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Heart disease in pregnancy 20-5-10
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Heart disease in pregnancy 20-5-10

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  • 1. HEART DISEASES IN PREGNANCY
  • 2. Incidence and types of heart diseases in pregnancy
    • Incidence of heart disease in pregnancy is around 1%
    • These can be congenital and acquired
    • of these, acquired heart diseases are most common in developing countries . These include:
    • RHD, cardiomyopathies and ischemic heart disease
  • 3.
    • Congenital heart diseases can be:
    • left to right shunts, stenotic lesions, right to left shunts
    • Most common cardiac lesion in pregnancy is RVHD(MS)
    • Most common arrhythmia in pregnancy is SVT
    • Most common acyanotic heart disease in pregnancy is ASD(ostium secundum )
    • Most common cyanotic heart disease- TOF
  • 4. HEMODYNAMIC CHANGES DURING PREGNANCY
    • 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
  • 5.
    • Mechanism for increase CO
    • increase Stroke volume = 27%
    • increase heart rate = 17%
    • increase in intravascular volume
    • 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 .
  • 6.
    • Systemic vascular resistance falls by 21%
    • Pulmonary vascular resistance falls by 34%
    • Colloid osmotic pressure falls by 14%
    • Aortic root – increase in size and compliance
    • Venous pressure-
    • femoral vein pressure:20cm of water (lying down) and 80 – 100 cm of water on standing.
    • BP: mid trimester fall in MAP of 10 -15 mm of Hg, reaching a nadir ~ 24-28 wk
    • No change in CVP
    • PCWP
  • 7. NORMAL CARDIAC FINDINGS
    • Raised JVP with prominent pulsations
    • Brisk and diffuse apex impulsation
    • Loud s1
    • Loud s2 and widely split
    • Occasional s3
    • Aortic or pulmonary flow murmurs
    • Venous hum
    • Mammary souffle
  • 8. ABNORMAL CARDIAC FINDINGS
    • Progressive dyspnea or orthopnea
    • Nocturnal cough
    • Hemoptysis
    • Syncope
    • Chest pain
    • Cyanosis
    • Clubbing
    • Persisstent neck vein distension
    • Systolic murmur grade 3 or above
  • 9.
    • Diastolic murmur
    • Cardiomegaly
    • Persistent arrhythmia
    • Persistent split s2
  • 10. PERIODS DURING PREGNANCY WHEN DANGER OF CARDIAC DECOMPENSATION IS HIGH
    • 12-16 WK- hemodynamic chngs of pregnancy begin
    • 28-32 wk- hemodynamic chngs peak
    • During labour and delivery
    • Immediately following delivery of baby and placental separation( max chances )
    • 4-5 days following delivery
  • 11. NYHA FUNCTIONAL CALSSIFICATION OF CARDIAC DISEASE
    • I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
    • II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
    • 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.
    • IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
  • 12. RISK OF MATERNAL MORTALITY AND MORBIDITY WITH HEART DISEASE
    • Group1( minimal risk) 0-1%
    • ASD
    • VSD
    • PDA
    • Corrected TOF
    • Corrected congenital heart disease without residual cardiac dysfunction
    • MVP
    • NYHA class 1,2
  • 13.
    • 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
  • 14.
    • Group3 (major) 25-50%
    • Pulmonary hypertension
    • Marfan’s syndrome with aortic valve involvement
    • Cardiomyopathy
    • Complicated coarctation of aorta
  • 15. PREDICTORS OF CARDIAC EVENTS DURING PREGNANCY (Sui and Coleman 2004)
    • N : NYHA grade 3,4 or cyanosis
    • O : obstructive lesion of left heart
    • MV area < 2 cm sq
    • Aortic valve area< 1.5 cm sq
    • pressure gradient > 30 mm of Hg
    • P : prior cardiac event
    • stroke/ arrythmia/TIA/stroke
    • E : EF< 40%
  • 16.
    • Heart disease and none of above, risk of adverse cardiac event during pregnancy~ 5%
    • Heart disease with any one of above- 25%
    • Heart disease with 2 or more of above- 75%
  • 17. Thank you

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