2. Physiologic Changes During Pregnancy
CO increases by 40% as SV increases
HR increases by 10 beats/min - 3rd trimester
CO peaks at 18-24 wks then stabilize
CO increase grade II systolic flow murmur
along the left sternal border without radiation
3. Diastolic murmur if present consider
pathologic investigate the cause
Increase venous return Cardiac fullness,
hypertrophy and displacement of heart
Apex beat superiorly and laterally
In ECG
Lt axis deviation
Flattened T wave
4. Cardiac Disease
1. Rheumatic accounts for 90% of heart
diseases in pregnancy. Reduces by 50% with
better treatment of RHD
2. Congenital accounts for 10% to 35% heart
diseases in pregnancy
6. Rheumatic Heart Disease
Specific and most common valvular disease
Incidence : 90 % heart disease cases
Mitral Stenosis
Rheumatic heart disease is a condition in which
the heart valves have been permanently damaged
by rheumatic fever. The heart valve damage may start
shortly after untreated or undertreated streptococcal
infection such as strep throat infection or scarlet fever.
7. Increase Risk of Heart failure
infective endocarditis
Thromboembolic disease
Increase of fetal wastage
During pregnancy CO increase obstruction
worsens
Asymptomatic pt. symptomatic
Symptoms of cardiac decompensations or pulmonary
edema appear as pregnancy progresses
Pt. with severe Mitral stenosis Atrial fibrillation &
CCF.
If Atrial fibrillation predates pregnancy 50% CCF.
8. