UNDERSTANDING
HEART DISEASE IN
PREGNANCY

DR NAZIMAH IDRIS
O&G
HOSPITAL ALOR SETAR
• 0.4-5.0% of pregnant women
• Commonest non-obstetric cause of maternal
mortality in Malaysia – 10% of all maternal
death...
Physiological changes
Antenatal
Parameter

1st TM

2nd TM

3rd TM

Blood volume
Cardiac output
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pre...
Blood volume
• Increases as pregnancy progresses, peaking
at 40-50% above non-pregnant level
between 32nd and 36th week, p...
Parameter

1st TM

2nd TM

3rd TM

Blood volume
Cardiac output
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pre...
• Cardiac output increases by 30-50% above
the pre-pregnancy level and peaks around
end of 2nd TM (20th-24th week)
• Incre...
Changes in CO, SV and HR in Pregnancy

↓BP due to ↓systemic vascular resistance
Parameter

1st TM

2nd TM

3rd TM

Blood volume
Cardiac output
Stroke volume
Heart rate
Systolic BP
Diastolic BP
Pulse pre...
• Fall in systemic vascular resistance
• Fall in blood pressure especially in
midpregnancy
• Increase in pulmonary blood f...
Labour and delivery
• Anxiety, pain and uterine contractions
increase cardiac output by about 50%
Cardiac output changes
Postpartum
• Immediate postpartum – increase in venous
return due to relief of caval compression
and auto-transfusion from the contra...
Note:
Physiological adaptations in healthy
women cannot be applied to patients
with pre-existing heart disease.
Management principles
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND
STRATIFICATION
OF MATERNAL
AND FETAL RISKS
• 3. M...
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY...
Pre-conceptual
counselling
• Target: Heart disease patients of
childbearing age and their
husband/family.
• Assessment: Ma...
Issues:
• - Effect of pregnancy on the heart
• - Effect of cardiac disorder on fetal
development
• - Effect of maternal dr...
• Patients with heart disease should be
encouraged to complete their family early and
discouraged from too many pregnancie...
• Whenever possible, correct cardiac
lesions before pregnancy, e.g.
- Congenital defects
- Mitral stenosis – symptomatic o...
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY...
Detection of cardiac
disease in pregnancy
• History
• Physical examination
• Investigation
Note: Symptoms and signs of hea...
History
• Dyspnea
• Palpitations
• Estimation of effort tolerance (NYHA
Functional Classification)
• History of rheumatic ...
NYHA Functional Class
• NYHA 1
no limitation. Ordinary physical activity
does not cause undue fatigue, dyspnoea
or palpita...
Physical examination
• Clubbing, cyanosis, features of Marfan
Syndrome
• Pulse for arrhythmia
• BP
• JVP
• Precordial exam...
Investigations
• ECG
• ECHO- sometimes this is the only
reliable method in determining whether
a cardiac murmur is signifi...
• THEREFORE,
THE THRESHOLD
FOR AN ECHO
SHOULD BE LOW.
RISK CATEGORIZATION
–
–
–
–
–
–
–
–

NYHA functional class.
Presence of cyanosis
Left and right ventricular function
Sever...
• NYHA Functional class:
- The maternal prognosis is strongly
related to NYHA functional class prior to
pregnancy.
• Mater...
Low risk
–
–
–
–
–
–

Uncomplicated septal defect.
Aortic and mitral regurgitation.
Pulmonary stenosis
Hypertrophic cardio...
Moderate risks
– Prosthetic valves on anticoagulant
– Coarctation of aorta
High maternal and fetal risks
– Pulmonary hypertension (pulmonary pressure
>75% systemic pressure)
– Eisenmenger syndrome
...
Additional fetal risks
• Impaired maternal functional class,
smoking and cyanosis are associated
with poor fetal outcomes.
Level of care
• HIGH RISK patients are ideally managed in
tertiary centre with a multidisciplinary team
approach.
• MODERA...
Specialist referral
• Known heart disease or previous cardiac
surgery who have not been assessed or risk
categorised prior...
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY...
General principles of Mx
•
•
•
•

