2. PHYSIOLOGICAL CHANGES IN PREGNANCY
Cardiac output 30-50%
Stroke volume 30-50%
Heart rate 10-20bpm
Systemic Peripheral
resistance 30%
Decrease in both systolic
(3-5mmHg) &diastolic
blood pressure (5-
10mmHg) .
Dr. Taila Amber
3. Gradient between colloid oncotic pressure and
Pulmonary Capillary wedge pressure
28%
Turning from left lateral to supine position, CO
25%
PHYSIOLOGICAL CHANGES IN PREGNANCY
Dr. Taila Amber
4. PHYSIOLOGICAL CHANGES DURING LABOUR
Rapid increase in HR and BP
Increase in Cardiac Output
15% in 1st stage
50% in 2nd stage
Uterine contractions -> auto-transfusion of 300-500ml
3rd Stage: 1L blood returns to circulation
Hence, risk of pulmonary edema in 2nd stage and immediately
post-partum
Changes revert ---
Rapidly in 1st week
Slowly in 6 weeks
Some may persist for 1 year
Dr. Taila Amber
5. Decreased exercise capacity
Tiredness
Dyspnea
Palpitations
Light headedness
SYMPTOMS DURING NORMAL PREGNANCY
THAT MAY MIMIC CARDIAC DISEASE
Dr. Taila Amber
6. SUSPECT HEART DISEASE
Previous history
Orthopnea and PND
Excessive fatigue
Palpitations with sweating/syncope
Chest pain
Dr. Taila Amber
7. SIGNS that mimic CARDIAC DISEASE
Loud S1
Exaggerated splitting of S2
Physiological S3 at the apex
Systolic ejection murmur at LSB ( up to Grade 3/6) (96%)
Continuous murmurs ( mammary soufflés, cervical
venous hum)
Bounding pulse
Ectopic beats
Dr. Taila Amber
9. TYPES OF CARDIAC DISEASES
CONGENITAL ACQUIRED
PDA
ASD/VSD
PULMONARY STENOSIS
TOF
CONGENITAL AORTIC / MITRAL VALVE
DISEASE
EISENMENGER’S SYNDROME
PRIMARY PULMONARY HTN
COARCTATION OF AORTA
MARFAN’S SYNDROME
CONGENITAL HEART BLOCK
TRICUSPID ATRESIA
RHEUMATIC HEART DISEASE
MS (90%)
MR (6.6%)
AS (1%)
AR (2.5%)
TR/TS
MI
CARDIOMYOPATHY
HOCM
Puerperal cardiomyopathy
ENDOMYOCARDIAL FIBROSIS
PERICARDIAL DISEASE
Dr. Taila Amber
10. CLASS I No functional limitation of activity.
No symptoms of cardiac de-compensation with activity.
CLASS II Patients are asymptomatic at rest. Ordinary physical
activity results in symptoms.
CLASS III Limitation of most physical activity.
Asymptomatic at rest
Minimal physical activity results in symptoms.
CLASS IV Severe limitation of physical activity results in
symptoms.
Patients may be symptomatic at rest /heart failure
at any point of pregnancy.
NEW YORK HEART ASSOCIATION
FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE
Dr. Taila Amber
11. SIGNIFICANCE OF HEART DISEASE
IN PREGNANCY
MATERNAL :
Restricted physical
activity
MM : 2.3/100,000
CAUSES:
• MS (in our country)
• Cardiomyopathy
• Pulmonary vascular
disease / HTN
• MI
• Dissecting aneurysm
• Endocarditis
FETAL:
Miascarriages
IUGR
IUD
Premature delivery
Increased PMR
Risk of CHD = 2-4%
Cardiac disease affects 3-3.5% of all pregnancies
Dr. Taila Amber
13. ASSESSMENT OF PREGNANT PATIENTS
HISTORY
• Dyspnea : NYHA classification, onset • Fever with arthralgia
• Prior events : (HF ,TIA ,STROKE). • Recurrent Cyanosis
• Associated diseases : (anemia ,thyrotoxicosis ,Htn).
• Drugs : (kind ,compliance ,education) • Past History
• Arrhythmia • Family history
EXAMINATION
• Murmurs.
