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Heart Diseases inHeart Diseases in
PregnancyPregnancy
Faisal Alatawi ,M.DFaisal Alatawi ,M.D
Consultant CardiologistConsul...
OutlineOutline
PhysiologyPhysiology
Incidence& Risk assessmentIncidence& Risk assessment
Congenital heart diseaseCongenita...
Basic heamodynamicsBasic heamodynamics
Stroke volume(SV)=amount of bloodStroke volume(SV)=amount of blood
ejected per cycl...
Heamodynamics In pregnancyHeamodynamics In pregnancy
Heamodynamics In pregnancyHeamodynamics In pregnancy
Haemodynamic changesHaemodynamic changes
Supine hypotensive (uterocaval)Supine hypotensive (uterocaval)
syndrome of pregna...
Haemodynamic changesHaemodynamic changes
Changes during labor:Changes during labor:
3 fold increase in oxygen consumption3...
The hemodynamic changes duringThe hemodynamic changes during
thethe post-partumpost-partum statestate
Mainly due to relief...
CharacteristicCharacteristic signs and symptomssigns and symptoms of normalof normal
pregnancypregnancy
Due to hemodynamic...
Cardiac assessmentCardiac assessment
Electrocardiogram:Electrocardiogram:
The electrocardiogram may reveal a leftward shif...
27 years female27 years female
,pregnant,pregnant
C/O SOBC/O SOB
EchocardiographyEchocardiography
Heart disease in pregnancyHeart disease in pregnancy
1-4% of pregnancies involve maternal CV1-4% of pregnancies involve ma...
RISK ASSESSMENTRISK ASSESSMENT
Preconception counselingPreconception counseling
Discussion of contraception,Discussion of ...
RISK ASSESSMENTRISK ASSESSMENT
Women with NYHA class III and IVWomen with NYHA class III and IV
face a mortality rate upwa...
In a study of 252 completed pregnancies inIn a study of 252 completed pregnancies in
women with cardiac disease, five fact...
Low RiskLow Risk
•• Ventricular septal defectVentricular septal defect
Atrial septal defectAtrial septal defect
•• Patent ...
Intermediate RiskIntermediate Risk
Large left to right shuntLarge left to right shunt
Coarctation of the aortaCoarctation ...
High riskHigh risk
Eisenmenger's syndromeEisenmenger's syndrome
Severe pulmonary hypertensionSevere pulmonary hypertension...
High riskHigh risk
The high-risk conditions are associatedThe high-risk conditions are associated
with increased maternal ...
Women with congenital heartWomen with congenital heart
disease outcome of pregnancydisease outcome of pregnancy
Good outco...
Fetal wastage in 45 % of cyanotic mothersFetal wastage in 45 % of cyanotic mothers
compared tocompared to
20 % in non cyan...
Women with congenital heartWomen with congenital heart
disease :disease :Labor and deliveryLabor and delivery
Elective ind...
ASDASD
– Well tolerated even with large shunts. NoWell tolerated even with large shunts. No
need for AB prophylaxis( if no...
Congenital Aortic StenosisCongenital Aortic Stenosis
– Moderate and severe AS has been associatesModerate and severe AS ha...
Pulmonary StenosisPulmonary Stenosis
– Well tolerated. Balloon valvoplasty isWell tolerated. Balloon valvoplasty is
consid...
Eisenmenger SyndromeEisenmenger Syndrome
High risk of maternal morbidity and mortality (40 %)High risk of maternal morbidi...
Women with Rhematic HDWomen with Rhematic HD
Acute RF:rare during pregnancyAcute RF:rare during pregnancy
Chronic RHDChron...
Rheumatic heart disease inRheumatic heart disease in
pregnancypregnancy
Stenotic lesions: get worseStenotic lesions: get w...
Rheumatic Mitral stenosisRheumatic Mitral stenosis
Increase maternal morbidity but no mortalityIncrease maternal morbidity...
In severe cases unresponsive to medicalIn severe cases unresponsive to medical
therapy Balloon valvoplastey or surgery ist...
