Pregnancy & cardiac disease lecture .ppt

Cardiology lec pregnancy in cardiac disease

1. Pregnancy & Cardiac
disease
Prof. Kh. Alaghbari

2. Hemodynamic changes during
normalpregnancy
Third
trimester
Second
trimester
First trimester
Blood volume
Cardiac out put
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pressure
Systemic vascular
resistance

3. Cardiac symptoms & physical
findings during normal
pregnancy

4. symptoms
1.Decrease exercise capacity.
2.Tiredness.
3.Dyspnea.
4.Orthopnea.
5.Lightheadness
6.Syncope.

5. Physical findings

6. Inspection
•Hyperventilation .
•Peripheral oedema
•Distended neck veins with prominent A& V
waves & Brisk X & Y descent.
•Capillary pulsation .

7. Pericordial palpation
•Brisk diffuse and displaced LV impulse
•Palpable RV impulse.
•Palpable pulmonary trunk impulse

8. Auscultation
Increased S1 with exaggerated splitting
Persistent splitting of S2.
Mid –systolic ejection murmur at Left lower
edge of the sternum & or over pulmonary area
radiating to LT side of the neck
continuous murmur (cervical venous
hum,mammary soufflé
Diastolic murmur (rare)

9. ECG in normal pregnancy
QRS axis deviation
ST –T changes
Small Q & inverted P wave
in LIII (abolished by inspiration )
Increase R In V2
Frequent sinus tachycardia
Increased incidence of arrhythmia

10. Chest X-ray
Straightening of the left upper cardiac
border
Horizontal position of the heart
Increased lung marking

11. Echo-Doppler
•Increased left & right ventricular dimensions
•Unchanged or slight increased size & systolic
function of the LV
•Mild increase in Lt & Rt atrial size
•Minimal pericardial effusion
•Functional TR & PR

14. Risk assessment & general principles
of management
•Preconsiption counceling
•Contraception advise
•Discussion of preconception counceling
•Discussion of potential maternal & fetal
acute & long term morbidity & mortality

15. Risk assessment & general principles
of management
•Baseline functional class
•Severity of cardiac disease (cyanotic
congnital heart disease , Eissemenger
syndrome, Severe pulmonary
hypertension )
•LV function
•Pulmonary pressure

16. Basic management principles for pregnant
woman with valvular heart disease
-Risk Assessment in preconception
-history
-Baseline exercise tolerance & functional
class
-ECG & Echo
-Discussion with the patient about the
potential risk to self & fetus

17. Basic management principles for pregnant
woman with valvular heart disease
-Risk Assessment during pregnancy
-Follow up once per trimester
-Monitor new symptoms
-Echo with any new symptoms

18. Basic management principles for pregnant
woman with valvular heart disease
Treatment during preconception
-Safe contraception
-Valve repair or replacement prior to
conception is indicated
-Adjust medications to prevent adverse
fetal effects

19. Basic management principles for pregnant
woman with valvular heart disease
Treatment during pregnancy
-Minimize medications
-If symptoms worsen & if indicated ,
consider correction .

20. Basic management principles for pregnant
woman with valvular heart disease
Treatment during delivery
-Invasive monitoring as needed
-Cesarean section for obstetric indication
-Monitor for decompensated HF or
pulmonary edema .

21. Basic management principles for pregnant
woman with valvular heart disease
Treatment during post partum
-Adjust medications
-Consider correction of anomaly or vavluar
repair or replacement if indicated
-Treat postpartum anemia
-Counseling & contraception for future
pregnancy

22. Cardiac diseases
•4 cardiac diseases are adversely affected
by pregnancy :
1.Valvular heart disease
2.Primary pulmonary Hypertension
3.Eisenmenger syndrome
4.Marfan syndrome.

23. Mitral stenosis

24. Therapeutic approach to ptwith
significant MS
If severe MS is identified prior to pregnancy , Valvotomy should
be done before conception
Asymptomatic woman should be observed closely but no
definitive therapy
In symptomatic pt or MVA<1.5cm2, HR&blood volume should
be reduced causiously by Digoxin , B blocker& Diuretics with
decrease salts & physical activity .
Vaginal delivery can be permitted in most Pt with MS
Hemodynamic monitoring is recommended during labour
&delivery
Closed mitral valvotomy (surgical or by ballon) can be carried
out during pregnancy if symptoms are severe
Open heart surgery is associated with an increase of fetal loss

26. Mitral regurgitation
•Is usually well tolerated during pregnancy
,presumably because peripheral
resistance is low .

27. Aortic Stenosis
AS is contraindication for pregnancy untill
the lesion has been corrected
Maternal mortality of 15% has been
reported in women with critical AS

