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Heart Disease & Pregnancy

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     				Heart Disease & Pregnancy Heart Disease & Pregnancy Presentation Transcript

    • Heart Disease & Pregnancy Pregnancy places an additional strain on the heart due to the cardiovascular changes that occur due to the physiological adaptation to pregnancy. www.doctor.sd
      • There is steady increase in blood volume reaching 40% increase by 36 weeks.
      • Parallel with the increase in volume there is an increase in cardiac out put due to increase of both stroke volume & heart rate (c.o.p. increases from 3-5L to 6-7.5 L).
      • Also immediately after delivery there is a transient increase after delivery of the placenta & retraction of the uterus.
      • There is marked reduction in peripheral resistance.
      • Blood pressure fall rather than increase & reaches its lowest level at the end of the second trimester.
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    • Incidence about 0.5-1%
      • Aetiology :-
      • 1) 70% of cases are of rheumatic origin usually causing mitral stenosis with mitral or aortic regurgitation being less common.
      • 2) 25% are due to congenital defects. in some developed countries it reaches 50% of cases (decline in rheumatic fever & increase survival due to surgery ).
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      • The commonest malformation are :-
      • Patent ductus arteriosus, atrial septal defect, ventricular septal defect, coarctation of the aorta, pulmonary stenosis, fallots tetralogy, aortic stenosis & eisenmengers syndrome.
      • 3) 5% due to other causes like disorder of rhythm, cardiomyopathy, thyrotoxicosis, aneamia.
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    • Complications
      • Cardiac disease is a major cause of maternal mortality due to heart failure & increase incidence of venous thrombosis & pulmonary embolism.
      • Unless heart failure develop cardiac disease does not alter the perinatal mortality but there is high incidence of IUGR & preterm labour.
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    • Assessment of cardiac function in pregnancy
      • The physiological change associated with pregnancy give rise to symptoms & sign which may cause confusion in the assessment of cardiac disorder such as dyspnoea, tachycardia ,ankle oedema ,soft ejection murmur.
      • The heart of every pregnant women should be auscultated at the first antenatal visit .
      • Any suspicious sign like grade 3 systolic murmur any diastolic murmur marked disturbance of rate & rhythm require further investigation preferably by cardiologist ,ECG, echocardiography .
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      • The functional capacity or the functional reserve of the heart should be assessed because it is usually more important than the anatomical nature of the lesion.
      • New york heart disease association proposed four grades.
      • Class1:- no limitation of physical activity.
      • Class2:- slight limitation of activity ordinary activity causes fatigue ,palpitation ,dyspnoea ,& anginal pain.
      • Class3:- marked limitation of physical activity symptoms occur with less than ordinary activity .
      • Class4:- inability to carry any physical activity without discomfort ( dyspnoea at rest)
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    • Management. Antenatal management
      • Aim is to prevent heart failure & to detect obstetric complications & to minimize them where possible .
      • General management:--
      • 1) ideally should be seen at a joint clinic by cardiologist and an obstetrican .
      • 2) visit need to be more frequent at least fortnightly in the first half of pregnancy and weekly in the second half.
      • 3) in each visit she should be asked about .
      • --any increase in her shortness of breath .
      • --any increase in exercise tolerance .
      • -- tachycardia .
      • --any marked increase in tiredness .
      • -- fetal movement.
      • Examination should always include pulse rate, rhythm, blood pressure jvp lung base ,increased sacral or ankle oedema liver ,fundal hieght and fetal growth.
      • A careful watch of pregnancy complications like PIH ,UTI, chest infection, bacterial endocarditis atrial fibrillation and anaemia
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      • 4) out patient management is used but if there are any signs of heart failure ,infection ,grade3 &4 disease ,obstetric complications indicate admission to hospital.
      • 5) adequate rest is essential with at least 9 hours at night & rest in bed in the afternoon.
      • 6) dietary supervision ensuring reasonable protein ,vitamin ,& iron intake & because of the additional cardiac strain imposed by anaemia prophylactic iron & folic acid is indicated.
