Heart diseases in pregnancy; NYHA classification; Valvular heart diseases in pregnancy; Arrythmias; Eisenmenger's Syndrome; Marfan's Syndrome; Peripartum cardiomyopathy

1. HEART DISEASES IN
PREGNANCY
DR. TAILA AMBER

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

8. SUSPECT HEART DISEASE
 Low volume pulse
 Tachycardia, Irregular pulse - Atrial
fibrillation
 Cyanosis, clubbing, Splinter
hemorrhages
 Signs of cardiac failure
– Raised JVP, hepatomegaly, pedal edema
 Pan-systolic murmurs (VSD,MR,TR)
with Thrill
 Late systolic murmurs (MR, MVP)
 Ejection systolic murmur (Grade > 3/6)
 Diastolic murmur 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

12. INITIAL MANAGEMENT
• ASSESSMENT OF PREGNANT PATIENT
• FETAL ASSESSMENT
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

16. SUBSEQUENT MANAGEMENT
1. Pre-conceptional counseling, Risk stratification
2. Antepartum management
3. Peripartum management
Dr. Taila Amber

17. PRE-CONCEPTIONAL COUNSELLING
Obstetrician and cardiologist
Prevent an unwanted pregnancy and asses the risks
associated with pregnancy
Continuation OR Termination
Dr. Taila Amber

18. RISK SCORE (CARPREG Study)
1. Preconception history of adverse cardiac events or arrhythmia
2. Poor functional class before pregnancy(NYHA class >II)
3. Left heart obstruction -MVA < 2 sqcm
AVA <1.5sqcm
Aortic valve gradient >30mmHg
4. LV Ejection Fraction <40%
5. Cyanosis
Estimated risk of adverse cardiac event
0 ------- 5%
1 ------- 27%
>1 ------- 75%
Dr. Taila Amber

19. Dr. Taila Amber

20. 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

22. ANTEPARTUM MANAGEMENT
• MEDICAL MANAGEMENT
• SURGICAL MANAGEMENT
• OBSTETRICAL MANAGEMENT
Dr. 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

35. SPECIFIC HEART DISEASES
Dr. Taila Amber

36. ARRHYTHMIAS
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

39. MITRAL STENOSIS
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

43. PERIPARTUM CARDIOMYOPATHY
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

45. MYOCARDIAL INFARCTION
• MATERNAL RISK:
– Rare in pregnancy
– 19 % immediate mortality
• MANAGEMENT:
– INITIAL:
• Opiates, anticoagulants
• Coronary angiography after delivery
• MOD: Vaginal with epidural analgesia
• Instrumental delivery
• Oxytocin infusion in 3rd stage
• Ergometrine avoided
– PUERPERIUM:
• MB-CPK raised
• Pregnancy discouraged in futureDr. Taila Amber

46. 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

51. THANK YOU
Dr. Taila Amber