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Understanding heart disease in pregnancy
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Understanding heart disease in pregnancy

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  • 1. UNDERSTANDING HEART DISEASE IN PREGNANCY DR NAZIMAH IDRIS O&G HOSPITAL ALOR SETAR
  • 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. Physiological changes
  • 4. Antenatal
  • 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. 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. 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. • 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. Changes in CO, SV and HR in Pregnancy ↓BP due to ↓systemic vascular resistance
  • 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. • 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. Labour and delivery
  • 13. • Anxiety, pain and uterine contractions increase cardiac output by about 50%
  • 14. Cardiac output changes
  • 15. Postpartum
  • 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. Note: Physiological adaptations in healthy women cannot be applied to patients with pre-existing heart disease.
  • 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. • 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. 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. 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. • 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. • 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. • 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. Detection of cardiac disease in pregnancy • History • Physical examination • Investigation Note: Symptoms and signs of heart disease and normal pregnancy may be similar.
  • 26. History • Dyspnea • Palpitations • Estimation of effort tolerance (NYHA Functional Classification) • History of rheumatic fever, cardiac surgery and hypertension • Drug history
  • 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. 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. 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. • THEREFORE, THE THRESHOLD FOR AN ECHO SHOULD BE LOW.
  • 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. • 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. Low risk – – – – – – Uncomplicated septal defect. Aortic and mitral regurgitation. Pulmonary stenosis Hypertrophic cardiomyopathy Acyanotic Ebstein’s anomaly Corrected transposition withour other defects
  • 34. Moderate risks – Prosthetic valves on anticoagulant – Coarctation of aorta
  • 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. Additional fetal risks • Impaired maternal functional class, smoking and cyanosis are associated with poor fetal outcomes.
  • 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. 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. • 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. 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. • 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. MANAGEMENT OF SPECIFIC CONDITIONS
  • 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. • 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. 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. 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. Anticoagulation in pregnancy Indications: - Mechanical heart valves - Venous thromboemboolism - Atrial fibrillation with structural heart disease
  • 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. 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. • 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. Labour & Delivery • When, where, how – individualised • Monitoring during labour and postpartum • Pain relief during labour • Antibiotic prophylaxis
  • 52. In summary…
  • 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. 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. • Complications should be looked for and treated • Patients requiring anticoagulants should be counseled on the available options
  • 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. 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. Pregnancy is special, lets make it safe.