Rheumatic heart disease inRheumatic heart disease in
pregnancypregnancy
MR is well toleratedMR is well tolerated
AR well t...
Present in 1.2 % of pregnant womenPresent in 1.2 % of pregnant women
B-blockers can be used for significantB-blockers can ...
Marfan syndromeMarfan syndrome
Patients with dilated aorta or with history ofPatients with dilated aorta or with history o...
Cardiomyopathy:Cardiomyopathy: HOCMHOCM
CHF is reported in 20 % of patientsCHF is reported in 20 % of patients
Arrhythmias...
Peripartum cardiomyopathyPeripartum cardiomyopathy
Form of DCM reported in up to 1in 1000 inForm of DCM reported in up to ...
CAD In PregnancyCAD In Pregnancy
Exclude Coronaries and aortic dissectionExclude Coronaries and aortic dissection
Coronary...
Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy
Most CV drugs cross placenta andMost CV drugs cross placenta and
secr...
Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy
ACE inhibitors - ContraindicatedACE inhibitors - Contraindicated
30% ...
Beta - blocker In PregnancyBeta - blocker In Pregnancy
Effective and relatively safeEffective and relatively safe
Metoprol...
Calcium Antagonists InCalcium Antagonists In
PregnancyPregnancy
Relatively safe for mother and fetusRelatively safe for mo...
Diuretics In PregnancyDiuretics In Pregnancy
Best not to use during pregnancyBest not to use during pregnancy
Fetal electr...
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Hematological changesHematological changes
clotting factor concen...
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Low Dose AspirinLow Dose Aspirin
Safe - antithrombotic effect not...
Warfarin EmbryopathyWarfarin Embryopathy
Bone and cartilaginous abnormality 30%Bone and cartilaginous abnormality 30%
Chon...
Bio-Prosthetic Valves:Bio-Prosthetic Valves:
PregnancyPregnancy
Tissue prosthesisTissue prosthesis
degeneration indegenera...
Metallic Valve Disease InMetallic Valve Disease In
PregnancyPregnancy
MechanicalMechanical
Thrombosis riskThrombosis risk
...
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Anticoagulation In PregnancyAnticoagulation In Pregnancy
Labor and Delivery
High Risk Time
Planned Delivery
Stop heparin p...
IE Prophylaxis In PregnancyIE Prophylaxis In Pregnancy
AHA guidelinesAHA guidelines
IE prophylaxis not required duringIE p...
Endocarditis ProphylaxisEndocarditis Prophylaxis
GI/GU regimenGI/GU regimen
Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120...
Thank youThank you
Best LuckBest Luck
Final pregnancy hd
Final pregnancy hd
Final pregnancy hd
Final pregnancy hd
Final pregnancy hd
Final pregnancy hd
Final pregnancy hd
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  1. 1. Heart Diseases inHeart Diseases in PregnancyPregnancy Faisal Alatawi ,M.DFaisal Alatawi ,M.D Consultant CardiologistConsultant Cardiologist PSCCPSCC
  2. 2. OutlineOutline PhysiologyPhysiology Incidence& Risk assessmentIncidence& Risk assessment Congenital heart diseaseCongenital heart disease Acquired heart diseaseAcquired heart disease AnticoagulationAnticoagulation SBE prophylaxisSBE prophylaxis
  3. 3. Basic heamodynamicsBasic heamodynamics Stroke volume(SV)=amount of bloodStroke volume(SV)=amount of blood ejected per cycleejected per cycle COP=SV*HRCOP=SV*HR Blood pressure=COP*SVRBlood pressure=COP*SVR Starling’s low:increase preload SVStarling’s low:increase preload SV Systemic vas. resistance(SVR) SVSystemic vas. resistance(SVR) SV
  4. 4. Heamodynamics In pregnancyHeamodynamics In pregnancy
  5. 5. Heamodynamics In pregnancyHeamodynamics In pregnancy
  6. 6. Haemodynamic changesHaemodynamic changes Supine hypotensive (uterocaval)Supine hypotensive (uterocaval) syndrome of pregnancy occurs in 11 % ofsyndrome of pregnancy occurs in 11 % of womenwomen Decrease HR&BP due to compresion onDecrease HR&BP due to compresion on IVCIVC Weakness ,nausea and dizziness evenWeakness ,nausea and dizziness even syncope avoid by lateral positioningsyncope avoid by lateral positioning
