Peripartum cardiomyopathy
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  • 1. Incidence and types of heart diseases in pregnancy 0 Incidence of heart disease in pregnancy is around 1% 0 These can be congenital or acquired 0 Of these, acquired heart diseases are more common in developing countries. These include: RHD, cardiomyopathies and ischemic heart disease
  • 2. 0 Congenital heart diseases can be: left to right shunts, stenotic lesions, right to left shunts 0 Most common cardiac lesion in pregnancy is MS 0 Most common arrhythmia in pregnancy is SVT 0 Most common acyanotic heart disease in pregnancy is ASD(ostium secundum ) 0 Most common cyanotic heart disease- TOF
  • 3. HEMODYNAMIC CHANGES DURING PREGNANCY 0 Cardiac output: increase in CO starts at ~5wk POG, reaches a maximum at 30-34 wk ( 40% increase over the prepregnant value) and remains elevated till term. During labour, it increases by ~20% with uterine contractions. Immediately following delivery CO increases further by~15-20% return to pre labour value= 1 hr after delivery return to pre pregnant value= 4 wk after delivery
  • 4. 0 Mechanism for increase CO increase Stroke volume = 27% increase heart rate = 17% increase in intravascular volume 0 Intravascular volume (IVV) increase in blood volume starts around 6 wk and gradually reaches a peak of ~30-40% by 32 wk plasma volume~ 40-50% RBC volume~ 20-30% IVV expansion is marked by systolic ejection murmur .
  • 5. 0 Systemic vascular resistance falls by 21% 0 Pulmonary vascular resistance falls by 34% 0 Colloid osmotic pressure falls by 14% 0 Aortic root – increase in size and compliance 0 Venous pressure- femoral vein pressure:20cm of water (lying down) and 80 – 100 cm of water on standing. 0 BP: mid trimester, fall in MAP of 10 -15 mm of Hg, reaching a nadir ~ 24-28 wk 0 No change in CVP PCWP
  • 6. NORMAL CARDIAC FINDINGS 0 Raised JVP with prominent pulsations 0 Brisk and diffuse apex impulse 0 Loud s1 0 Loud s2 and widely split 0 Occasional s3 0 Aortic or pulmonary flow murmurs 0 Venous hum 0 Mammary souffle
  • 7. ABNORMAL CARDIAC FINDINGS 0 Progressive dyspnea or orthopnea 0 Nocturnal cough 0 Hemoptysis 0 Syncope 0 Chest pain 0 Cyanosis 0 Clubbing 0 Persistent neck vein distension 0 Systolic murmur grade 3 or above
  • 8. 0 Diastolic murmur 0 Cardiomegaly 0 Persistent arrhythmia 0 Persistent split s2
  • 9. PERIODS DURING PREGNANCY WHEN DANGER OF CARDIAC DECOMPENSATION IS HIGH 0 12-16 WK- hemodynamic changes of pregnancy begin 0 28-32 wk- hemodynamic changes peak 0 During labour and delivery 0 Immediately following delivery of baby and placental separation( max chances) 0 4-5 days following delivery
  • 10. NYHA FUNCTIONAL CALSSIFICATION OF CARDIAC DISEASE 0 I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. 0 IIMild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. 0 III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m).Comfortable only at rest. 0 IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
  • 11. RISK OF MATERNAL MORTALITY AND MORBIDITY WITH HEART DISEASE 0 Group1( minimal risk) 0-1% ASD VSD PDA Corrected TOF Corrected congenital heart disease without residual cardiac dysfunction MVP NYHA class 1,2
  • 12. 0 Group 2( moderate risk) 5-15%  AS Marfan’s syndrome with normal aorta Uncorrected TOF Previous MI Artificial valve H/o peripartum cardiomyopathy with no residual ventricular dysfunction NYHA class 3,4
  • 13. 0 Group3 (major) 25-50% Pulmonary hypertension Marfan’s syndrome with aortic valve involvement Cardiomyopathy Complicated coarctation of aorta
  • 14. PERIPARTUM CARDIOMYOPATHY 0 Incidence: 1 in 4000 pregnancies 0 More common after age 30 0 Can result in severe CHF 0 Clinically present by 3rd trimester 0 Close hemodynamic monitoring and early delivery maybe necessary 0 Cardiomyopathy may persist even after delivery 0 High rate of recurrence so birth control recommended
  • 15. Diagnostic criteria 0 Diagnosis of exclusion 0 Cardiac failure within last month of pregnancy or within 5 months postpartum 0 No determinable cause for failure 0 Absence of previous heart disease 0 Left ventricular dysfunction evidenced on echoejection fraction < 45 % & left ventricular end diastolic dimension > 2.7cm/m2
  • 16. Etiology 0 Unknown 0 Myocarditis 0 Viruses-Epstein-Barr ,Parvovirus B19, CMV 0 Genetic causes 0 Inflammation 0 Preeclampsia
  • 17. Presentation 0 Progressive dyspnea or Orthopnea 0 Palpitations 0 Cough 0 Chest pain 0 Dizziness 0 Decrease exercise tolerance
  • 18. Presentation 0 Often presents with major event 0Heart failure 0 Respiratory failure 0Stroke 0 Physical Exam 0Loud S2 0Pulmonary rales 0Elevated JVP 096% pulmonic systolic ejection murmur 0Increasing peripheral edema ( suddenly at end of pregnancy)
  • 19. Differential Diagnosis 0 Aortic Stenosis 0 Cardiomyopathy, other types 0 Hypertension 0 Mitral Stenosis 0 Pulmonary Disease 0 Pulmonary Edema
  • 20. Workup 0 Echocardiogram 0 Chest X-ray 0 Stress testing
  • 21. Treatment Bed rest 0 Digoxin 0 Loop diuretics 0 Afterload reduction with hydralazine 0 Beta- blockers 0 Heparin when EF< 30% 0 Consider tertiary center
  • 22. Treatment Route of delivery 0 Vaginal preferred 0 Less incidence PE 0 Epidural anesthesia ideal
  • 23. Prognosis 0 30% patients return to baseline ventricular function within 6 months 0 50% of patients have significant improvement 0 Mortality 3% to 9.6%, ( 16% for African American) 0 Progressive heart failure 0 Arrhythmia, 0 Thromboembolism. Up to 30%