Assess maternal and fetal health.
Assess NYHA functional class.
Confirm clinical diagnos...
• Identify factors that can precipitate
complications e.g. Anemia, infection,
hypertension - treat accordingly.
• Complica...
MANAGEMENT OF SPECIFIC
CONDITIONS
Valvular heart disease
• Mitral stenosis:
• -Mild to moderate (MV area >1 cm²)
tolerates pregnancy well with use of
diuret...
• Mitral Regurgitation and Aortic Regurgitation –
generally well tolerated
• Mild to moderate Aortic stenosis – well toler...
Congenital heart disease
• Risk of CHD to offspring is increased (3.416.1%)
• Low birth weight, prematurity and fetal
wast...
Pulmonary Hypertension
• Present when the pulmonary artery systolic and
mean pressures are >30mmHg and >20mmHg.
• High mat...
Anticoagulation in
pregnancy
Indications:
- Mechanical heart valves
- Venous thromboemboolism
- Atrial fibrillation with s...
Anticoagulation agents
Warfarin
- excellent anticoagulation
- generally avoided in first trimester
(risk of embryopathy es...
Anticoagulation regimes
Fetal Complications

Maternal
Complications

Spont Abort

Cong AbN

TE

Death

Option I

Combined
...
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY...
Labour & Delivery
• When, where, how – individualised
• Monitoring during labour and
postpartum
• Pain relief during labou...
In summary…
Pre-pregnancy
• All women with heart disease should be
counselled on maternal and fetal risks
should they become pregnant
...
During pregnancy
• Pregnant patients with heart disease
should be risk stratified
• Low risk – Managed by primary care
doc...
• Complications should be looked for and
treated
• Patients requiring anticoagulants should
be counseled on the available ...
Labour and delivery
• Moderate and high risk – Labour and delivery
best managed by multidisciplinary team
• Timing and mod...
CONCLUSION
• Cardiovascular diseases are major
maternal mortality and morbidity

causes of

• An understanding of the phys...
Pregnancy is special,
lets make it safe.
Understanding heart disease in pregnancy
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Understanding heart disease in pregnancy

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Understanding heart disease in pregnancy

