96770c07-2291-46cb-851c-d0844cdfe49a.pptx

Renal parenchymal disease – CKD, PCKD, Obstructive Uropathy

1. Cardiac Diseases in
Pregnancy
Abdullah Matar Badran

Hasan Arafat

2. Subjects

* Introduction
+ Heart Diseases in Pregnancy

* Management

3. Introduction

* Normal Cardiac Changes During
Pregnancy

* Pre- Pregnancy Counselling

4. Normal Cardiac Changes During Pregnancy

+ Cardiac output increases up to 50% by 20 weeks (ie. Heart Rate,
Stroke Volume are both Increased )

* COis the lowest in supine position
* COis the highest in the left lateral position
+ CO increases progressively through the three stages of labor

+ Systolic Ejection Murmur is present due to increased CO passing
through the aortic and pulmonary valves

5. Pre-pregnancy Counselling

+ Women with heart disease should be aware of their condition prior
to pregnancy and they should be also assessed by Cardiologist “
managed or treated according to situation ”

+ Issues related to that :

- Risk of maternal death

- Possible reduction of maternal life expectancy

- Effects of pregnancy on cardiac diseases

- Risk of fetus developing Congenital Heart Disease

- Risk of preterm labor & Fetal Growth Restriction

- Intensive Maternal and Fetal monitorino durino labor

6. Heart Diseases in
Pregnancy

+ Rheumatic
* Congenital
> Arrhythmia

7. Rheumatic Heart Disease

+ The most common lesion is mitral stenosis

+ Patients are at high risk for developing heart failure, subacute
endocarditis and thromboembolic disease

* Increased risk for fetal wastage
+ Onset of pulmonary edema: 40 weeks of gestation

+ Severe MS leads to atrial fibrillation, which can lead to CHF

8. Congenital Heart Diseases

nclude atrial and ventricular septal defects, primary pulmonary
hypertension and cyanotic heart disease

Patients with complete surgical correction can tolerate pregnancy

Patients with persistent septal defect generally tolerate pregnancy

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

PH can lead to pulmonary congestion, heart failure and
hypotension, all of which can lead to sudden death

9. 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

10. Peripartum Cardiomyopathy

+ Specific to pregnant or pos

partum women

« Patient has no underlying heart disease

+ Symptoms appear in the la
months after delivery

st week of pregnancy or within 6

* Dilatational cardiomyopathy, decreased ejection fraction

« Hx of preeclampsia, hypertension or poor nourishment

* Mortality rate: 20%, persis

ence: 30%- 50%, recurrence: 20%- 50%

11. Management

Depends on two factors
+ The NYHA classification of heart

* The type of defect is important as well

12. Management

Classi N
Class II

o signs or symptoms of cardiac decompensation

o symptoms at risk, but minor limitation on
physical activity

Class III No symptoms at rest, but major limitation on

physical activity

Class IV Symptoms present at rest, increase with any

A sacl tc Pee e

13. Management (Cont'd)

* Risk for types I and Il is minimal
+ Risk for types III and IV is marked

+ Risk increases if cyanosis is present

14. Management (Cont'd)

Risk also depends on the type of defect

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

Regurgitant diseases carry a lower risk

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

15. Management: Antenatal

+ Pregnant with significant Heart Disease should be managed in a joint
obstetrician/ cardiac Clinic .

+ Physicians have to distinguish Between Normal Pregnancy changes and
impending heart failure

+ 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 examination “ Pulse rate and pressure, BP, JVP, and
sacral and ankle edema, presence of basal crackles “

16. Management: Antenatal (Cont'd)

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

+ Echocardiography is good to assess Fxn and valves,
Echocardiogram is usually done around 28 week - at the booking
visit -.

+ Avoidance of excessive weight gain and edema

+ Avoidance of Anemia

17. Management: Antenatal (Cont'd)

+ The use of anticoagulants during pregnancy is a complicated issue .

+ This is because Warfarin is teratogenic * 1* trimester’ and linked
with fetal intracranial hemorrhage “314 trimester’

+ LMWH may be insufficient at preventing thrombosis in women w/
prosthetic heart valves ( risk >10% )

* Anticoagulation is essential in patients w/ congenital heart disease

who have pulmonary hypertension or artificial valve replacement ,
or for those at risk of atrial fibrillation

**

18. Fetal Risks of Maternal Cardiac Diseases

Recurrence ( congenital Heart Disease )

Maternal cyanosis > Fetal Hypoxia

atrogenic Prematurity

« FGR

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

19. Management: Labor and Delivery

+ The aim of management is to await the onset of spontaneous labor

* Induction of labor should be considered for the usual obstetrician
Indications and in high risk women

+ 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 .

20. Management: Labor and Delivery (Cont'd)

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

* Monitoring of Oxygen Saturation and Arterial Blood Pressure is
appropriate during labor

+ The 2" stage of normal labor may be intentionally shortened using
forceps or vacuum

* CS should only be done for normal obstetrician indications

+ CS increases the risk of hemorrhage, thrombosis and infection

21. Management: Labor and Delivery (Cont'd)

+ Postpartum Hemorrhage in particular can lead to major
Cardiovascular Instability

+ 3 stage of labor is managed actively by oxytocin ONLY
“ not w/ ergometrine “

+ As oxytocin is a vasodilator, it should be administrated SLOWLY to
patients w/ significant heart disease

(w/ low-dose infusions preferable )

* High-level maternal surveillance is required until the main
hemodynamic changes following delivery have passed

22. Management: Labor and Delivery (SUMMERY)

+ Avoid induction of labor if possible

Use prophylactic Antibiotics

Ensure Fluid Balance

Avoid the supine position

Discuss the type of anesthesia w/ senior anesthetist

eep the 2" stage SHORT

Use oxytocin judiciously

23. Thank You