29. Artificial heart valves
☺Warfarin is contraindicated because of its
teratogeniceffect but it can be used if the
dose is less or equal 5mg
☺Heparin is preferable but it may cause
bleeding &fetal loss

30. Frequency of fetal & maternal complications according to
anticoagulant regimen used during pregnancy in women
with mechanical valve
Maternal
death%
Thromboembolic
complications %
Spontanous
abortion %
Embryopathy
%
regimen
1.8
40
6.7
4.2
3.9
60
25
9.2
25
20
25
25
6.4
0
0
3.4
Warfarin
Lowdose
heparin
Adjusted
Dose heparin
Heparin -
warfarin

31. Tissue valves
*Tissue valves are less thrombogenic, but their
limited durability in young adults is a seriouse
disadvantage
*SBE prophylaxis is mandatory in women with
artifecial valve before any surgical interferance
*in normal vaginal delivery SBE prophylaxis has
no general acceptance !!

32. Pulmonary hypertension &
Eisenmenger syndrome
PH of all causes is a strong contraindication
for pregnancy
If PPSP>45mmHg in first trimester ,termination
of pregnancy is advised
In woman with CHD, PH & Rt to Lt shunt i.e
Eisenmenger syndrome ,both maternal and fetal
mortality are high.

34. Marfan syndrome
Cardiovascular manifestations of Marfan syndrome
include (MVP, mitral and aortic abnormalities & AR due
to dilated Aortic root
When Aortic root >40mm, the risk for Aortic dissection
& rupture during pregnancy is increased so pregnancy
should be avoided in this situation
If such woman become pregnant an refuse abortion ,
Beta blockeris advised to reduced the force of
myocardial contraction & the resultant shear stress on
the aorta

36. •Other forms of cardiac
disease

37. Atrial septal defect
-In the absence of pulmonary hypertension ,
ASD is well toleratedby pregnant woman
Although the risk for fetal loss is increased

38. Ventricular septal defect
•With out PH also it is well tolerated
•But VSD is complicated by SBE , so SBE
prophylaxis at time of delivery is advised

39. Mitral valve prolapse
•MVP dose not complicate pregnancy and
not complicated by pregnancy

40. Hypertrophic cardiomyopathy
•HOCM generally tolerate pregnancy
well,indeed the gestational hypervolemia
may be associated`with reduction of
intraventricular `pressure gradient and
thus ameliorate symptoms

41. Dilated cardiomyopathy
•Because of poor prognosis DCMP with HF
is contraindication for pregnancy

42. Peripartum
cardiomyopathy
It is a form of acute dilated cardiomyopathy
appears 1 month before or during 6 months
after delivery in previously normal heart

43. Etiology
Is still unknown but it has been postulated that
PPCM may be due to :-
1.Nutritional deficiency
2.Small vessel coronary artery disease
3.Hormonal effect.
4.Toximia
5.Maternal immunological response to fetal
antigen
6.Myocarditis

44. The clinical course of PPCM varies with
approximately50-60% of pt. showing
complete recovery of clinical status &
cardiac function usually within 6 months
post partum.
The rest of the pt demonstrate either
continous clinical deterioration ,leading to
cardiac transplantation or early death or
persistant HF

45. Management
Acute HF should be treated vigrously with
O2,Diurtics, digoxin,vasodilators
Anticoagulant therapy to prevent Thrombus
formation
Avoid subsequent pregnancies.

46. Ischemicheart disease
•It is un common in pregnancy???
•In familial hypercholesterolemia, smoking,
obesity, DM, older age at conception account for
increasing numbers .
•Such woman may develop angina during
pregnancy and may need treatment by BB
&calcium antagonist
•PTCA can be performed safely with care to
minimise the radiation to the fetus in the
second trimester

47. Arrhythmias
Common arrythmia during pregnancy are PVCs
& SVT in which PVCs are well tolerated &and
dose not need treatment
Treat arrythmias by elemination of stimulants
,rest and reassurance because drug therapy
should be avoided if possible
DC shock used safely to treat tachyarrhythmias
during pregnancy

48. •In a previously a symptomatic women become
breathless during her first pregnancy .her echo shows
mitral stenosis which one of the following statements
is correct :
a.The lesion has been Unmasked by the physiological
decrease in cardiac output occuring during pregnancy
b.A dilated CMP of pregnancy is likely to have occurred
unmasking the condition
c.Most new cardiac murmurs detected in pregnancy
are related to stenotic lesions
d.She should be treated with aggressive diuretics &
pregnancy
e.Pulmonary oedema due to mitral stenosis in
pregnancy is usually best treated by valvotomy