valvoplasty in experienced center experienced center
Present in 1.2 % of pregnant womenPresent in 1.2 % of pregnant women
B-blockers can be used for significant B-blockers can be used for significant
symptomssymptoms
AB prophylaxis:if associated with MRAB prophylaxis:if associated with MR
Mitral valve prolapse
Marfan syndromeMarfan syndrome
Patients with dilated aorta or with history of Patients with dilated aorta or with history of dissection should be advised against pregnancydissection should be advised against pregnancy
Progressive dilatation of the aorta leading to AR Progressive dilatation of the aorta leading to AR and CHF. Aortic dissectionand CHF. Aortic dissection
Aortic diameter less then 40 mm is usually Aortic diameter less then 40 mm is usually toleratedtolerated
Avoid physical exertion. B-blocker decrease Avoid physical exertion. B-blocker decrease aortic dilatationaortic dilatation
CS is preferred in patients with dilated aorta or CS is preferred in patients with dilated aorta or with dissection with dissection
Cardiomyopathy: Cardiomyopathy: HOCMHOCM
CHF is reported in 20 % of patientsCHF is reported in 20 % of patients
Arrhythmias (SVT,AF, VT). SCDArrhythmias (SVT,AF, VT). SCD
Up to 50% inheritanceUp to 50% inheritance
Rx: B-blockers, Ca-channel blockers, diuretics. Pacing. Rx: B-blockers, Ca-channel blockers, diuretics. Pacing. ICD ICD
Vaginal delivery with shortening of 2Vaginal delivery with shortening of 2ndnd stage. stage.
Spinal and epidural anesthesia should be used with Spinal and epidural anesthesia should be used with caution.caution.
Fluid replacement and AB prophylaxis Fluid replacement and AB prophylaxis
Peripartum cardiomyopathyPeripartum cardiomyopathy
Form of DCM reported in up to 1in 1000 in Form of DCM reported in up to 1in 1000 in certain parts of Africa. Develop during certain parts of Africa. Develop during pregnancy or 6 mo post partumpregnancy or 6 mo post partumCommon in multiparous, preeclampsia, and twin Common in multiparous, preeclampsia, and twin pregnancy, as well as in women > 30 ypregnancy, as well as in women > 30 yUnknown etiologyUnknown etiology50 to 60 % of patients show complete or near 50 to 60 % of patients show complete or near complete recoverycomplete recoveryDeath or cardiac Tx in 12 to 18 %Death or cardiac Tx in 12 to 18 %Relapse can occur with a mortality of 2 % in Relapse can occur with a mortality of 2 % in those with recovered LVF, and up to 17 % in those with recovered LVF, and up to 17 % in those with residual LVD. those with residual LVD.
CAD In PregnancyCAD In Pregnancy
Exclude Coronaries and aortic dissectionExclude Coronaries and aortic dissection
Coronary angio, aortic imaging Coronary angio, aortic imaging
PCI, CABGPCI, CABG
ThrombolysisThrombolysis
Consider if angio not availableConsider if angio not available
High-riskHigh-risk
Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy
Most CV drugs cross placenta and Most CV drugs cross placenta and secreted in breast milksecreted in breast milk
Weigh risk/benefit ratio - avoid when Weigh risk/benefit ratio - avoid when possible possible
Use drugs with long safety recordUse drugs with long safety record
Prescribe lowest dose for shortest durationPrescribe lowest dose for shortest duration
Avoid multi-drug regimensAvoid multi-drug regimens
No drug is completely safeNo drug is completely safe
Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy
ACE inhibitors - ContraindicatedACE inhibitors - Contraindicated
30% fetal morbidity 30% fetal morbidity
Fetal renal tubular dysplasiaFetal renal tubular dysplasia
Neonatal renal failure - oligohydramniosNeonatal renal failure - oligohydramnios
Lack of cranial ossification, IUGRLack of cranial ossification, IUGR
Angiotensin II receptors blocker - Angiotensin II receptors blocker - contraindicatedcontraindicated
Beta - blocker In PregnancyBeta - blocker In Pregnancy
Effective and relatively safeEffective and relatively safe
Metoprolol, Atenolol, LabetalolMetoprolol, Atenolol, Labetalol
