Prof. M.C. Bansal. MBBS.MS. MICOG . FICOG . Founder Principal & Controller., Jhalawar Medical College & Hospital , Jhalawar ( Raj.)Ex. P&C .MGMC and hospital,. Sitapura Jaipur
Breathlessness ( Dyspnoea ) / shortness of breath /difficult, laboured , consciousness about taking breath is a common symptom during pregnancy. May be related to physiological changes in cardio- pulmonary, haemopoetic system , increase in weight etc. Degree of breathlessness---1. Orthopnoea-breathlessness when lying flat. 2. Paroxysmal Nocturnal Dyspnoea- sudden onset of dyspnoea at night. 3. Dyspnoea on rest. 4. Dyspnoea-Mild , Moderate Extraneous.
Breathlessness of cardiac origin—Cardio- myopathies and congenital anomalies (surgically corrected or uncorrected ). Breathlessness of Respiratory origin. Haematological---Anaemia. Drug induced—NFT , NSAIDs, Inhalers , Amiodarone . Psychological– anxiety , fear , Minor or major illness. Metabolic—Acidosis / Alkalosis.
Breathlessness caused by cardiomyopaty in pregnancy mainly comprises three types---- 1, Peripartum., 2, Dilated 3, hypertrophic. Dilated and hypertrophic can effect any one and at any time in pregnancy. Peripartum cardiomyopathy occurs mostly in young women of Afro –Caribbean origin during last trimester or in the 1st 6 weeks of postpartum.
- occurring in 1 in 3000-15000 pregnancy. -Some form of viral myocarditis has been postulated. -Maternal mortality is as high as 20% though foetal outcome is good. -Management is to correct the impaired systolic function of ventricles. -There is substantial risk of recurrence in future pregnancy and permanent impairment of left ventricular function.
Condition is poorly tolerated in pregnancy. 7% maternal mortality . There is elevated risk of heart failure., to be managed on same line of treatment as that for non pregnant women. Angiotensin converting enzyme inhibitors are avoided as they cause renal agenesis in foetus.
Patient with hypertrophic cardiomyopathy usually tolerate the increased load in pregnancy ,. as left ventricle adopts in a physiological way. Women with murmur and increased gradient across the left ventricular flow may present with breathlessness for the 1st time in pregnancy. There is no risk of sudden death and maternal mortality.
ECG, Ecogardiography trademill, genetic counselling are done for diagnosis. Women with severe diastolic dysfunction develop pulmonary congestion---leading to increased breathlessness and even pulmonary edema. complete bed rest, B-blockers are continued and diuretics are added. Atrial fibrillation is managed with low-molecular weight heparin and B- blockade . Cardioconversion may be done after excluding thrombus in atrium by trans oesophagial echocrdigraphy. prophylactic low forceps – vaginal delivery can be managed in as usual way for other cardiac patients., less chances of prolonged labour and blood loss.
Classification of congenital Heart disease---- 1. Low risk lesion. Ventricular septal defect . Atrial septal Defect ( unoperated) coarctation Of aorta Teratology of fallot repaired 2. Moderate Risk lesion Mitral Stenosis Aortic Stenosis Fortan- type circulation 3. High Risk Lesion Marfan Syndrome Eisenmanger Syndrome
Lesion Exclude before Potential risk Recomonded Rx Pregnancy in preg & puerperiumLow Risk Lesion1.Ventrcular Pulmonary Arrhythmias Antibioticseptal defe3ct arterial SABE Prophylaxis foe hypertension SABE2.Atrial septal Pulmonary Arrhythmia Thrombodefect arterial prophylaxis if pt (un operated ) hypertension Is on complete Ventricular bed rest dysfunction
Lesion Exclude Potential Recomonded Before hazards Rx in preg., 7 pregnancy PUERPARIUM3.Coarctation Re-coarctation PIH Low dose Asprin(reported) Aneurism Aortic therapy formation at dilatation/ the site of dissection B-blockers to operation. control BP Associated C HF Lesions— Aortic Endocarditis Elective LSCS bicuspid valve ( as soon as with / with out foetal lung stenosis / maturity regurgitation , obtained ascending Antibiotic atropathy , prophylaxis. Systemic BP