• Signs of heart failure
• Signs of endocarditis
ECG&ECHO
• ECG: arrhythmia.
• ECHO
• CXR, MRI
• Angiography
Dr. Taila Amber
14. ECG
Axis deviation to the left 15-20
Small Q waves
T wave inversion in lead III
Sinus tachycardia
TROPONIN
Not affected by pregnancy, useful in IHD
TRANSTHORACIC ECHOCARDIOGRAPHY-Cornerstone of
evaluation
LV / RV / LA / RA dimensions, pericardial effusion, Small Functional TR /
PR / MR/ AR
CXR
MRI , CT scan
ANGIOGRAPHY
INVESTIGATIONS
Dr. Taila Amber
15. FETAL ASSESSMENT
• 1st Trimester USG: sensitivity=85%, Specificity = 99%
• 2nd Trimester (18-20wk): Optimal time
• When fetal cardiac anomaly suspected:
– Full fetal Echocardiography
– Detailed anomaly scan
– Family history
– Maternal medical history
– Fetal karyotype
– Referral to maternal-fetal medicine specialist ,pediatric
cardiologist, geneticist, neonatologist
– Delivery where NNU facilities are available
Dr. Taila Amber
21. TERMINATION OF PREGNANCY
TERMINATION - <12wks OF PREGNANCY
Eisenmenger's syndrome
Marfan syndrome with aortic involvement
Severe Pulmonary hypertension
Coarctation of aorta
Symptomatic severe AS, MS
Severe left ventricular dysfunction EF<40%
Metallic prosthetic valve –complications
1st and 2nd trimester : suction evacuation safe
If medical management : Mifepristone in 1st
PG E1,2 , misoprostolDr. Taila Amber
23. MEDICAL MANAGEMENT
Multidisciplinary Team – cardiologist, obstetricians,
fetal medicine specialists, pediatrician
NYHA CLASS I or II
1. Limit strenuous exercise
2. Adequate rest
3. Iron and Vitamins to minimize anemia
4. Low salt diet if ventricular dysfunction
5. Regular cardiac and obstetric evaluation
Identify and treat early - infections, anemia,
hypertension, hyperthyroidism & arrthymias
Dr. Taila Amber
24. NYHA CLASS III or IV
1. Hospitalisation for bed rest
2. Intensive Close monitoring
3. Cardiac intervention, surgery
4. Termination of pregnancy
Treat precipitating events – infections, arrhythmia,
anemia, hyperthyroidism
DISEASE SPECIFIC
MEDICAL MANAGEMENT
Dr. Taila Amber
25. SURGICAL MANAGEMENT
• Rarely required, in certain cases of acquired heart
disease
• Open heart surgery avoided (10-30% Risk of fetal loss)
• Closed valvotomy or valvuloplasty preferred for
valvular lesions
• Optimal time -> 2nd trimester
Dr. Taila Amber
26. OBSTETRICAL MANAGEMENT
Frequency of visits:
2 weekly
Assessment of cardiac status, fetal size, liquor, FM
USG
Anomaly scan
2 weekly growth scan
Hospital admission
Low threshold
Time and mode of delivery
Labour Dr. Taila Amber
27. TIME OF DELIVERY
• Multidisciplinary Approach
• TIMING OF DELIVERY:
Individualized on
– Cardiac status
– Bishop score
– Fetal well-being
– Lung maturity
Dr. Taila Amber
28. MODE OF DELIVERY
Normal vaginal delivery - in patients hemodynamically
stable (ESC guidelines)
– Less risk of blood loss, infections, VTE
Cesarean section is indicated in:
1. Aortic dissection
2. Marfan syndrome with dilated aortic root( >45mm)
3. Hemodynamically Unstabillity in particular case of
severe AS.
4. Obstetric causes
5. OACs
Dr. Taila Amber
29. INDUCTION OF LABOUR
• BISHOP favorable : ARM & Oxytocin infusion
• BISHOP unfavorable:
– Misoprostol : Low risk of coronary vasospasm &
arrhythmias
– Dinoprostol: Affects B.P, Contraindicated in active
CVD
– Mechanical methods preferred
Dr. Taila Amber
30. LABOUR
Intensive Hemodynamic monitoring in severe stenotic lesions
or low EF.
