3. ANATOMICAL CHANGES
Occurs due to elevation of the
diaphragm consequent to the
enlarged uterus, the heart is pushed
upwards and outwards with slight
rotation to the left.
4. REGIONAL DISTRIBUTION OF BLOOD FLOW
• Uterine blood flow increases from 50ml/min in non pregnant state to
about 750ml/min near term.
• This is due to combined effect of utero-placental and feto-
placental vasodilatation.
• The vasodilatation is due to the smooth muscles relaxing effects of
progesterone, oestrogen, nitric oxide (endothelium derived factor),
prostaglandins and atrial natriuretic peptide (ANP).
• Pulmonary blood flow (normal 6000ml/min) is increased by
2500ml/min.
• Renal blood flow (normal 800ml/min) is increased by 400ml/min.
5. CARDIAC OUTPUT
• Start to increase from 5th week of pregnancy and becomes 40 – 50%
higher at about 30 – 34 wks.
• CO increases further during labour (+50%) and immediately during
delivery (+70%) over the pre-labour values.
• There is squeezing out of blood from the uterus into maternal
circulation (auto transfusion) during labour and in the immediate
postpartum.
• CO returns to prelabour values by 1hr following delivery and to the
prepregnant level by another 4wks time.
6. BLOOD PRESSURE
• BP = CO × SVR
• Systemic vascular resistance (SVR) decreases to -21% due to
smooth muscles relaxing effects of progesterone,
prostaglandins etc.
• Inspite of the large increase in CO, the maternal BP is
decreased due to decrease in SVR.
• Hence there is overall decrease in diastolic blood pressure
(DBP) and mean arterial pressure (MAP) by 5 – 10mmHg.
7. VENOUS PRESSURE
• Antecubital venous pressure remains unaffected
• Femoral venous pressure is markedly raised specifically in the latter
months of pregnancy.
• It is due to the pressure exerted by the gravid uterus on the common iliac
veins,
• It is more on the right side due to dextrorotation of the uterus.
• The femoral venous pressure is raised from 8 – 10cm of water in non
pregnant state to around 25cm of water during pregnancy in lying
down position to about 80 – 100cm of water in standing position.
• This explains the fact that the physiological oedema of pregnancy subsides by
rest alone.
9. • due to the physiological changes in cardiovascular system during
pregnancy….
• The patient may experience palpitations
• The apex beat is shifted to the 4th intercostal space 2.5cm outside the
midclavicular line.
• Pulse rate is slightly raised often with extrasystoles.
• A systolic murmur may be audible in the apical or pulmonary area.
• This is due to decreased blood viscosity and torsion of great vessels
• A continuous hissing murmur may be audible over the tricuspid area
in the left 2nd and 3rd intercostal spaces called mammary murmur.
• It is due to increased blood flow through the internal mammary vessels.
10. As a doctor you should be familiar
with these physiological findings and
should execute continuous approach
in diagnosis of heart disease during
pregnancy.
11. HEART DISEASES IN PREGNANCY
•The incidence of cardiac lesions is less than
1% amongst hospital deliveries.
•The commonest cardiac lesson is of
rheumatic origin followed by congenital
ones.
15. DEFINITION
Peripartum cardiomyopathy is defined as
the onset of acute heart failure without
demonstrable cause in the last trimester
of pregnancy or within the first 5 months
after delivery.
16. •A form of Dilated Cardiomyopathy
•Left ventricular systolic dysfunction
•Results in signs and symptoms of heart failure
•Often unrecognized, as symptoms of normal
pregnancy commonly mimic those of mild heart
failure.
17.
18. CRITERIA FOR PERIPARTUM
CARDIOMYOPATHY
1.Development of Cardiac failure in the last month of
pregnancy or within 5 month after delivery
2. Absence of an identifiable cause for the cardiac failure.
3.Absence of recognizable heart disease prior to the last
month of pregnancy.
4.Left ventricular systolic dysfunction demonstrated by
classic Echo Cardio Graphic criteria such as depressed
shortening fraction or ejection fraction.
19. INCIDENCE
The incidence in the west ranges from 1 in 4000 deliveries
60% present within the first 2 months postpartum
Up to 7% may present in the last trimester of pregnancy.