  1. 1. UNDERSTANDING HEART DISEASE IN PREGNANCY DR NAZIMAH IDRIS O&G HOSPITAL ALOR SETAR
  2. 2. • 0.4-5.0% of pregnant women • Commonest non-obstetric cause of maternal mortality in Malaysia – 10% of all maternal deaths in 1996 • Most common disorders : rheumatic valve disease, congenital heart disease, cardiomyopathy
  3. 3. Physiological changes
  4. 4. Antenatal
  5. 5. Parameter 1st TM 2nd TM 3rd TM Blood volume Cardiac output Stroke volume Heart rate Systolic BP Diastolic BP Pulse pressure Systemic vascular resistance ↑ ↑ ↑ ↑ ↔ ↓ ↑ ↓ ↑↑ ↑ ↑- ↑ ↑ ↑ ↑↑↑ ↑↑ ↓ ↓↓ ↑↑ ↓↓↓ ↑↑↑ ↑ ↑- ↑ ↑ ↑ ↑, ↔ or ↓ ↑ ↑- ↑ ↑ ↑ ↔ ↓ ↔ ↓↓
  6. 6. Blood volume • Increases as pregnancy progresses, peaking at 40-50% above non-pregnant level between 32nd and 36th week, plateaus until term. • Clinical importance: physiological anaemia. (RBC mass increases by only 17-40%)
  7. 7. Parameter 1st TM 2nd TM 3rd TM Blood volume Cardiac output Stroke volume Heart rate Systolic BP Diastolic BP Pulse pressure Systemic vascular resistance ↑ ↑ ↑ ↑ ↔ ↓ ↑ ↓ ↑↑ ↑ ↑- ↑ ↑ ↑ ↑↑↑ ↑↑ ↓ ↓↓ ↑↑ ↓↓↓ ↑↑↑ ↑ ↑- ↑ ↑ ↑ ↑, ↔ or ↓ ↑ ↑- ↑ ↑ ↑ ↔ ↓ ↔ ↓↓
  8. 8. • Cardiac output increases by 30-50% above the pre-pregnancy level and peaks around end of 2nd TM (20th-24th week) • Increase is due to increase in stroke volume initially and then an increase in heart rate by about 20%. (CO = SV x HR)
  9. 9. Changes in CO, SV and HR in Pregnancy ↓BP due to ↓systemic vascular resistance
  10. 10. Parameter 1st TM 2nd TM 3rd TM Blood volume Cardiac output Stroke volume Heart rate Systolic BP Diastolic BP Pulse pressure Systemic vascular resistance ↑ ↑ ↑ ↑ ↔ ↓ ↑ ↓ ↑↑ ↑ ↑- ↑ ↑ ↑ ↑↑↑ ↑↑ ↓ ↓↓ ↑↑ ↓↓↓ ↑↑↑ ↑ ↑- ↑ ↑ ↑ ↑, ↔ or ↓ ↑ ↑- ↑ ↑ ↑ ↔ ↓ ↔ ↓↓
  11. 11. • Fall in systemic vascular resistance • Fall in blood pressure especially in midpregnancy • Increase in pulmonary blood flow, reduce pulmonary vascular resistance, unchanged pulmonary artery pressure • Supine hypotension syndrome in late pregnancy
  12. 12. Labour and delivery
  13. 13. • Anxiety, pain and uterine contractions increase cardiac output by about 50%
  14. 14. Cardiac output changes
  15. 15. Postpartum
  16. 16. • Immediate postpartum – increase in venous return due to relief of caval compression and auto-transfusion from the contracting uterus. • Within hours – heart rate and cardiac output starts to decrease
  17. 17. Note: Physiological adaptations in healthy women cannot be applied to patients with pre-existing heart disease.
  18. 18. Management principles • 1. PRE-CONCEPTUAL CONSELLING • 2. ASSESSMENT AND STRATIFICATION OF MATERNAL AND FETAL RISKS • 3. MANAGEMENT OF PREGNANCY AND COMPLICATIONS OF HEART DISEASE
  19. 19. • 1. PRE-CONCEPTUAL CONSELLING • 2. ASSESSMENT AND STRATIFICATION OF MATERNAL AND FETAL RISKS • 3. MANAGEMENT OF PREGNANCY AND COMPLICATIONS OF HEART DISEASE • 4. DETERMINING TIMING, MODE AND PLACE OF DELIVERY
  20. 20. Pre-conceptual counselling • Target: Heart disease patients of childbearing age and their husband/family. • Assessment: Maternal and fetal risks in the event of pregnancy
  21. 21. Issues: • - Effect of pregnancy on the heart • - Effect of cardiac disorder on fetal development • - Effect of maternal drugs on fetus • - risk of genetic transmission to fetus • - need for compliance
  22. 22. • Patients with heart disease should be encouraged to complete their family early and discouraged from too many pregnancies • High risk patients – advise for sterilization. E.g. Pulmonary HPT, Eisenmenger’s syndrome, Cyanotic heart disease, Poor left ventricular function, Marfan’s syndrome
  23. 23. • Whenever possible, correct cardiac lesions before pregnancy, e.g. - Congenital defects - Mitral stenosis – symptomatic or severe MS with MV area <1.0 cm². - Severe aortic stenosis (valve area <1.0 cm²), impaired exercise tolerance, reduced left ventricular function.