IndicationsIndications
Arrhythmias, aortic disease, HCM, HTNArrhythmias, aortic disease, HCM, HTN
Concerns - fetal and neonatalConcerns - fetal and neonatal
IUGR, apnea, HR, hypoglycemiaIUGR, apnea, HR, hypoglycemia
Calcium Antagonists In Calcium Antagonists In PregnancyPregnancy
Relatively safe for mother and fetusRelatively safe for mother and fetus
Tocolytic effect - stop near termTocolytic effect - stop near term
Dysfunctional labor, postpartum hemorrhageDysfunctional labor, postpartum hemorrhage
May uteroplacental perfusionMay uteroplacental perfusion
Beta-blocker preferred if toleratedBeta-blocker preferred if tolerated
Diuretics In PregnancyDiuretics In Pregnancy
Best not to use during pregnancyBest not to use during pregnancy
Fetal electrolyte and platelet effectFetal electrolyte and platelet effect
maternal intravascular volumematernal intravascular volume
utero-placental perfusionutero-placental perfusion
Use only in setting of CHFUse only in setting of CHF
Better to start before pregnancyBetter to start before pregnancy
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Hematological changesHematological changes
clotting factor concentrationclotting factor concentration
platelet adhesivenessplatelet adhesiveness
fibrinolysisfibrinolysis
risk thrombosis and embolismrisk thrombosis and embolism
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Low Dose AspirinLow Dose Aspirin
Safe - antithrombotic effect not provenSafe - antithrombotic effect not proven
Recommended for pt with shunts, cyanosis and Recommended for pt with shunts, cyanosis and biological valvesbiological valves
Possible incidence of preeclampsiaPossible incidence of preeclampsia
Low molecular weight heparinLow molecular weight heparin
Not enough information available in Not enough information available in
Thrombolytic therapyThrombolytic therapy
Emergency use onlyEmergency use only
Warfarin EmbryopathyWarfarin Embryopathy
Bone and cartilaginous abnormality 30%Bone and cartilaginous abnormality 30%
ChondrodysplasiaChondrodysplasia
Nasal hypoplasiaNasal hypoplasia
Optic atrophy with micropthalmiaOptic atrophy with micropthalmia
Developmental delayDevelopmental delay
Miscarriage or stillbirth 37%Miscarriage or stillbirth 37%
Very low risk <5mgVery low risk <5mg
Bio-Prosthetic Valves: Bio-Prosthetic Valves: PregnancyPregnancy
Tissue prosthesisTissue prosthesis
degeneration in degeneration in young young
73% in 10 years 73% in 10 years
Accelerated Accelerated degenerationdegeneration
Possible in Possible in pregnancypregnancy
Reoperation riskReoperation risk
Metallic Valve Disease In Metallic Valve Disease In PregnancyPregnancy
MechanicalMechanical Thrombosis riskThrombosis risk
High mortality 10%High mortality 10%
Limited Rx optionsLimited Rx options
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Labor and DeliveryHigh Risk Time
Planned DeliveryStop heparin peripartum
Resume after 4 - 6 hr
IE Prophylaxis In PregnancyIE Prophylaxis In Pregnancy
AHA guidelinesAHA guidelines
IE prophylaxis not required during IE prophylaxis not required during uncomplicated deliveryuncomplicated delivery
Not required Not required
Isolated ASDIsolated ASD
6 months after PDA or VSD closure6 months after PDA or VSD closure
Reasonable to administer IEReasonable to administer IE
prophylaxis in high-risk patientsprophylaxis in high-risk patients
Endocarditis ProphylaxisEndocarditis Prophylaxis
GI/GU regimenGI/GU regimen
Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) im Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) im
or iv 30 min before procedureor iv 30 min before procedure
6 hrs later6 hrs later
Ampicillin 1 gm im or iv or Amoxicillin 1 gm poAmpicillin 1 gm im or iv or Amoxicillin 1 gm po
PCN allergicPCN allergic
Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5 Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5 mg/kg (<120 mg) im or ivmg/kg (<120 mg) im or iv
Complete Rx within 30 min of procedureComplete Rx within 30 min of procedure
Thank you Thank you
Best LuckBest Luck