Lesion Exclude before Potential Risks Recommended pregnancy treatment In prig, puerperium4.Tetralogy of Severe Right Arrhythmias Pre termFallot Ventricular delivery if RVF outflow tract develop obstruction , RVF Antibiotics severe pulmonary Endocarditis obstruction ,right ventricular dysfunction, DiGeorge Syndrom
Moderate RiskLesionsLesion exclude Before Potential Recomonded Pregnancy Hazards Treatment in Preg , puerperium1. Mitral Severe Stenosis Atrial Beta –BlockersStenosis Pulmonary Fibrillation Venous Thrombi- Low dose Hypertension embolic Aspirin Phenomenon Hospitalization Pulmonary in 3rd trimester edema . Thrmboprophyl axisAntibiotics
Lesion Exclude before Potential Recommended Pregnancy Hazards Treatment during Pregnancy2. Aortic stenos is Severe Stenosis ( Arrhythmia Hospitalization peak pressure withThromboprop gradient on USG > hylaxis 80 mmHg, ST segment depression Angina Balloon aortic ,symptoms) Valvotomy , Pre Left Ventricular term LSCS By pass dysfunction. surgery carries 20% risk of foetal death.Fontan –Type Ventricular Heart Failure Low molecularcirculation dysfunction, Arrhythmia , Heparine& aspirin Arrhythmias , thromboembolic , in whole preg, Heart failure Endocarditis Antibiotics
High Risk lesionsLesions Exclude before Potential Risks Recomonded Pregnancy Treatment in Preg, puerperiumMarfan Syndrome Aortic Root Type A Dissection of Beta—blockers dilatation >4 cm aorta Elective LSCS at 35 weeks .Eisenmanger Ventricular 30-50 % risk of Therapuetic MTP.syndrome dysfunction maternal deathPulmonary arterial If pregnancyHypertension Arrhythmias Arrhythmia continues , CVs Heart failure Monitoring, Endocarditis hospitalization , pulmonary vasodilators with O2 supplimentation. Cntnue same in puerperium
1. Ventricular Septal defect----A small VSD with normal right sided pressures Puts no added risk to pregnancy . Prophylactic antibiotics and care full ANC is that all needed. Paradoxical embolism ia not common in VSD with large pressure gradient across the defect . Large VSD with pulmonary HTN & Eisenmenger complex need special cardiac care.
2. Unoperated Atrial Septal Defect--- Unrepaired ASD are well tolerate pregnancy , when pulmonary resistance is normal. Pre existing tendency to atrial fibrillation --- hypercoagulable state of pregnancy and potential right to left shunt increase the chances of paradoxical embolism., more so when intra thorasic pressure increases during active labour. This accident can also occur in cases of patent foramen ovale. There is definite role of prophylactic antilcoaglant therapy.
3. Repaired Coarctation of Aorta----As majority of pt get operated in childhood hence it puts no risk in pregnancy as long as there is no development of aneurism at the site of repair . This can be confirmed by MRI. 4. Repaired Teratology of Fallot ---Most common cynotic congenital heart disease ., once corrected one lives asymptomatic normal life . Pregnancy is well tolerated by such women.one need not to emphasise to asses such patients thoroughly before planning pregnancy. , torule out and treat any decompensation before hand.
5. Fontan Type Circulation—These patient are not cynosed . , but experience long standing low output circulation and risk of ventricular failure and atrial arrhythmias. They need long term ore warferin therapy and arte to be put on low molecular Heparin therapy as soon as pregnancy is planned or diagnosed. There is 30 % twice more risk of abortion as compared to normal pregnant women. Maternal outcome depends on functional capacity of ventricle , it is better when single ventricle is left. Advice to continue the pregnancy is given when there is no decompensation.
6. Mitral Stenosis— Commonest rheumatic valvular disease ( corrected / uncorrected –compensated or decompensated )is diagnosed during ANC ,. More common in developing, over populated ,localities with poor sanitation, medical and health services. it can remain silent till the 3rd decade., symptoms often develop during pregnancy as cardiac load increases . Congenital fusion of the commissures, parchute mitral valve or left atrial mixoma are other causes of mitral stenosis.