  7. 7. Haemodynamic changesHaemodynamic changes Changes during labor:Changes during labor: 3 fold increase in oxygen consumption3 fold increase in oxygen consumption Increase COIncrease CO Increase in BP mainly in 2Increase in BP mainly in 2ndnd stagestage Pain reduction, local and epidualPain reduction, local and epidual anesthesia limit hamodynamic changesanesthesia limit hamodynamic changes and O2 consumptionand O2 consumption
  8. 8. The hemodynamic changes duringThe hemodynamic changes during thethe post-partumpost-partum statestate Mainly due to relief of vena cavalMainly due to relief of vena caval compression after delivery.compression after delivery. Increase in venous return augmentsIncrease in venous return augments cardiac output and causes a brisk diuresis.cardiac output and causes a brisk diuresis. The hemodynamic changes return to theThe hemodynamic changes return to the pre-pregnant baseline within 3 to 4 weekspre-pregnant baseline within 3 to 4 weeks following deliveryfollowing delivery
  9. 9. CharacteristicCharacteristic signs and symptomssigns and symptoms of normalof normal pregnancypregnancy Due to hemodynamic changes associated with pregnancyDue to hemodynamic changes associated with pregnancy Fatigue, dyspnea, and decreased exercise capacity.Fatigue, dyspnea, and decreased exercise capacity. Pregnant women usually have peripheral edema and jugular venousPregnant women usually have peripheral edema and jugular venous distension.distension. Most pregnant women have Full and collapsing pulseMost pregnant women have Full and collapsing pulse Displaced and enlarged apex, RV heaveDisplaced and enlarged apex, RV heave A physiologic third heart sound (S3), reflecting the volume overloaded state,A physiologic third heart sound (S3), reflecting the volume overloaded state, can often be appreciatedcan often be appreciated Most have audible physiologic systolic murmurs, created by augmentedMost have audible physiologic systolic murmurs, created by augmented blood flow.blood flow. Normal exam can mimic heart diseaseNormal exam can mimic heart disease Not normal : S4, Loud SM, DM, Fixed split S2Not normal : S4, Loud SM, DM, Fixed split S2
  10. 10. Cardiac assessmentCardiac assessment Electrocardiogram:Electrocardiogram: The electrocardiogram may reveal a leftward shift of the electrical axis, especiallyThe electrocardiogram may reveal a leftward shift of the electrical axis, especially during the third trimester when the diaphragm is pushed upwards by the uterusduring the third trimester when the diaphragm is pushed upwards by the uterus Chest radiograph:Chest radiograph: Routine chest radiographs should be avoided, especially in the first trimesterRoutine chest radiographs should be avoided, especially in the first trimester Echocardiography :Echocardiography : Of choice tool for diagnosis and evaluation of suspected cardiac disease in theOf choice tool for diagnosis and evaluation of suspected cardiac disease in the pregnant patient.pregnant patient. Normal changes attributable to pregnancy include increased left ventricularNormal changes attributable to pregnancy include increased left ventricular mass andmass and dimensionsdimensions
  11. 11. 27 years female27 years female ,pregnant,pregnant C/O SOBC/O SOB EchocardiographyEchocardiography
  12. 12. Heart disease in pregnancyHeart disease in pregnancy 1-4% of pregnancies involve maternal CV1-4% of pregnancies involve maternal CV diseasesdiseases CV disease does not preclude pregnancyCV disease does not preclude pregnancy but poses increased risk to mother andbut poses increased risk to mother and fetusfetus
  13. 13. RISK ASSESSMENTRISK ASSESSMENT Preconception counselingPreconception counseling Discussion of contraception,Discussion of contraception, Maternal and fetal risks during pregnancy,Maternal and fetal risks during pregnancy, Potential long-term maternal morbidity andPotential long-term maternal morbidity and mortality.mortality. The New York Heart Association(NYHA)The New York Heart Association(NYHA) functional class is often used as a predictor offunctional class is often used as a predictor of outcome.outcome.
