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Heart disease in pregnancy
- 1. Heart disease in pregnancy Muntadhar Haider
- 2. Heart disease in pregnancy pregnancy-induced anatomical and functional changes in cardiac physiology can have a profound effect on underlying heart disease
- 3. Heart disease in pregnancy ā¢ Women with underlying cardiac disease may not always accommodate these changes ā¢ ventricular dysfunction leads to cardiogenic heart failure ā¢ these women should be fully assessed by an obstetrician and cardiologist before be pregnant ā¢ maternal and fetal risks carefully explained. ā¢ A plan to optimize medication should be made and ā¢ if there is a possibility that the heart disease will require surgical correction, it is recommended that this should be undertaken before a pregnancy
- 4. Issues in prepregnancy counselling of women with heart disease
- 5. DIAGNOSIS OF HEART DISEASE The physiological adaptations of normal pregnancy can induce symptoms and alter clinical findings that may confound the diagnosis of heart disease.
- 6. Clinical findings that may suggest heart disease Symptoms Progressive dyspnea or orthopnea Nocturnal cough Hemoptysis Syncope Chest pain Clinical Findings Cyanosis Clubbing of fingers Persistent neck vein distention Systolic murmur grade 3/6 or greater Diastolic murmur Cardiomegaly Persistent arrhythmia Persistent split second sound Criteria for pulmonary hypertension ā¢ Pregnant women with none of these rarely have serious heart disease
- 7. Stages of heart failure ā (NYHA) classification
- 8. Predictors of cardiac complications included Toronto risk markers for maternal cardiac events
- 9. (WHO) Risk Classification of Cardiovascular Disease and Pregnancy WHO 1āRisk no higher than general population Uncomplicated, small, or mild: Pulmonary stenosis Ventricular septal defect Patent ductus arteriosus Mitral valve prolapse with no more than trivial mitral regurgitation Successfully repaired simple lesions: Ostium secundum atrial septal defect Ventricular septal defect Patent ductus arteriosus Total anomalous pulmonary venous drainage Isolated ventricular extrasystoles and atrial ectopic beats
- 10. (WHO) Risk Classification of Cardiovascular Disease and Pregnancy WHO 2āSmall increase in risk of maternal mortality and morbidity If otherwise uncomplicated: Unoperated atrial septal defect Repaired Fallot tetralogy Most arrhythmias WHO 2 or 3ādepends on individual case Mild left ventricular impairment Hypertrophic cardiomyopathy Native or tissue valvular heart disease not considered WHO 4 Marfan syndrome without aortic dilation Heart transplantation
- 11. (WHO) Risk Classification of Cardiovascular Disease and Pregnancy WHO 3āSignificantly increased risk of maternal mortality or expert cardiac and obstetrical care required Mechanical valve Systemic right ventricleācongenitally corrected transposition, simple transposition post-Mustard or -Senning repair Post-Fontan operation Cyanotic heart disease Other complex congenital heart disease
- 12. (WHO) Risk Classification of Cardiovascular Disease and Pregnancy WHO 4āVery high risk of maternal mortality or severe morbidity; pregnancy contraindicated and termination discussed ā¢ Pulmonary arterial hypertension ā¢ Severe systemic ventricular dysfunction (NYHA III-IV or LVEF < 30%) ā¢ Previous peripartum cardiomyopathy with any residual impairment of left ventricular function ā¢ Severe left heart obstruction ā¢ Marfan syndrome with aorta dilated > 40 mm
- 13. Fetal risks of maternal cardiac disease
- 14. Diagnostic Studies Electrocardiography As the diaphragm is elevated in advancing pregnancy, there is an average 15-degree left-axis deviation , mild ST changes may be seen in the inferior leads. Atrial and ventricular premature contractions are relatively frequent Chest Radiography (AP) and lateral chest radiographs are useful, and when a lead apron shield is used, Gross cardiomegaly can usually be excluded, but slight heart enlargement cannot be detected accurately because the heart silhouette normally is larger in pregnancy. This is accentuated further with a portable AP chest radiograph. Echocardiography :- allowed accurate diagnosis of most heart diseases during pregnancy, noninvasive, Some normal pregnancy-induced changes include slightly but significantly increased tricuspid regurgitation, left atrial end-diastolic dimension, and left ventricular mass
- 15. Antenatal management ā¢ Experienced physicians and obstetricians should manage pregnant women with significant heart disease in a joint obstetric/cardiac clinic ā¢ Most women will remain well during the antenatal period and outpatient management is usually possible ā¢ women should be advised to reducing their normal physical activities ā¢ Prophylactic antibiotics should be given to any woman with a structural heart defect to reduce the risk of bacterial endocarditis ā¢ Echocardiography & echocardiogram at the booking visit and at around 28 weeksā gestation is usual. ā¢ Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension (PH) or artificial valve replacements, at risk of atrial fibrillation.