Heamodynamic changes in pregnant women with mitral stenosis include Elevated left atrial , pulmonary ( venous and arterial ) pressures which flow across the mitral valve. Maternal complications include pulmonary edema, pulmonary hypertension and right ventricular failure. Tachycardia and dyspnoea may be precipitated by exertion , anxiety , anaemia, fever.this may decrease diastolic left ventricular filling time , further elevation of left atrial pressure there by decreased cardiac output.The end result is biventricular failure., atrial fibrillation ,pulmonary edema and embolic phenomenon
Clinical Presentation--- pregnant woman with MS may come in state of failure of both left and right ventricles depending upon the degree of decompensation, duration and severity of valvular disease. Symptoms of left ventricular failure are more common --- orthopnoea , paroxysmal nocturnal / exertional dyspnoea, hamoptesis. Symptoms of right ventricular failure develop very late and include ascites and edema feet .
careful cardiac examination specially for opening snap and a diastolic rumbling murmur with pre systolic accentuation in mitral area. Elevated jugular venous pressure , hepatomegaly , loud P2 , right ventricular haeve in epigastric region support the diagnosis of MS. Transthorasic Echocardiography helps in diagnosis as well as severity of cardiac dysfunction ,important to assess the success of percutaneous mitral valvuloplasty by baloon. It can be done safely in such women.
Symptomatic AS is less common than MS in pregnancy.Rheumatic AS is more common in developing countries . Conge4nital AS secondary to membrane on bicuspid valve may also be seen, women is at risk of dissection of aorta related to hormonal changes on connective tissue in pregnancy.Pressure gradient across aortic valve is responsible for haemodynamic changes in AS.Increase in left ventricular systolic pressure leads to left ventricular hypertrophy and later on left ventricular failure and diminished coronary flow.
Increase in stroke volume and fall in peripheral resistance in pregnancy are responsible for increase in pressure gradient across Aortic valve. Increase demand to increase Cardiac output in late pregnancy and labour ---women with AS develops symptoms of left ventricular failure. Clinical Presentation depends on degree of stenosis .woman with aortic valve area > 1.0cm tolerate pregnancy well. Women with more severe stenosis will develop left ventricular failure., manifesting as dyspnea and pulmonary edema. Left ventricular impulse is sustained and displaced laterally towards maxilla. A systolic ejection murmur is heard along right boarder of sternum and radiates to neck in carotid area.
A systolic ejection click may be heard. 4th heart sound may be present indicating abnormal diastolic function too. Presence of slow rising pulse and narrow pulse pressure (difference between systolic and diastolic pressure indicates significant aortic Stenosis. Diagnosis can be confirmed by echocardiography and aortic gradient and area of aortic valve can be calculated by dopller flow study. Patient with < 55% ejection flow are at risk of left ventricular failure . fetus of mother with congenital AS is at risk (15%) of developing same cardiac anomaly.
Pregnant women carries 1% risk of type A aortic dissection. But it is ten time more when Aortic root diameter is > 4cm. Its repair carries 22% maternal mortality., such women should be advise against going for pregnancy. Women who become pregnant and want to continue it , should be kept on B –blockers and under go elective LSCS on fetal maturity. Patients should also be aware of the 50% recurrence rate..
Pulmonary hypertension of any reason carries a high maternal risk.Patient with Eisenmenger complex carries > 50% mortality. Women should be advised not to become pregnant.In the event of pregnancy MTP in early weeks (6- 10 ) is indicated .Male partner should be vasectomies / laparoscopic sterilization can be done with explained risk.The progesterone sub dermal implant contraceptive is as effective as sterilization and safe also.
ANC Such women once become pregnant or as soon as heart disease is diagnosed for the 1st time in ANC should be referred to tertiary care centre with 24hrs available facility of cardiologist, high risk pregnancy care , cardiac anesthetist , parental medicine , and well equipped premature NICU. Patient and her husband should be involved in decision making and let them understand the ‘minimal risk approach’ Generous approach to hospitalization as and when needed and more so in last trimester. Patient confined to bed rest should receive Low molecule Heparin as prophylaxis against risk of thrombi embolism.
Pregnant women with congenital heart disease , Atrial arrhyhmias , prolonged bed rest Are at 6 fold increased risk of thromboembolism in pregnancy and 11fold more in puerperium.Therefore achieving thorough anticoagulation is more important in such cases. Anti coagulation therapy also carries maternal fetal complications. Warfare crosses the placenta and carries more risk to fetus hence not recommended. Heparin does not cross the placenta hence safe . Strict monitoring of dose and regular laboratory test must bed done .