Geographic variations exist with a higher incidence
reported in areas of Africa because of malnutrition and
local customs in the puerperium
21. RISK FACTORS
•Age >30 years old
•Multiparity
•African Descent
•Maternal cocaine
abuse
•Long term tocolytic
therapy (>4weeks)
•Pregnancy with multiple
fetuses
•History of Preeclampsia,
eclampsia, or postpartum
HTN
•Nutritional deficiencies
22. SYMPTOMS
Dyspnoea on exertion
fatigue
ankle oedema
embolic phenomena
atypical chest pains
Haemoptysis.
Palpitation
Abdominal
discomfort
Cough
orthopnoea
Many of above symptoms may occur even in normal pregnancy and
can be mistaken for a diseased state.
Symptoms of worsening cardiac failure like:
23. SIGNS
•evidence of a raised CVP
•tachycardia
•cardiomegaly with a gallop rhythm (S3)
•mitral regurgitation
•pulmonary crackles and
•peripheral oedema.
24. TIMING OF DIAGNOSIS
•Diagnosis Requires being in the last month
of pregnancy
•If earlier, consider underlying heart disease
(ischemic, valvular, or myopathic)
27. On auscultation of the heart:
• loud first heart sound
• exaggerated splitting
• mid systolic murmur and
• continuous venous hum
These physical signs may confuse and there could be
mistakes in the form of over diagnosis or disregarding
of heart disease.
30. Echocardiography / Doppler
• may reveal enlargement of all four
chambers with marked reduction in left
ventricular systolic function
• small to moderate pericardial effusion
and
• mitral, tricuspid and pulmonary
regurgitation
• Ventricular wall motion, ejection
fraction and cardiac output are
decreased and
• pulmonary wedge pressure is increased.
• Spherical LV
• Left Atrial enlargement
31. • The clinical presentation and hemodynamic features in PPCM are
indistinguishable from those of other forms of dilated
cardiomyopathy.
• In the absence of any cardiac symptoms, one of the early indications
about this condition is revealed during evaluation of the fetus with a
fetal monitor and ultrasound
• Fetal growth is dependent on good blood flow to the uterus and
placenta
• An insufficient blood flow means decreased oxygenation resulting in
slowed growth
• This should prompt further investigation to discover heart disease.
NOTE:
32. MANAGEMENT OF PPCM
• Bed rest
• Delivery – preferably vaginal
• Similar to other forms of CHF
• Diuretics
• ß-blockers
• Digoxin
• Anticoagulants
• Epidural anaesthesia is ideal
Must consider pregnancy class/breast-feeding harm
potential!
34. Diuretics
•Lasix Class C
•Reserved for cardiac
conditions
•Not recommended in
PIH
•May decrease
placental perfusion
•Thiazide Diuretics
•Reserved for cardiac
conditions
•Not recommended in
PIH
•Thrombocytopenia has
been reported in
breast feeding infants
37. Anticoagulants
•Heparin Class C
•Short half life-can be
discontinued prior to
delivery to prevent
maternal hemorrhage
•Not excreted in breast
milk
•Warfarin Class D
•Contraindicated in
pregnancy
•Safe in breast
feeding. Not
excreted in breast
milk.
38. Other Therapy
• IV Immune Globulin
• Cardiac Transplant
• Estimated that transplant is performed in up to 1/3 of
PPCM patients
• Pts should be strongly advised against future pregnancies.
• Increased risk of HTN, preeclampsia, and preterm labor
• Also at risk for graft failure due to recurrent disease.
39. DIFFERENTIAL DIAGNOSIS
•PIH
•However, HF associated with PIH represents a
diastolic failure, vs. systolic in PPCM
•Pulmonary Embolism
•Again, usually ruled out by CXR
•If still suspicious, can order spiral CT
40. THE PROGNOSIS
• 50-60% patients show complete or near complete
recovery within the first 6 months postpartum
• In others, either continued clinical deterioration leading
to early death or persistent left ventricular dysfunction
and chronic heart failure results
• There is an initial high risk period with mortality of 25-
50% in the first 3 months postpartum.
• Patients with persistent cardiomegaly at 6 months have a
reported mortality of 85% at 5 years.
41. Future Pregnancies??
• Opinions widely vary
• Most experts agree that patients should avoid future pregnancy
if LV dysfunction is persistent greater than 6 months
• Highly Individual
• Patient education of risks
• Cardiologist involvement in decision
• If future pregnancy desired:
• Maternal Echocardiogram per trimester
• Serial sonograms for growth
• Again, Subspecialty involvement
