heartdiseaseinpregnancy-210607102252.pptx

Heart disease in pregnancy

1. HEART DISEASE IN PREGNANCY Dr. Deepika Agarwal Moderator: Dr. Sonika Sharma

2. Incidence

3. EFFECT OF CARDIOVASCULAR PHYSIOLOGY ON HEART LESION

4. Factors responsible for cardiac failure:

5. EFFECTS OF HEART LESION ON PREGNANCY

6. New York Heart Association Cardiac Functional Classification Class I No limitations of physical activity; ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Class II Slight limitation of physical activity; ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Class III Marked limitation of physical activity; less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Class IV Inability to perform any physical activity without discomfort; symptoms of cardiac insufficiency or anginal syndrome may be present, even at rest; any physical activity increases discomfort

7. Risk of Maternal and Fetal Morbidity Associated with Pregnancy Low Risk Mitral valve prolapse without severe regurgitation Atrial and ventricular septal defect previously repaired or without pulmonary hypertension Corrected congenital heart disease without residual cardiac dysfunction Patent ductus arteriosus Pulmonary stenosis Mild mitral or aortic valvular disease (stenosis or regurgitation) with normal left ventricular function: New York Heart Association class I or II

8. Risk of Maternal and Fetal Morbidity Associated with Pregnancy Continued... Moderate Risk Marfan’s syndrome with normal aorta History of peripartum cardiomyopathy with no residual ventricular dysfunction Previous myocardial infarction

9. Risk of Maternal and Fetal Morbidity Associated with Pregnancy Continued... High Risk Any condition with New York Heart Association class III or IV. Moderate to severe systemic ventricular dysfunction Pulmonary hypertension from any cause Tetralogy of Fallot; uncorrected or with residual disease Coarctation of the aorta Mitral stenosis with atrial fibrillation Severe aortic stenosis Mechanical valve requiring anticoagulation Marfan’s syndrome with aortic involvement History of peripartum cardiomyopathy with residual ventricular dysfunction

10. Risks of Maternal Mortality with Heart Disease (NYHA, 1992) Cardiac Disease Mortality(%) Group 1 (minimal risk): ASD, VSD, PDA, Fallot tetralogy (corrected), Mitral stenosis (NYHA– Grade I and II), bioprosthetic valve 0-1% Group 2 (moderate risk): MS (NYHA – III and IV) AS, Marfan syndrome (Normal aorta), Fallot tetralogy (uncorrected), M S with atrial f brillation, artif cial valve 5-15% Group 3 (major risk): Pulmonary hypertension, Marfan syndrome (aortic involvement), aortic coarctation with valvular involvement 25-50%

11. PROGNOSIS

12. Maternal prognosis Nature of lesion. Functional capacity of the heart. Quality of medical supervision provided during pregnancy, labor and puerperium. Presence of other risk factors. Whether patient has undergone corrective surgery or not.

13. Maternal mortality is lowest in rheumatic heart lesions and acyanotic group of heart diseases—less than 1%. With elevation of pulmonary vascular resistance especially with cyanotic heart lesions, the mortality may be raised to even 50% (Eisenmenger’s syndrome). Most of the deaths occur due to cardiac failure and the maximum deaths occur following birth.

14. The other causes of death are—(a) pulmonary edema (b) pulmonary embolism (c) active rheumatic carditis (d) subacute bacterial endocarditis and (e) rupture of cerebral aneurysm in coarctation of aorta. Pregnancy does not affect the long term survival of a woman with rheumatic heart lesion provided she survives pregnancy itself.

15. Fetal prognosis In rheumatic heart lesions, the fetal outcome is usually good and in no way different from the patients without any heart lesion. In cyanotic group of heart lesion, there is increased fetal loss (45%) due to abortion, IUGR and prematurity. Fetal congenital cardiac disease is increased by 3–10% if either of the parents have congenital lesions.

16. Risk of Congenital Heart Defect in Offspring of Women with Congenital Heart Disease Congenital heart defect Neonatal risk(%) Any defect 5-6 ASD 4-6 VSD 6-10 Tetralogy of Fallot 3-5 Transposition of great vessels Aortic Coarctation 4 Aortic Stenosis 4-18 Pulmonary stenosis 3-4 Ebstein’s anomaly 4-6

17. DIAGNOSIS

18. Symptoms Symptoms Signs Breathlessness Chest murmurs—pansystolic, late systolic, louder ejection systolic or diastolic associated with a thrill. Nocturnal cough Cardiac enlargement, arrhythmia Syncope CXR (using lead shield): Cardiomegaly, increased pulmonary vascular markings, enlargement of pulmonary veins. Chest pain Electrocardiography: T wave inversion, biatrial enlargement, dysrhythmias Echocardiography (color flow Doppler study): Structural abnormalities (ASD, VSD), valve anatomy, valve area, function, left ventricular ejection fraction, pulmonary artery systolic pressure Cardiac MRI can delineate complex anatomy

19. MANAGEMENT

20. GENERAL MANAGEMENT

21. Prepregnancy : Ideally in patients with significant heart disease, pregnancy is a planned event. The patient’s cardiologist should be an active participant. Maternal disease status should be determined. A careful history is obtained to identify previous cardiac complications, including arrhythmias. The patient’s functional status should also be established by New York Heart Association (NYHA) classification system.

22. Prenatal

23. Therapeutic Termination

24. DURING LABOR

25. MANAGEMENT OF CARDIAC FAILURE IN PREGNANCY

26. PREDICTORS OF ADVERSE MATERNAL OUTCOMES

27. RHEUMATIC HEART DISEASE

28. Rates of IUGR and prematurity are increased with complicated rheumatic heart disease.

29. General management

30. MITRAL STENOSIS

31. MANAGEMENT

32. PREPREGNANCY

33. In symptomatic patients or those with severely stenotic valves, surgical correction should take place before conception. Surgical commissurotomy (traditional treatment modality). Percutaneous mitral valve commissurotomy (an alternative in patients without calcified valves or significant regurgitation).

34. PRENATAL

35. LABOR AND DELIVERY

36. Family planning

37. AORTIC STENOSIS

38. Management

39. Cardiomyopathies

40. Peripartum cardiomyopathy

41. Management

42. Prepregnancy

43. Prenatal

44. Labor and Delivery and postpartum

45. CONGENITAL HEART DISEASE

46. Acyanotic ASD(Ostium secundum-most common) VSD PDA Mitral valve prolapse Cyanotic Fallot’s Tetralogy Eisenmenger’s syndrome

47. C. Others Coarctation of aorta Primary Pulmonary Hypertension Marfan’s syndrome