Cardiac Diseases in Pregnancy pptx

A simple description of heart diseases in pregnancy

1. WANYAMA RONALD STEPHEN SENIOR CLERKSHIP Cardiac Diseases in Pregnancy

2. Contents Introduction Classification Clinical presentation Investigations Management Prognosis

3. Heart diseases in pregnancy They complicate more than 1% of all pregnancies. 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 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 CO; increases by 40% from 8wks and is maximal by mid pregnancy. Blood Volume; The mean plasma volume increase is 50% over the pre pregnancy volume. This maintains a dilated sytemic vasculature. 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. 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 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. Heart Diseases in Pregnancy Rheumatic Congenital Arrhythmia Cardiomyopathy

9. 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. The most common lesion is mitral stenosis Pts are at high risk for developing HF, subacute endocarditis and thromboembolic diseases. Increased risk for fetal wastage Onset of pul . Edema : 40 WOG Severe MS leads to atrial fib. Which can lead to CHF.

10. Congenital Heart Diseases Include atrial and ventricular septal defects, primary hypertension and cyanotic heart disease. Pts with complete surgical correction can tolerate pregnancy. Pts with persistent septal defect generally tolerate pregnancy Pts with PH (primary or as a result of cyanotic heart disease) should not get pregnqnt . PH can lead to pul . Congestion, HF and hypotension, all of which can lead to sudden death.

11. 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.

12. 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 in a 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 Mortality rate:20% , persistence: 30%-50%, recurrence: 20-50%

13. Diagnosis Chest radiography (using lead shield) Cardiomegaly Increased pulmonary vascular markings Pleural effusion 2. ECG 3. Echocardiography 4. Cardiac MRI

14. Management Principles; 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.

15. Indications for termination of pregnancy Absolute Primary pulmonary hypertension Eisenmenger’s syndrome Pulmonary veno -occlusive disease Relative Parous woman with grade III and IV cardiac lesion Grade I or II with previous h/o cardiac failure in early months or in between pregnancy

16. Management (cont’d) Risk for classes i and ii is minimal Risk for classes iii and iv is marked Risk increases if cyanosis is present 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.

17. Management: Antenatal 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. 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

18. These women should be advised to reduce their normal physical activities Echocardiography is good to assess fxn and valves, echocardiogram is usually done around 28wks 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 st trimester and linked with fetal intracranial hemorrhage in 3 rd 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.

19. 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 2 nd 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

20. PPH in particular can lead to major cardiovascular instability 3 rd stages of labour is managed actively by oxytocin ONLY not with ergometrine As oxytocin is a vasodilator, it should b administered slowly to patients with significant heart disease High level maternal surveillance is requirex until the main hemodynamic changes following delivery have passed

21. In summary Avoid induction of labour if possible Use prophylactic antibiotics Ensure fluid balance Avoid the supine position Discuss the type of anesthesia with senior anethetist Keep the 2 nd stage Short Use oxytocin judiciously

22. Thank you for listening