      • 7) infection must be avoided . The onset of any intercurrent infection even corysa is an indication of hospital treatment . Complete dental care & tooth extraction should be under antibiotic cover
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    • Specific management
      • Similar to that for the non pregnant .
      • 1) digoxin:- indicated primarily in patient with atrial fibrillation & acute heart failure. Prophylactic therapy is sometime advocated but evidence infavour of this is not strong.
      • 2) diuretics:- thiazide diuretics can be used in chronic congestive failure with k supplement .frusemide is required for acute heart failure.
      • 3) beta adrenargic blocker may be required for dysrhythmia .
      • 4)aminophylline is of considerable value in alleviation of broncho spasm & pulmonary oedema
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      • 5) heparin is indicated in patient with prosthetic valve, atrial fibrillation & pulmonary hypertension .
      • 6) in acute pulmonary oedema morphine, oxygen, digoxin, lasix, & aminophylline.
      • 7)cardic surgery:- with close surgery (mitral valvotomy) there is little increase risk for the fetus but open surgery involving cardio pulmonary by pass result in increase incidence of fetal loss.
      • Indication of surgery is recurrent pulmonary oedema in association with predominant mitral stenosis occuring early in pregnancy and with failure to respond to medical treatment .
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      • -mitral stenosis ---mitral valvotomy.
      • -ligation of patent ductus arteriosus.
      • -closure of atrial & ventricular septal defects are difficult during pregnancy. Best result of surgery is obtained between 16 & 20 th week of pregnancy.
      • 8) therapeutic abortion:-
      • With increase sophistication of cardiac surgery the need for therapeutic abortion has been reduced . It should be reserved for those women in the first 20 th week of pregnancy who remain in grade 3&4 despite medical treatment & who are assessed as unsuitable for surgery.
      • Termination is also may be indicated for patient with cynotic heart disease ,primary or secondary pulmonary hypertension , or eisemmengers syndrome
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    • Management of labour
      • -vaginal delivery is preferable to caesarian section except in cases of coarctation of the aorta . However if there is obstetric indication for caesarian section it is not contraindicated .
      • -there is no place for trial of labour.
      • -labour is managed like in healthy women.
      • -oxygen should be available .
      • -adequate sedation and analgesia are important by pethidine but epidural is the best method of pain relief .
      • -assisted delivery by forceps or ventouse is indicated unless the second stage of labour is very rapid.
      • -third stage it is usual to give only syntocinon as ergometrine is contraindicated as it may precipitate heart failure.
      • -antibiotic prophylaxis is commonly given to guard against the risk of bacterial endocarditis
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    • Management of the puerperium
      • - the high risk of acute cardiac failure persist for 24 hours after delivery & careful observation during this period is essential .
      • -breast feeding is not contraindicated.
      • -although adequate rest essential early ambulation is desirable to minimize the risk of thrombo embolic disorders.
      • The use of anticoagulant is contraversial.
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    • Future pregnancy
      • -if the patient wants more children she can safely become pregnant provided that she is grade 1or2 & her heart is well compensated . Grade 3&4 should be discouraged from being pregnant until cardiac surgery has been performed.
      • If the patient desire no further children contraception can be used oral pills & condom are preferable to IUCD.
      • Tubal ligation is best deferred until the patient has overcome the burden of pregnancy & puerperium
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    • Cardiomyopathy of pregnancy
      • 1) hypertrophic obstructive cardiomyopathy characterized by hypertrophy & disorganization of cardiac muscle particularly the left ventricle and septum.
      • -cause is unknown .
      • -the patient present with chest pain ,syncope ,arrhythmia ,or the symptoms of heart failure. treatment is by B-blockers
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    • 2)Pregnancy cardiomyopathy
      • -occurs in the last quarter of pregnancy & puerperium .
      • -the heart is growthly dilated .
      • Usually in multiparous – black-relatively elderly women of low social class.
      • -pulmonary ,peripheral ,and cerebral embolism is a major cause of morbidity & mortality.
      • -the condition recur.
      • -cause unknown. It is considered to be a form of congestive cardiomyopathy .
      • -treatment is with anti failure drugs & anticoagulant until the heart size return to normal.
      • -assuming that the patient recover from the initial episode the long term prognosis is good.
      • -
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