  24. 24. • 1. PRE-CONCEPTUAL CONSELLING • 2. ASSESSMENT AND STRATIFICATION OF MATERNAL AND FETAL RISKS • 3. MANAGEMENT OF PREGNANCY AND COMPLICATIONS OF HEART DISEASE • 4. DETERMINING TIMING, MODE AND PLACE OF DELIVERY
  25. 25. Detection of cardiac disease in pregnancy • History • Physical examination • Investigation Note: Symptoms and signs of heart disease and normal pregnancy may be similar.
  26. 26. History • Dyspnea • Palpitations • Estimation of effort tolerance (NYHA Functional Classification) • History of rheumatic fever, cardiac surgery and hypertension • Drug history
  27. 27. NYHA Functional Class • NYHA 1 no limitation. Ordinary physical activity does not cause undue fatigue, dyspnoea or palpitation. • NYHA 2 slight limitation of activity. Comfortable at rest. Ordinary physical activity results fatigue, dyspnoea or palpitation. • NYHA 3 marked limitation of physical activity. Comfortable at rest but less than ordinary activity will lead to symptoms. • NYHA 4 symptoms of failure are present at rest. With any physical activity, increased discomfort is present. in
  28. 28. Physical examination • Clubbing, cyanosis, features of Marfan Syndrome • Pulse for arrhythmia • BP • JVP • Precordial examination – murmurs, RV hypertrophy, presence of loud second heart sound (pulmonary hypertension)
  29. 29. Investigations • ECG • ECHO- sometimes this is the only reliable method in determining whether a cardiac murmur is significant/non significant in a pregnant patient.
  30. 30. • THEREFORE, THE THRESHOLD FOR AN ECHO SHOULD BE LOW.
  31. 31. RISK CATEGORIZATION – – – – – – – – NYHA functional class. Presence of cyanosis Left and right ventricular function Severity of pulmonary hypertension Presence of valve/conduit stenosis Presence of conduction defects/arrhythmias Smoking Multiple gestation
  32. 32. • NYHA Functional class: - The maternal prognosis is strongly related to NYHA functional class prior to pregnancy. • Maternal mortality varies from <1% in those with NYHA 1 or 2 to around 7% in those with NYHA 3 or 4.
  33. 33. Low risk – – – – – – Uncomplicated septal defect. Aortic and mitral regurgitation. Pulmonary stenosis Hypertrophic cardiomyopathy Acyanotic Ebstein’s anomaly Corrected transposition withour other defects
  34. 34. Moderate risks – Prosthetic valves on anticoagulant – Coarctation of aorta
  35. 35. High maternal and fetal risks – Pulmonary hypertension (pulmonary pressure >75% systemic pressure) – Eisenmenger syndrome – Uncorrected Cyanotic heart disease – Severe aortic stenosis – Severe mitral stenosis – Poor LVF(LVEF<40%) irrespective of etiology – Marfan’s syndrome (aortic root diameter >40mm)
  36. 36. Additional fetal risks • Impaired maternal functional class, smoking and cyanosis are associated with poor fetal outcomes.
  37. 37. Level of care • HIGH RISK patients are ideally managed in tertiary centre with a multidisciplinary team approach. • MODERATE RISK can be managed in hospitals where specialists are available. • LOW RISK can be managed in the clinic by their primary care doctors.
  38. 38. Specialist referral • Known heart disease or previous cardiac surgery who have not been assessed or risk categorised prior to pregnancy • Moderate to high risk • Worsening symptoms due to heart disease • Suspected heart disease, to confirm or refute diagnosis
  39. 39. • 1. PRE-CONCEPTUAL CONSELLING • 2. ASSESSMENT AND STRATIFICATION OF MATERNAL AND FETAL RISKS • 3. MANAGEMENT OF PREGNANCY AND COMPLICATIONS OF HEART DISEASE • 4. DETERMINING TIMING, MODE AND PLACE OF DELIVERY
  40. 40. General principles of Mx • • • • Assess maternal and fetal health. Assess NYHA functional class. Confirm clinical diagnosis. Establish baseline hemodynamics (LVEF, PAP by ECHO) • Consider termination in high risk cases
  41. 41. • Identify factors that can precipitate complications e.g. Anemia, infection, hypertension - treat accordingly. • Complications of heart disease should be identified and treated. – – – – Heart failure Worsening left to right shunt Thromboembolism Arrhythmias