- 16. Management of labour and delivery ā¢ the aim of management is to await the onset of spontaneous labour, ā¢ Induction of labour should be considered for the usual obstetric indications and in very high-risk women, to ensure that delivery occurs at a reasonably predictable time ā¢ Epidural anesthesia is often recommended, as this reduces the pain related stress and, thereby, reduce some of the demand on cardiac function ā¢ regional anesthesia ? ā¢ Fluid blance ā¢ in labour, the time of the second stage can kept short, with an elective forceps or ventouse delivery if normal delivery does not occur readily. ā¢ Caesarean section should only be performed in situations where the maternal condition is considered too unstable to tolerate the physiological demands of labour.
- 17. Management of labour and delivery
- 18. heart failure in pregnancy Diagnosis confirmed:- by clinical examination for signs of heart failure and by echocardiography confirming ventricular dysfunction ) ejection fraction < 0.45(
- 19. heart failure in pregnancy ā¢ treatment are the same as in the non-pregnant individual. ā¢ Pulmonary edema from heart failure usually responds promptly with diuretic administration to reduce preload. ā¢ Hypertension is common, and afterload reduction is accomplished with hydralazine or another vasodilator ā¢ Oxygen, Digoxin, morphine , prophylactic heparin may be required ā¢ assessment of fetal wellbeing is essential and should include fetal ultrasound to assess fetal growth and regular cardiotocography (CTG) ā¢ If there is evidence of fetal compromise, premature delivery may be considered.
- 20. heart failure in pregnancy ā¢ Cardiovascular decompensation during labor may manifest as pulmonary edema with hypoxia or as hypotension, or both. ā¢ proper therapeutic approach depends on the specific hemodynamic status and the underlying cardiac lesion ā¢ Women may still decompensate postpartum when fluid mobilization into the intravascular compartment and reduction of peripheral vascular resistance place higher demands on myocardial performance ā¢ Therefore, it is important that meticulous care be continued into the puerperium
- 21. Ischemic heart disease ā¢ Most pregnant women with myocardial infarction (MI) are >40 years with <1% are <35 years ā¢ classic risk factors such as diabetes, smoking, hypertension, hyperlipidemia, obesity, parous women older than 35 years ā¢ The diagnosis of MI in pregnant women is often missed, and prompt diagnosis and therapy are necessary to reduce the high associated maternal and perinatal mortality. ā¢ Diagnosis during pregnancy is not different from the nonpregnant patient. Measurement of serum levels of the cardiac-specific contractile protein troponin I provides an accurate diagnosis
- 22. Ischemic heart disease ā¢ Acute management includes administration of oxygen, nitroglycerin, low-dose aspirin, heparin, and Ī²- blocking drugs with close blood pressure monitoring. Lidocaine is used to suppress malignant arrhythmias and calcium-channel blockers or Ī²- blockers are given if indicated ā¢ PTCA is only used when absolutely necessary. ā¢ avoiding the time when the fetus is most susceptible to radiation (8ā15 weeks) ā¢ There is little experience with thrombolytic therapy in pregnancy, and although not apparently teratogenic, there are risks of fetal and maternal hemorrhage ā¢ If the infarct has healed sufficiently, cesarean delivery is reserved for obstetrical indications, and epidural analgesia is ideal for labor
