51753251-a561-4b92-822d-142cbfd5adb7.pptx

Endocrine Causes – Primary Aldosteronism, Pheochromocytoma, Cushing Syndrome, Thyroid Disease( Hyper and Hypo ) and Thyrotoxicosis, Hyperparathyroidism , Acromegaly

1. Cardiac Diseases in Pregnancy

WANYAMA RONALD STEPHEN
SENIOR CLERKSHIP

2. Contents

+ Introduction

+ Classification

+ Clinical presentation
e Investigations

e Management

e Prognosis

3. Heart diseases in pregnancy

e They complicate more than 1% of all
pregnancies.

e They are now the leading cause of indirect
maternal deaths accounting to 20% of all cases.

+ Cardiovascular diseases also accounts for
significant maternal morbidity and are a leading
cause of obstetric ICU admission

e The increasing prevalence , is likely due to; high
rates of obesity , HTN, DM others ; delayed child
bearing, congenital heart disease

4. Normal Cardiac changes in
Pregnancy

e CO; increases by 40% from 8wks and is maximal
by mid pregnancy.

e Blood Volume; The mean plasma volume
increase is 50% over the pre pregnancy volume.
This maintains a dilated sytemic vasculature.

e Venous pressure increase, esp. In the lower
extremities, occurs in pregnancy.

+ Slight heart enlargement, due to upward and
leftward anatomic displacement of the heart.

+ Systolic ejection murmur is present due to
increased CO passing thru the aortic and pul.
valves

5. Pre-pregnancy Counselling

+ Women with CVD should be aware of their
conditions prior to pregnancy and they should be
also assessed by the Cardiologist, managed or
treated according to situation.

e Issues related to that;

> Risk of maternal death

> Possible reduction of maternal life expectancy
> Effects of pregnancy on cardiac diseases

> Risk of fetus developing CHD

> Risk of preterm labour and FGR

> Intensive maternal and fetal monitoring during
labor

6. Clinical indicators of Heart disease
during pregnancy

e Symptoms include;

= Progressive dysnea or Orthopnea or PND
= Nocturnal cough

= Hemoptysis

= Syncope

= Chest pain

7. Signs

= Cyanosis

= Finger clubbing

= Persistent neck vein distention

= Systolic murmur grade 3/6 or greater

= Diastolic murmur

= Cardiomegaly

= Persistent tachycardia and/or arrhythmia
= Persistent split heart sound

= Fourth heart sound

8. Anatomical and physiological changes during pregnancy
that mimic cardiac disease

Hyperdynamic circulation

Systolic ejection murmur at left sternal border (due to
increased blood flow across the aortic and pulmonary
valves)

Dyspnea, decreased exercise tolerance, fatigue,
syncope

Tachycardia, shift of ventricular apex

Continuous murmur at 2nd to 4th intercostal space—
mammary souffle

Loud first sound with splitting

Symptoms must be carefully assessed and investigations
are to be done to confirm the diagnosis

9. Heart Diseases in Pregnancy

+ Rheumatic
e Congenital
e Arrhythmia
+ Cardiomyopathy

10. Rheumatic Heart Disease

+ Is now distinctly uncommon in developed
countries

+ Women are at risk of developing HVHD 10-20
years after initial episode of RF.

e The most common lesion is mitral stenosis

e Pts are at high risk for developing HF, subacute
endocarditis and thromboembolic diseases.

e Increased risk for fetal wastage
e Onset of pul. Edema: 40 WOG

e Severe MS leads to atrial fib. Which can lead to
CHF.

11. Congenital Heart Diseases

e Include atrial and ventricular septal defects,
primary hypertension and cyanotic heart
disease.

+ Pts with complete surgical correction can tolerate
pregnancy.

e Pts with persistent septal defect generally tolerate
pregnancy

e Pts with PH (primary or as a result of cyanotic
heart disease) should not get pregnant.

+ PH can lead to pul. Congestion, HF and
hypotension, all of which can lead to sudden
death.

12. 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.

13. cardiomyopathy

+ DCM
Cardiac chambers are severely dilated and left ventricle is
diffusely hypokinetic, LV wall tension is increased and
systolic pump fxn progressively declines. Consequently
CO falls and filling pressure increases.-> progressive
dyspnea, edema and fatigue.estsblished DCM even ina
compansated HF , is a contraindication to pregnancy

. Peripartum Cardiomyopathy. Specific to pregnancy or
postpartum women.

pt has no underlying HD, Symptoms appear in the last wk of
preg. Or within 6 months after delivery.