  14. 14. RISK ASSESSMENTRISK ASSESSMENT Women with NYHA class III and IVWomen with NYHA class III and IV face a mortality rate upwards of 7%face a mortality rate upwards of 7% and a morbidity rate of over 30%.and a morbidity rate of over 30%. These women should be stronglyThese women should be strongly cautioned against pregnancy.cautioned against pregnancy.
  15. 15. In a study of 252 completed pregnancies inIn a study of 252 completed pregnancies in women with cardiac disease, five factors werewomen with cardiac disease, five factors were found to be predictive of maternal cardiacfound to be predictive of maternal cardiac complicationscomplications Prior CHF, TIA, stroke or arrhythmiaPrior CHF, TIA, stroke or arrhythmia Baseline NYHA class >II or cyanosisBaseline NYHA class >II or cyanosis Left heart obstructionLeft heart obstruction MVA <2 cmMVA <2 cm22 , AVA <1.5cm, AVA <1.5cm LVOT gradient >30 mm Hg by echoLVOT gradient >30 mm Hg by echo systemic vent dysfunction (EF <40%)systemic vent dysfunction (EF <40%) RISK ASSESSMENTRISK ASSESSMENT
  16. 16. Low RiskLow Risk •• Ventricular septal defectVentricular septal defect Atrial septal defectAtrial septal defect •• Patent ductus arteriosusPatent ductus arteriosus •• Asymptomatic AS with low mean gradient and normal LV functionAsymptomatic AS with low mean gradient and normal LV function (EF>50%)(EF>50%) •• AR with normal LV function and NYHA class I or IIAR with normal LV function and NYHA class I or II •• MVP (isolated or with mild/moderate MR and normal LV function)MVP (isolated or with mild/moderate MR and normal LV function) •• MR with normal LV function and NYHA class I or IIMR with normal LV function and NYHA class I or II •• Mild/moderate MS (MVA >1.5 cmMild/moderate MS (MVA >1.5 cm22 , mean gradient <5 mm Hg) without, mean gradient <5 mm Hg) without severe pulmonary hypertensionsevere pulmonary hypertension •• Mild/moderate PSMild/moderate PS Repaired acyanotic congenital heart disease without residual cardiacRepaired acyanotic congenital heart disease without residual cardiac dysfunctiondysfunction
  17. 17. Intermediate RiskIntermediate Risk Large left to right shuntLarge left to right shunt Coarctation of the aortaCoarctation of the aorta Marfan's syndrome with a normal aortic rootMarfan's syndrome with a normal aortic root Moderate/severe MSModerate/severe MS Mild/moderate ASMild/moderate AS Severe PSSevere PS History of prior peripartum cardiomyopathy withHistory of prior peripartum cardiomyopathy with no residual ventricular dysfunctionno residual ventricular dysfunction
  18. 18. High riskHigh risk Eisenmenger's syndromeEisenmenger's syndrome Severe pulmonary hypertensionSevere pulmonary hypertension Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA,Complex cyanotic heart disease (TOF, Ebstein's anomaly, TA, TGA, tricuspid atresia)tricuspid atresia) Marfan's syndrome with aortic root or valve involvementMarfan's syndrome with aortic root or valve involvement Severe AS with or without symptomsSevere AS with or without symptoms Aortic and/or mitral valve disease with moderate/severe LV dysfunctionAortic and/or mitral valve disease with moderate/severe LV dysfunction (EF<40%)(EF<40%) NYHA class III to IV symptoms associated with any valvular disease orNYHA class III to IV symptoms associated with any valvular disease or with cardiomyopathy of any etiologywith cardiomyopathy of any etiology History of peripartum cardiomyopathy with persistent LV dysfunctionHistory of peripartum cardiomyopathy with persistent LV dysfunction AS = aortic stenosis, LV = left ventricle, EF = ejection fraction, AR = aortic regurgitation, NYHA = New York Heart Association, MVP = mitral valve prolapse, MS = mitral stenosis, MVA = mitral valve area, PS = pulmonary stenosis, TOF = tetralogy of Falot, TA = Truncus arteriosus, TGA = transposition of the great arteries Adapted from reference 3.