- 23. Mitral and aortic stenosis ā¢ risk factors for maternal morbidity and mortality, as they result in an inability to increase cardiac output to meet the demands of pregnancy ā¢ The principal underlying hemodynamic problem is the fixed cardiac output associated with severe stenosis. ā¢ Number of events acutely decrease preload further and thus aggravate the fixed cardiac output. These include 1- vena caval occlusion, 2- regional analgesia, and hemorrhage. Importantly, these also decrease cardiac, cerebral, and uterine perfusion
- 24. Aortic stenosis ā¢ Aortic stenosis (AS) is usually congenital in origin ā¢ Pregnancy is usually well tolerated in women with isolated and mild and moderate AS ā¢ the risk of maternal death in those with severe AS is reported as 17%, with fetal mortality of 30%. ā¢ For the asymptomatic woman with aortic stenosis, no treatment except close observation is required. Management of the symptomatic woman includes strict limitation of activity and prompt treatment of infections, anticoagulant, antiarrhythmias, ā¢ If symptoms persist, valve replacement or valvotomy using cardiopulmonary bypass must be considered. ā¢ balloon valvotomy?? ā¢ Labor??
- 25. Mitral stenosis ā¢ mitral stenosis usually rheumatic in origin. ā¢ 40% experience worsening symptoms in the pregnancy, ā¢ Maternal mortality is reported at 2% and the risk of an adverse fetal outcome is directly related to the severity of mitral stenosis ā¢ The aim of treatment is to reduce the heart rate, achieved through bed rest, oxygen, beta-blockade and diuretic therapy. ā¢ Balloon mitral valvotomy is the treatment of choice after delivery, but can be considered in pregnancy depending on the clinical condition and gestation.
- 26. Mitral Regurgitation and Aortic Regurgitation ā¢ MR and AR generally well tolerated during pregnancy. ā¢ The pregnancy-induced decrease in systemic vascular resistance reduces the risk of cardiac failure with these conditions ā¢ If symptoms of heart failure develop, diuretics are given and bed rest is encouraged.
- 27. Marfan Syndrome ā¢ autosomal dominant connective tissue abnormality that ā¢ may lead to mitral valve prolapse and aortic regurgitation, aortic root dilatation and aortic rupture or dissection ā¢ Pregnancy increases the risk of aortic rupture or dissection and has been associated with maternal mortality of up to 50% where there is marked aortic root dilatation ā¢ Echocardiography is the principal investigation ā¢ A number of obstetric complications have also been described in women with Marfan syndrome: early pregnancy loss, preterm labour, cervical weakness, uterine inversion and postpartum hemorrhage.
- 28. Pulmonary Hypertension ā¢ pregnancy is associated with a high risk of maternal death. ā¢ Pregnancy is contraindicated ā¢ The demands of increasing blood volume and cardiac output may not be met by an already compromised right ventricle. ā¢ Close monitoring by a multidisciplinary team is crucial as the mortality of the condition remains high at 30ā50%. ā¢ In women who choose to continue their pregnancy, targeted pulmonary vascular therapy is an option, with timely admission to hospital and delivery according to the progress of the woman and condition of the fetus.
