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Cardiac disease in pregnancy
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Cardiac disease in pregnancy

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  • 1. CARDIAC DISEASE IN PREGNANCY DR SHAMSA TARIQ ASSISTANT PROFESSOR GYNE /OBST UNIT II HOLY FAMILY HOSPITAL
  • 2. PHYSIOLOGIC CHANGES DURING PREGNANY     CO increases by 40%  as SV increases HR increases by 10 beats/min - 3rd trimester CO peaks at 18-24 wks then stabilize CO increase  grade II systolic flow murmur along the left sternal border without radiation
  • 3.       Diastolic murmur  if present consider pathologic  investigate IncreaseVR  Cardiac fullness & hypertrophy displacement of heart Apex beat  superiorly and laterally ECG Lt axis deviation Flattened T wave
  • 4. CARDIAC DISEASE 1. Rheumatic  90% of HD in pregnancy Reduces by 50% with better treatment of RHD and decrease pathogenisty of organism 2. Congenital  35% HD
  • 5. RHEUMATIC HEART DISEASE Mitral stenosis   Specific valvular disease Increase Risk of  Heart failure  SABE  Thromboembolic disease  Increase of fetal wastage
  • 6. MITRAL STENOSIS       90% During pregnancy  CO increase obstruction worsens Asymptomatic pt.  symptomatic Symptoms of cardiac decompensitions or pulmonary edema appear as pregnancy progresses Pt. with severe Mitral stenosis  Atrial fibrillation CCF. If Atrial fibrillation predates pregnancy  50% CCF.
  • 7. OTHER CARDIAC LESION  Mitral insufficency  Aortic stenosis
  • 8. CONGENITAL HEART DISEASE 1. 2. 3. 4. 5. Atrial septal defects Ventricular septal defects Fallot tetrology Primary Pulmonary hypertension (eisenmenger’s syndrome ) Cyanotic heart disease
  • 9. 1. Defects corrected in childhood with no residual damage pregnancy progresses without complication. 2. Atrial and ventricular septal defects + tetralogy of fallot tolerated pregnancy after surgical correction. 3. Maternal mortality increases by 25-50% in 4th and 5th condition (pregnancy and postpartum period)
  • 10. CAUSE OF DEATH Overload Pulmonary Congestion Hypotension Hypoxia Sudden death
  • 11. CARDIAC ARRHYTHMIAS Benign  Paroxysmal atrial tachycardia  Supraventicular tachycardia due to the structural changes in heart
  • 12. CARDIAC ARRHYTHMIAS Serious  Atrial fibrillation  Atrial flutter assosiated with underlying cardiac disease Management  same in pregnant & non pregnant
  • 13. PERIPARTUM & POSTPARTUM CARDIOMYOPATHY Rare  No etiological factor found  No underlying cardiac disease  Symptoms of cardiac decompensation appear during last weeks of pregnancy or ( 2-20wks) postpartum.
  • 14. Women prone to this condition gives h/o  Pre-eclampsia  Hypertension  Malnutrition
  • 15. MANAGEMENT NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION (NYHA) OF HEART DISEASE     CLASS I  No signs or symptoms of cardiac decompensation. CLASS II  No symptoms at rest but minor limitation of physical activity. CLASS III  No symptoms at rest but marked limitation of physical activity. CLASS IV  Symptoms present at rest increses discomfort with any kind of physical activity.
  • 16.  With I and II  Maternal and fetal  small  With III and IV Increases risk in both
  • 17. PRENATAL MANAGEMENT  Management with the help of cardiologist .  Frequent antenatal visit and admissions in class III and IV.
  • 18. GUIDELINES FOR MANAGEMENT 1. Avoid excessive weight gain and odema 2. Avoid sternuous activity 3. Avoid anemia 4. Early detection of a problem
  • 19. AVOID EXCESSIVE WEIGHT GAIN & ODEMA  Low sodium diet (2 gm/day)  Rest in left lateral position  Adequate sleep
  • 20. AVOID STERNUOUS ACTIVITY  Unable to increase CO  to meet demand of exercise  Extract more oxygen from arterial blood  large AV difference  uteroplacental circulation suffer
  • 21. AVOID ANEMIA  Oxygen carrying capacity decreases  increase CO  increase HR  Mitral stenosis worsens  increase heart rate  decrease in left ventricular filling time  pulmonary congestion  odema
  • 22. EARLY DETECTION OF A PROBLEM On each visit look for  Infection  Cardiac decompensation  Pulmonary congestion  Cardiac arrhythmias
  • 23. SYMPTOMS OF CARDIAC DECOMPENSATION      Pulse increases more than 100 bpm Engorged neck veins Increase JVP Liver, spleen enlarged and tender Weight gain and generalized edema Treatment  Digitalization  Diuretic
  • 24. SYMPTOMS OF PULMONARY CONGESTION 1. 2. 3. 4. Dyspnoea Orthopnea Pulmonary creptation Decrease vital capacity Mostly appear at  18-24 weeks  During labour  During delivery  Immediate postpartum
  • 25. MANAGEMENT OF LABOUR  CO increases  40-50% of pre-labour level  80% of pre-pregnancy  increase catecholamine release  pain and apprehension  abdominal and uterine muscle contractions
  • 26. TO MINIMIZE INCREASE CARDIAC OUTPUT  Assurance  Sedation  Epidural analgesia
  • 27. TO CONTROL INFECTION  Prophylactic antibiotic (penicilline – gentamylin)  Early labour  postpartum (1-2 weeks)
  • 28.  Left lateral position  decrease risk of supine hypotension  Increase oxygen carrying capacity of blood
  • 29. IN SEVERE CARDIAC DISEASE (III & IV)       Monitoring of CV status is essential arterial and swan- ganzcathetors Monitor  arterial pressure and CO with right atrial main pulmonary artery pressure Fluid intake and urine output Arterial blood gases Hemoglobin % Electrolytes
  • 30. INVOLVEMENT OF CARDIOLOGIST IS MUST DURING LABOUR, DELIVERY AND POSTPARTUM PERIOD
  • 31. OBSTETRICAL MANAGEMENT  Labour and foetal monitoring by using ext. electrode  Limit number of pelvic exam  Vaginal delivery preffered unless obstetrical indication for C section  Shorten 2nd stage  outlet  vacumn
  • 32.  Pushing avoided  increase CO due to increase VR  No ergometrine  Delivery of placenta increase 500 ml of blood so lower extremities should kept at lower level  No massage of uterus  Small postpartum hge is desirable.