  19. 19. High riskHigh risk The high-risk conditions are associatedThe high-risk conditions are associated with increased maternal and fetalwith increased maternal and fetal mortality. Pregnancy is not advised.mortality. Pregnancy is not advised. If pregnancy should occur, therapeuticIf pregnancy should occur, therapeutic abortion to be considered .abortion to be considered . These patients are best managed with theThese patients are best managed with the assistance of a cardiologistassistance of a cardiologist
  20. 20. Women with congenital heartWomen with congenital heart disease outcome of pregnancydisease outcome of pregnancy Good outcome is expected inGood outcome is expected in presence of acyanotic CHDpresence of acyanotic CHD – Disease natureDisease nature – Surgical repairSurgical repair – PAP, LV dysfunction,PAP, LV dysfunction, – Functional capacityFunctional capacity – LV obstructionLV obstruction – ArrhythmiaArrhythmia
  21. 21. Fetal wastage in 45 % of cyanotic mothersFetal wastage in 45 % of cyanotic mothers compared tocompared to 20 % in non cyanotic20 % in non cyanotic Low birth weightLow birth weight PrematuriteyPrematuritey Risk of Cong.HD (4 to 8 %)Risk of Cong.HD (4 to 8 %) Women with congenital heartWomen with congenital heart disease outcome of pregnancydisease outcome of pregnancy
  22. 22. Women with congenital heartWomen with congenital heart disease :disease :Labor and deliveryLabor and delivery Elective induction of labor when maturity isElective induction of labor when maturity is confirmedconfirmed Vaginal delivery is recommendedVaginal delivery is recommended Oxygen, pain control, fluid lossOxygen, pain control, fluid loss management, Antibiotic prophylaxismanagement, Antibiotic prophylaxis
  23. 23. ASDASD – Well tolerated even with large shunts. NoWell tolerated even with large shunts. No need for AB prophylaxis( if no association)need for AB prophylaxis( if no association) VSDVSD – Usually tolerated. CHF, arrhythmia areUsually tolerated. CHF, arrhythmia are reported. Hypotension and fluid loss canreported. Hypotension and fluid loss can enhance shunt reversal in those withenhance shunt reversal in those with pulmonary HTNpulmonary HTN PDAPDA – Shunt reversal need to be avoided. CHF hasShunt reversal need to be avoided. CHF has been reportedbeen reported
  24. 24. Congenital Aortic StenosisCongenital Aortic Stenosis – Moderate and severe AS has been associatesModerate and severe AS has been associates with maternal morbidity and mortalitywith maternal morbidity and mortality – Symptoms include SOB, chest pain andSymptoms include SOB, chest pain and syncopesyncope – Severe AS managed by abortion followed bySevere AS managed by abortion followed by AVR, or continuation of pregnancy with AVR,AVR, or continuation of pregnancy with AVR, or AVB in case of clinical deteriorationor AVB in case of clinical deterioration AO CoarctationAO Coarctation – HTN, CHF, Aortic dissection have beenHTN, CHF, Aortic dissection have been reported. Avoid exertion, control BPreported. Avoid exertion, control BP
  25. 25. Pulmonary StenosisPulmonary Stenosis – Well tolerated. Balloon valvoplasty isWell tolerated. Balloon valvoplasty is considered in case of progressive Rconsidered in case of progressive R ventricular failure, increased cyanosis due toventricular failure, increased cyanosis due to associated shuntsassociated shunts Tetrology Of FallotTetrology Of Fallot – Repaired ( do well)Repaired ( do well) – Un repaired or those with residual lesionsUn repaired or those with residual lesions have increase risk mainly due to deteriorationhave increase risk mainly due to deterioration of cyanosisof cyanosis