- 29. Thank you
Editor's Notes
- -- cardiac output increases approximately 40 percent during pregnancy. Almost half of this total increase takes place by 8 weeks and is maximal by midpregnancy -- The early increase stems from augmented stroke volume that results from decreased vascular resistance. -- Later in pregnancy, resting pulse and stroke volume increase even more because of increased end-diastolic ventricular volume that results from pregnancy hypervolemia. --Importantly, intrinsic left ventricular contractility did not change. Thus, normal left ventricular function is maintained during pregnancy, that is, pregnancy is not characterized by hyperdynamic function -- These changes are even more profound in multifetal pregnancy
- -- women with severe cardiac dysfunction may experience evidence of heart failure before midpregnancy. -- In others, heart failure may develop after 28 weeks when pregnancy-induced hypervolemia and cardiac output reach their maximum --heart failure develops peripartum when labor, delivery, and a number common obstetrical conditions add undue cardiac burdens. Some of these include preeclampsia, hemorrhage and anemia, and sepsis syndrome.
- Trying to distinguish between ānormalā symptoms of pregnancy that impending cardiac failure fatigue and exercise intolerance develop in most women. respiratory effort is accentuated and at times suggests dyspnea edema in the lower extremities after midpregnancy is common; normal pregnancy, functional systolic heart murmurs are common;
- - it is important to ask the pregnant woman if she has noted any breathlessness, particularly at night, any change in her heart rate or rhythm, any increased tiredness or a reduction in exercise tolerance Routine physical examination should include pulse rate, blood pressure, jugular venous pressure, heart sounds, ankle and sacral oedema and presence of basal crepitations. mean pulmonary artery (mPA) ā„25 mm Hg at rest, as assessed by right heart catheterization.
- prior heart failure, transient ischemic attack, arrhythmia, or stroke; baseline NYHA class III or IV or cyanosis; Leftsided obstruction defined as mitral valve area < 2 cm2, aortic valve area < 1.5 cm2, or peak left ventricular outflow tract gradient > 30 mm Hg by echocardiography ejection fraction less than 40 percent Toronto risk markers for maternal cardiac events
- The Fontan procedure or FontanāKreutzer procedure is a palliative surgical procedure used in children with univentricular hearts. It involves diverting the venous blood from the inferior vena cava (IVC) and superior vena cava (SVC) to the pulmonary arteries without passing through the morphologic right ventricle;
- Electrocardiography :- As the diaphragm is elevated in advancing pregnancy, there is an average 15-degree left-axis deviation in the electrocardiogram (ECG), and mild ST changes may be seen in the inferior leads. Atrial and ventricular premature contractions are relatively frequent Chest Radiography :- Anteroposterior (AP) and lateral chest radiographs are useful, and when a lead apron shield is used, fetal radiation exposure is minimal. Gross cardiomegaly can usually be excluded, but slight heart enlargement cannot be detected accurately because the heart silhouette normally is larger in pregnancy. This is accentuated further with a portable AP chest radiograph. Echocardiography :- Widespread use of echocardiography has allowed accurate diagnosis of most heart diseases during pregnancy. It allows noninvasive evaluation of structural and functional cardiac factors. Some normal pregnancy-induced changes include slightly but significantly increased tricuspid regurgitation, left atrial end-diastolic dimension, and left ventricular mass
- The use of anticoagulants during pregnancy is a complicated issue because warfarin is teratogenic if used in the first trimester, and is linked with fetal intracranial hemorrhage in the third trimester. Low molecular-weight heparin is often used as an alternative to warfarin, especially in the first and third trimester
- regional anaesthesia is not without some risk to both the mother and baby in some cardiac conditions, principally because of the potential complication of maternal hypotension. Caesarean delivery is associated with an increased risk of haemorrhage, thrombosis and infection, conditions that are likely to be much less well tolerated in women with cardiac disease Postpartum haemorrhage in particular can lead to major cardiovascular instability. Ergometrine may be associated with intense vasoconstriction, hypertension and heart failure, and therefore active management of the third stage is usually with Syntocinonā¢ (synthetic oxytocin) alone. Syntocinon is a vasodilator and therefore should be given slowly to patients with significant heart disease, with low-dose infusions preferable. recommends cesarean delivery for women with: dilated aortic root >4 cm or aortic aneurysm; acute severe congestive heart failure; recent myocardial infarction; severe symptomaticaortic stenosis; warfarin administration within 2 weeks of delivery; and need for emergency valve replacement immediately after delivery.