  42. 42. MANAGEMENT OF SPECIFIC CONDITIONS
  43. 43. Valvular heart disease • Mitral stenosis: • -Mild to moderate (MV area >1 cm²) tolerates pregnancy well with use of diuretics and beta-blockers • -Severe MS (MV area <1 cm² and/or PHT) should be considered for mitral vulvotomy during 2nd TM
  44. 44. • Mitral Regurgitation and Aortic Regurgitation – generally well tolerated • Mild to moderate Aortic stenosis – well tolerated • Severe Aortic stenosis – if clinical deterioration is evident – terminate pregnancy • Pulmonary stenosis – rarely problematic • Prosthetic heart valves –most tolerate pregnancy well. Requires full anti-coagulation.
  45. 45. Congenital heart disease • Risk of CHD to offspring is increased (3.416.1%) • Low birth weight, prematurity and fetal wastage increased in cyanotic mothers. • Acyanotic CHD (ASD, VSD, PDA) – well tolerated in pregnancy • Cyanotic CHD – associated with Pulmonary HPT.
  46. 46. Pulmonary Hypertension • Present when the pulmonary artery systolic and mean pressures are >30mmHg and >20mmHg. • High maternal mortality – 40-50%, usually at the time of delivery or early postpartum • Mx: - consider termination if early, - anticoagulation, continuous O2 therapy, hydration if near fetal viability
  47. 47. Anticoagulation in pregnancy Indications: - Mechanical heart valves - Venous thromboemboolism - Atrial fibrillation with structural heart disease
  48. 48. Anticoagulation agents Warfarin - excellent anticoagulation - generally avoided in first trimester (risk of embryopathy esp. in doses >5mg dly - avoided after 37 weeks (risk of fetal bleeding in labour) Heparin - does not cross placenta - in first trimester and after 37 weeks - prob. of thrombocytopenia and osteopenia Low Molecular Weight Heparin (LMWH) - advantages over unfractionated heparin (UFH)
  49. 49. Anticoagulation regimes Fetal Complications Maternal Complications Spont Abort Cong AbN TE Death Option I Combined heparin and warfarin 24.8% 3.4% 9.2% 4.2% Option II Heparin throughout 23.8% 0– 2.8% 33.3% 15% Option III Warfarin throughout 24.7% 6.4% 3.9% 1.8%
  50. 50. • 1. PRE-CONCEPTUAL CONSELLING • 2. ASSESSMENT AND STRATIFICATION OF MATERNAL AND FETAL RISKS • 3. MANAGEMENT OF PREGNANCY AND COMPLICATIONS OF HEART DISEASE • 4. DETERMINING TIMING, MODE AND PLACE OF DELIVERY
  51. 51. Labour & Delivery • When, where, how – individualised • Monitoring during labour and postpartum • Pain relief during labour • Antibiotic prophylaxis
  52. 52. In summary…
  53. 53. Pre-pregnancy • All women with heart disease should be counselled on maternal and fetal risks should they become pregnant • Wherever indicated, significant cardiac lesions should be corrected prior to pregnancy
  54. 54. During pregnancy • Pregnant patients with heart disease should be risk stratified • Low risk – Managed by primary care doctors • Moderate risk – Hospital with Specialists • High risk – Tertiary care centre
  55. 55. • Complications should be looked for and treated • Patients requiring anticoagulants should be counseled on the available options
  56. 56. Labour and delivery • Moderate and high risk – Labour and delivery best managed by multidisciplinary team • Timing and mode of delivery should be individualised • Adequate analgesia during labour is important • Antibiotic prophylaxis during labour in patients susceptible to endocarditis
  57. 57. CONCLUSION • Cardiovascular diseases are major maternal mortality and morbidity causes of • An understanding of the physiology of the cardiovascular adaptation in pregnancy and its pathophysiology in disease states is crucial to efficient management of these diseases in pregnancy • The importance of prevention of pregnancy cannot be overemphasized in certain cardiac diseases
  58. 58. Pregnancy is special, lets make it safe.

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