  26. 26. Eisenmenger SyndromeEisenmenger Syndrome High risk of maternal morbidity and mortality (40 %)High risk of maternal morbidity and mortality (40 %) Pregnancy is not allowed, and abortion isPregnancy is not allowed, and abortion is recommended.recommended. Close follow-up for those insist to proceed withClose follow-up for those insist to proceed with pregnancy. hyperviscositey, infection should bepregnancy. hyperviscositey, infection should be monitored. Anticoagulation is recommended in thirdmonitored. Anticoagulation is recommended in third trimester.trimester. Vaginal delivery is preferred with shortening of 2Vaginal delivery is preferred with shortening of 2ndnd
  27. 27. Women with Rhematic HDWomen with Rhematic HD Acute RF:rare during pregnancyAcute RF:rare during pregnancy Chronic RHDChronic RHD Restriction of activity in symptomatic patientsRestriction of activity in symptomatic patients Antibiotic prophylaxisAntibiotic prophylaxis Haemodynamic monitoring during labour and 24Haemodynamic monitoring during labour and 24 hour post partum in patients who hadhour post partum in patients who had – LV FailureLV Failure – with severe diseasewith severe disease – pulmonary HTNpulmonary HTN
  28. 28. Rheumatic heart disease inRheumatic heart disease in pregnancypregnancy Stenotic lesions: get worseStenotic lesions: get worse – Because of increase flowBecause of increase flow Regurgitant Lesions : well toleratedRegurgitant Lesions : well tolerated – Because of decrease vascular resistantBecause of decrease vascular resistant
  29. 29. Rheumatic Mitral stenosisRheumatic Mitral stenosis Increase maternal morbidity but no mortalityIncrease maternal morbidity but no mortality Symptoms in moderate and severe stenosisSymptoms in moderate and severe stenosis worsens by 1, or 2 NYHA classworsens by 1, or 2 NYHA class Increased blood volume, HR increase MVIncreased blood volume, HR increase MV gradient and hence LA pressure and predisposegradient and hence LA pressure and predispose AF and pulmonary edema.AF and pulmonary edema. Rx: activity restriction, fluid and salt restriction.Rx: activity restriction, fluid and salt restriction. B-blockers, digoxin, diuretics.B-blockers, digoxin, diuretics.
  30. 30. In severe cases unresponsive to medicalIn severe cases unresponsive to medical therapy Balloon valvoplastey or surgery istherapy Balloon valvoplastey or surgery is recommendedrecommended Maternal Risk of MV repair or replacementMaternal Risk of MV repair or replacement is comparable to non pregnant women.is comparable to non pregnant women. Foetal daeth during open heart surgeryFoetal daeth during open heart surgery (20-30%)(20-30%) Closed commissurotomy is associatedClosed commissurotomy is associated with minimal risk to the fetus.with minimal risk to the fetus. Rheumatic Mitral stenosisRheumatic Mitral stenosis
  31. 31. Rheumatic heart disease inRheumatic heart disease in pregnancypregnancy MR is well toleratedMR is well tolerated AR well toleratedAR well tolerated Aortic stenosis : severe disease mandateAortic stenosis : severe disease mandate termination or valve surgery,Valvoplasty intermination or valve surgery,Valvoplasty in experienced centerexperienced center
  32. 32. Present in 1.2 % of pregnant womenPresent in 1.2 % of pregnant women B-blockers can be used for significantB-blockers can be used for significant symptomssymptoms AB prophylaxis:if associated with MRAB prophylaxis:if associated with MR Mitral valve prolapse
  33. 33. Marfan syndromeMarfan syndrome Patients with dilated aorta or with history ofPatients with dilated aorta or with history of dissection should be advised against pregnancydissection should be advised against pregnancy Progressive dilatation of the aorta leading to ARProgressive dilatation of the aorta leading to AR and CHF. Aortic dissectionand CHF. Aortic dissection Aortic diameter less then 40 mm is usuallyAortic diameter less then 40 mm is usually toleratedtolerated Avoid physical exertion. B-blocker decreaseAvoid physical exertion. B-blocker decrease aortic dilatationaortic dilatation CS is preferred in patients with dilated aorta orCS is preferred in patients with dilated aorta or with dissectionwith dissection