Admit few days before labour
Pulse, BP, O2 saturation, Left lateral position.
Careful attention to volume status
NS < 75 ml/hour
Inj. Furosemide , Digoxin
- Asses pulmonary basal crepts, JVP
Treatment of arrhythmias
Epidural analgesia to provide analgesia and thus avoid
increase in CO due to pain and anxiety
Procedures (ventouse / forceps) to cut short the 2nd stage of
labour Dr. Taila Amber
31. DELIVERY IN ANTICOAGULATED WOMEN
WITH PROSTHETIC VALVES
• ELECTIVE DELIVERY:
– OACs shifted to LMWH / UFH from 36 weeks
– LMWH shifted to UFH 36 hrs before induction/ C-section
– UFH discont. 4-6 hrs before delivery, restarted 4-6 hrs after
delivery
• EMERGENCY DELIVERY:
– If on UFH/LMWH --- consider Protamine
– If on OACs --- C-section
• FFP & Oral Vit K (0.5-1mg) before C-section
• Target INR ≤ 2
• FFP & Vit K to newborn
Dr. Taila Amber
32. Warfarin is the favored anticoagulant during
the 2nd, 3rd trimesters until the 36th wk
(Class IC ESC guidelines).
Warfarin is favored in the 1st trimester if the
dose <5mg /24hrs(Class IIaC ECS guidelines)
ESC GUIDELINES
Dr. Taila Amber
33. POST PARTUM CARE
• Slow IV oxytocin infusion @ <2U/min
• PGF analogues in PPH
• Methylergometrine contraindicated (10% risk of
vasoconstriction & HTN)
• Leg care, elastic stockings, early ambulation to
prevent VTE
• Hemodynamic monitoring for 24-72 hours post-
partum
Dr. Taila Amber
34. LACTATION
• Prevents Mastitis, hence Bacteremia
• Diuretic requirement fall
• If severely unwell --- Bottle feed
Dr. Taila Amber
37. • Acute atrial flutter or atrial fibrillation
treated promptly
• Ventricular Arrhythmias commonest
cardiac complication during pregnancy
• If possible, all antiarrhythmic drugs should
be avoided during the first trimester, and
those known to be teratogenicity should be
avoided throughout pregnancy.
• Because of their safety profiles, preferred
drugs include digoxin, beta-blockers and
adenosine.
ARRHYTHMIAS
Dr. Taila Amber
38. EISENMENGER’S SYNDROME
• MATERNAL RISK: Mortality = 20-50%
• NEONATAL OUTCOME: Live birth < 12%
• MANAGEMENT:
• If Pregnancy ------ Termination
• If pt. choose to continue ---
• Bed rest, O2 saturation
• Anticoagulation
• Diuretics if heart failure
• Oral/ IV Fe, if Iron deficiency
• Delivery ---
• C-section if maternal/ fetal condition
deteriorates
• Otherwise, timely admission, planned delivery
Dr. Taila Amber
40. • Responsible for most of morbidity and mortality of RHD in pregnancy
• MATERNAL RISK:
• Heart failure (MVA<1.5sqcm), Pulmonary edema
• OBSTETRIC/ OFFSPRING RISK:
• Prematurity = 20-30%
• IUGR = 5-20%
• Still birth = 1-3%
• MANAGEMENT:
• Moderate/Severe MS --- counsel against pregnancy
• Mild MS: Echo monthly
• Medical: β1 blocker, diuretics, anticoagulants
• Surgical: Percutaneous mitral commisurotomy after 20
weeks in NYHA III/IV
• MOD:
• Mild --- Vaginal
• Moderate/Severe ---- Cesarean section
MITRAL STENOSIS
Dr. Taila Amber
41. • MATERNAL RISK:
– VTE in 5%
– Arrhythmia
• OBSTETRIC RISK:
– Pre-eclampsia
– SGA
• MANAGEMENT:
– MOD: Vaginal
– Catheter device closure if condition deteriorates
– Prevention of embolisation
• Compression stockings
• Avoiding supine position
• Early ambulation after delivery
ASD/VSD
Dr. Taila Amber
42. COARCTATION OF AORTA
• MATERNAL RISK:
– Class II WHO
– Risk of aortic or cerebral aneurysm rupture
• OBSTETRIC/OFFSSPRING RISK:
– HTN
– Miscarriage
• MANAGEMENT:
– MOD: Vaginal with epidural (ESC)
Cesarean section in some references
– Follow up in each trimester
– Treat HTN, but not to cause hypo perfusion
– Percutaneous intervention could be done
Dr. Taila Amber