RF; older maternal age, Htn, multiple gestation
aon rate:20% , persistence: 30%-50%, recurrence: 20-
o

14. Diagnosis

1. Chest radiography (using lead shield)
y Cardiomegaly
Y Increased pulmonary vascular markings
y Pleural effusion

2. ECG

3. Echocardiography

4. Cardiac MRI

15. Management

Principles;
e Early diagnosis and evaluation of anatomical type
and functional grade of the case.

+ To detect the high risk factors and to prevent
cardiac failure

+ Optimise care (Obstetrician and Cardiologist) and
ensure mandatory hospital delivery.

16. Indications for termination of
pregnancy

Absolute

y Primary pulmonary hypertension

y Eisenmenger’s syndrome

y Pulmonary veno-occlusive disease
Relative

v Parous woman with grade III and IV cardiac
lesion

y Grade | or Il with previous h/o cardiac failure in
early months or in between pregnancy

17. Management

a

ass! No signs or symptoms of cardiac decompensation

(A

ass I No symptoms at risk, but minor limitation on
physical activity

Class III No symptoms at rest, but major limitation on
physical activity

a

ass IV Symptoms present at rest, increase with any
Kind of physical activity

18. Management (cont'd)

e Risk for classes i and ii is minimal

e Risk for classes iii and iv is marked

e Risk increases if cyanosis is present

e Risk also depends on the type of defect

e Mitral and aortic stenosis (obstructive diseases)
carry a high risk for decompensation

+ Regurgitant diseases carry a lower risk

e Other high risk conditions: PH, marfan syndrome,
mechanical valve, ventricular ejection fraction
less than 40%, or a previous history of cardiac
event during pregnancy.

19. Management: Antenatal

e Pregnancy with significant HD should be
managed in a joint obstetriccian/cardiologist care.

+ Physicians have to distinguish between normal
pregnancy changes and impending heart failure.

e 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 exam: PR ‚BP JVP and sacral
and ankle edema, presence of basal crackles

20. + These women should be advised to reduce their
normal physical activities

e Echocardiography is good to assess fxn and valves,
echocardiogram is usually done around 28wks

e Avoidance of excessive weight gain and edema

+ Avoidance of anemia

The use of anticoagulant during pregnancy is a
complicated issue this is because warfarin is
tetratogenic in the 1* trimester and linked with fetal
intracranial hemorrhage in 3" trimester

Anticoagulation is essential in patients with congenital
heart disease who have pulmonary hypertension or
artificial valve replacement or for those at risk of atrial
fib.

21. Fetal Risks of Maternal Cardiac Diseases

* Recurrence ( congenital Heart Disease )
« Maternal cyanosis > Fetal Hypoxia

+ latrogenic Prematurity

+ FGR

« Effects of Maternal Drugs ( Teratogenesis , Growth Restrictions,
Fetal Loss )

22. Management: Labor and Delivery

+ The aim of management is to await the onset of
spontaneous labour.

Induction of labour should be considered for the
usual obstetrical indications and in high risk mothers.

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

Prophylactic antibiotics should be given to any woman
with cardiac defects to reduce risk of endocarditis

2nd stage of normal labour should be shortened

CS should only be done on obstetrical indications
sinceit inreases the risk og haemorrhage, thrombosis
and sepsis/infections

23. e PPH in particular can lead to major
cardiovascular instability

e 3" stages of labour is managed actively by
oxytocin ONLY not with ergometrine

e As oxytocin is a vasodilator, it should b
administered slowly to patients with significant
heart disease

e High level maternal surveillance is requirex until
the main hemodynamic changes following
delivery have passed

24. In summary

+ Avoid induction of labour if possible
e Use prophylactic antibiotics

e Ensure fluid balance

e Avoid the supine position

e Discuss the type of anesthesia with senior
anethetist

e Keep the 2" stage Short
e Use oxytocin judiciously

25. In conclusion...

Due to medical and surgical advances and advancing
maternal age, increasing incidences of cardiac disease
in pregnancy are emerging

Knowledge of cardiac physiology in pregnancy and what
to expect as to outcome in patients with cardiac diseases
is of utmost importance

Optimizing cardiac function and decreasing risk of
cardiac complications by proper management and
proper prenatal surveillance is the key

26. Thank you for listening

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