  34. 34. Cardiomyopathy:Cardiomyopathy: HOCMHOCM CHF is reported in 20 % of patientsCHF is reported in 20 % of patients Arrhythmias (SVT,AF, VT). SCDArrhythmias (SVT,AF, VT). SCD Up to 50% inheritanceUp to 50% inheritance Rx: B-blockers, Ca-channel blockers, diuretics. Pacing.Rx: B-blockers, Ca-channel blockers, diuretics. Pacing. ICDICD Vaginal delivery with shortening of 2Vaginal delivery with shortening of 2ndnd stage.stage. Spinal and epidural anesthesia should be used withSpinal and epidural anesthesia should be used with caution.caution. Fluid replacement and AB prophylaxisFluid replacement and AB prophylaxis
  35. 35. Peripartum cardiomyopathyPeripartum cardiomyopathy Form of DCM reported in up to 1in 1000 inForm of DCM reported in up to 1in 1000 in certain parts of Africa. Develop duringcertain parts of Africa. Develop during pregnancy or 6 mo post partumpregnancy or 6 mo post partum Common in multiparous, preeclampsia, and twinCommon in multiparous, preeclampsia, and twin pregnancy, as well as in women > 30 ypregnancy, as well as in women > 30 y Unknown etiologyUnknown etiology 50 to 60 % of patients show complete or near50 to 60 % of patients show complete or near complete recoverycomplete recovery Death or cardiac Tx in 12 to 18 %Death or cardiac Tx in 12 to 18 % Relapse can occur with a mortality of 2 % inRelapse can occur with a mortality of 2 % in those with recovered LVF, and up to 17 % inthose with recovered LVF, and up to 17 % in those with residual LVD.those with residual LVD.
  36. 36. CAD In PregnancyCAD In Pregnancy Exclude Coronaries and aortic dissectionExclude Coronaries and aortic dissection Coronary angio, aortic imagingCoronary angio, aortic imaging PCI, CABGPCI, CABG ThrombolysisThrombolysis Consider if angio not availableConsider if angio not available High-riskHigh-risk
  37. 37. Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy Most CV drugs cross placenta andMost CV drugs cross placenta and secreted in breast milksecreted in breast milk Weigh risk/benefit ratio - avoid whenWeigh risk/benefit ratio - avoid when possiblepossible Use drugs with long safety recordUse drugs with long safety record Prescribe lowest dose for shortestPrescribe lowest dose for shortest durationduration Avoid multi-drug regimensAvoid multi-drug regimens No drug is completely safeNo drug is completely safe
  38. 38. Cardiac Drugs In PregnancyCardiac Drugs In Pregnancy ACE inhibitors - ContraindicatedACE inhibitors - Contraindicated 30% fetal morbidity30% fetal morbidity Fetal renal tubular dysplasiaFetal renal tubular dysplasia Neonatal renal failure - oligohydramniosNeonatal renal failure - oligohydramnios Lack of cranial ossification, IUGRLack of cranial ossification, IUGR Angiotensin II receptors blocker -Angiotensin II receptors blocker - contraindicatedcontraindicated
  39. 39. Beta - blocker In PregnancyBeta - blocker In Pregnancy Effective and relatively safeEffective and relatively safe Metoprolol, Atenolol, LabetalolMetoprolol, Atenolol, Labetalol IndicationsIndications Arrhythmias, aortic disease, HCM, HTNArrhythmias, aortic disease, HCM, HTN Concerns - fetal and neonatalConcerns - fetal and neonatal IUGR, apnea, HR, hypoglycemiaIUGR, apnea, HR, hypoglycemia
  40. 40. Calcium Antagonists InCalcium Antagonists In PregnancyPregnancy Relatively safe for mother and fetusRelatively safe for mother and fetus Tocolytic effect - stop near termTocolytic effect - stop near term Dysfunctional labor, postpartum hemorrhageDysfunctional labor, postpartum hemorrhage May uteroplacental perfusionMay uteroplacental perfusion Beta-blocker preferred if toleratedBeta-blocker preferred if tolerated