44. • Idiopathic CM presenting with heart failure secondary to LV systolic
dysfunction towards end of pregnancy or in months following delivery
• EF always reduced to below 45%
• PREDISPOSING FACTORS:
– Multiparity, family history, smoking, DM, HTN, Pre-
eclampsia, malnutrition
• S/S: of heart failure
• INVESTIGATION: Echocardiography
• TREATMENT:
• Medical treatment of heart failure
• Hydralazine, Nitrates, Dopamine, β blockers are
safe
• ACE inhibitors, ARBs, Renin Inhibitors avoided
PERIPARTUM CARDIOMYOPATHY
Dr. Taila Amber
47. PREGNANCY AND DRUGS
STENOTIC LESIONS REGURGITATION LESIONS
• Bblocker: metoprolol ,propranolol
(class C ),atenolol (class D ).
• C channel antagonist: verapamil ,
diltiazem (class C)
• Digoxin : (class C).
• Diuretic: for patient with pulmonary
congestion.
• Vasodilators: only If BP is high :
• Hydralazine:(class C ).
• Nitrate :(class C ).
• Diuretic:
• Thiazide: ( class B).
• Loop diuretic: (class C ).
• Avoid hypotension & placental
hypoperfusion
ACE inhibitor ,ARBS (class X ).
Dr. Taila Amber
48. CONTRACEPTION
• Barrier methods – unreliable.
• COC contraindicated.
• Progesterone only pill have better side effect profile
& long acting slow releasing as Mirena intrauterine
system have improved efficacy.
• Sterilization where family completed. (Laparoscopic
clip sterilization carries risk).
Dr. Taila Amber
49. CONCLUSION
Pregnancy causes significant haemodynamic changes
and imposes an additional burden on the cardiac
patient, especially around the time of labour and in
the immediate puerperium.
To achieve a successful pregnancy outcome, a clear
understanding of these haemodynamic adaptations
as well as meticulous maternal and foetal
surveillance for risk factors and complications
throughout the pregnancy is essential.
Dr. Taila Amber
50. CONCLUSION
Appropriate contraceptive and family planning advice
as well as pre-conceptional counseling are also
important.
The concerted efforts of a team consisting of the
obstetrician, cardiologist, anesthetist, cardiothoracic
surgeon, neonatologist, and pediatric cardiologist are
mandatory to ensure optimal results.
Dr. Taila Amber
3rd stage : 1 L due to relief of IVC obstruction and contraction of uterus
Left axis deviation due to more horizontal position of heart.
There is no evidence of an increased fetal risk of congenital malformations, intellectual disability, growth restriction, or pregnancy loss at doses of radiation to the pregnant woman of ,50 mGy. risk of malformations is increased at doses
.100 mGy, whereas the risk between 50 and 100 mGy is less clear.
The fetal dose from a chest radiograph is ,0.01 mGy.25 Nevertheless,
a chest radiograph should only be obtained if other methods
fail to clarify the cause of dyspnoea, cough, or other symptoms.
Trans-esophageal Echo can be done provided precautions to avoid aspiration are undertaken.
CXR, Ct scan , MRI are safe in pregnancy.
MRI should only be performed if other diagnostic measures, including transthoracic and transoesophageal echocardiography, are not sufficient for complete diagnosis.
Computed tomography (CT)31 is usually not necessary to diagnose CVD during pregnancy and, because of the radiation dose involved, is therefore not recommended. One exception is that it may be required for the accurate diagnosis or definite exclusion of pulmonary embolism.
Angiography usually post-poned until after pregnancy, but shouldn’t in acute coronary syndromes. During coronary angiography the mean radiation exposure to the unshielded abdomen is 1.5 mGy, and ,20% of this reaches the fetus because of tissue attenuation.