- women who develop peripartum heart failure almost always have obstetrical complications that either contribute to or precipitate heart failure preeclampsia is common and may precipitate afterload failure. High-output states caused by hemorrhage and acute anemia increase cardiac workload and magnify the physiological effects of compromised ventricular function. infection and sepsis syndrome increase cardiac output and oxygen utilization tremendously obesity is a common cofactor with chronic hypertension, and it leads to eccentric ventricular hypertrophy diagnosis confirmed by clinical examination for signs of heart failure and by echocardiography confirming ventricular dysfunction. rales, frequently accompanied by a nocturnal cough, sudden decline in the ability to complete usual duties, increased dyspnea on exertion, and/or attacks of cough are symptoms of serious heartfailure. Clinical findings may include hemoptysis, progressive edema, tachypnea, and tachycardia. Dyspnea is universal, and other symptoms include orthopnea, palpitations, and substernal chest pain Echocardiographic findings include an ejection fraction < 0.45
- the risks to the mother of continuing the pregnancy and the risks to the fetus of premature delivery must be carefully balanced.
- * Percutaneous transluminal coronary angioplasty (PTCA) myocardial ischemia associated with prostaglandin E1 vaginal suppositories for labor induction
- In general, balloon valvotomy for aortic valve disease is avoided because of serious complications, which exceed 10 percent. These include stroke, aortic rupture, aortic valve insufficiency, and death For women with critical aortic stenosis, intensive monitoring during labor is important. Pulmonary artery catheterization may be helpful because of the narrow margin separating fluid overload from hypovolemia. Women with aortic stenosis are dependent on adequate end-diastolic ventricular filling pressures to maintain cardiac output and systemic perfusion. Abrupt decreases in end-diastolic volume may result in hypotension, syncope, myocardial infarction, and sudden death. Thus, the management key is avoidance of decreased ventricular preload and the maintenance of cardiac output
- new-onset atrial fibrillation develops, intravenous verapamil, 5 to 10 mg, is given, or electrocardioversion Therapeutic anticoagulation with heparin is indicated with persistent fibrillation. symptomatic mitral stenosis. Uterine contractions increase cardiac output by increasing circulating blood volume. Pain, exertion, and anxiety cause tachycardia with possible rate-related heart failure. Epidural analgesia for labor is ideal, but with strict attention to avoid fluid overload. Abrupt increases in preload may increase pulmonary capillary wedge pressure and cause pulmonary edema. hypothesize that this is likely due to loss of the low-resistance placental circulation along with the venous āautotransfusionā from a now-empty uterus and from the lower extremities and pelvis.
- Chronic mitral regurgitation has a number of causes, including rheumatic fever, mitral valve prolapse, or left ventricular dilatation of any etiologyāfor example, dilated cardiomyopathy causes of abnormal insufficiency are rheumatic fever, connective-tissue abnormalities, and congenital lesions. With Marfan syndrome
- as it is able to determine the size of the aortic root, and should be performed serially throughout pregnancy, especially in women who enter pregnancy with an aortic root that is already dilated (>4 cm). Prophylactic Ī²-blocker therapy has become the standard medical approach for pregnant women with Marfan syndrome because it reduces hemodynamic stress on the ascending aorta and slows the rate of Dilation When the aortic root measures 4 to 5 cm or greater, elective cesarean delivery is recommended with consideration of postpartum replacement of the proximal aorta with a prosthetic graft If dilatation reaches 5 to 6 cm, then elective surgery should be considered before pregnancy
- include endothelin blockers, such as bosentan, and phosphodiesterase inhibitors such as sildenafil. Prostacyclin analogues that can be administered parenterally include epoprostenol and treprostinil, whereas iloprost is inhaled
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