  41. 41. Diuretics In PregnancyDiuretics In Pregnancy Best not to use during pregnancyBest not to use during pregnancy Fetal electrolyte and platelet effectFetal electrolyte and platelet effect maternal intravascular volumematernal intravascular volume utero-placental perfusionutero-placental perfusion Use only in setting of CHFUse only in setting of CHF Better to start before pregnancyBetter to start before pregnancy
  42. 42. Anticoagulation In PregnancyAnticoagulation In Pregnancy Hematological changesHematological changes clotting factor concentrationclotting factor concentration platelet adhesivenessplatelet adhesiveness fibrinolysisfibrinolysis risk thrombosis and embolismrisk thrombosis and embolism
  43. 43. Anticoagulation In PregnancyAnticoagulation In Pregnancy Low Dose AspirinLow Dose Aspirin Safe - antithrombotic effect not provenSafe - antithrombotic effect not proven Recommended for pt with shunts, cyanosis andRecommended for pt with shunts, cyanosis and biological valvesbiological valves Possible incidence of preeclampsiaPossible incidence of preeclampsia Low molecular weight heparinLow molecular weight heparin Not enough information available inNot enough information available in Thrombolytic therapyThrombolytic therapy Emergency use onlyEmergency use only
  44. 44. Warfarin EmbryopathyWarfarin Embryopathy Bone and cartilaginous abnormality 30%Bone and cartilaginous abnormality 30% ChondrodysplasiaChondrodysplasia Nasal hypoplasiaNasal hypoplasia Optic atrophy with micropthalmiaOptic atrophy with micropthalmia Developmental delayDevelopmental delay Miscarriage or stillbirth 37%Miscarriage or stillbirth 37% Very low risk <5mgVery low risk <5mg
  45. 45. Bio-Prosthetic Valves:Bio-Prosthetic Valves: PregnancyPregnancy Tissue prosthesisTissue prosthesis degeneration indegeneration in youngyoung 73% in 10 years73% in 10 years AcceleratedAccelerated degenerationdegeneration Possible inPossible in pregnancypregnancy Reoperation riskReoperation risk
  46. 46. Metallic Valve Disease InMetallic Valve Disease In PregnancyPregnancy MechanicalMechanical Thrombosis riskThrombosis risk High mortality 10%High mortality 10% Limited Rx optionsLimited Rx options
  47. 47. Anticoagulation In PregnancyAnticoagulation In Pregnancy
  48. 48. Anticoagulation In PregnancyAnticoagulation In Pregnancy Labor and Delivery High Risk Time Planned Delivery Stop heparin peripartum Resume after 4 - 6 hr
  49. 49. IE Prophylaxis In PregnancyIE Prophylaxis In Pregnancy AHA guidelinesAHA guidelines IE prophylaxis not required duringIE prophylaxis not required during uncomplicated deliveryuncomplicated delivery Not requiredNot required Isolated ASDIsolated ASD 6 months after PDA or VSD closure6 months after PDA or VSD closure Reasonable to administer IEReasonable to administer IE prophylaxis in high-risk patientsprophylaxis in high-risk patients
  50. 50. Endocarditis ProphylaxisEndocarditis Prophylaxis GI/GU regimenGI/GU regimen Ampicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) imAmpicillin 2 gm and Gentamicin 1.5 mg/kg (<120 mg) im or iv 30 min before procedureor iv 30 min before procedure 6 hrs later6 hrs later Ampicillin 1 gm im or iv or Amoxicillin 1 gm poAmpicillin 1 gm im or iv or Amoxicillin 1 gm po PCN allergicPCN allergic Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5Vancomycin 1 gm iv over 1 - 2 hrs and Gentamicin 1.5 mg/kg (<120 mg) im or ivmg/kg (<120 mg) im or iv Complete Rx within 30 min of procedureComplete Rx within 30 min of procedure
  51. 51. Thank youThank you Best LuckBest Luck
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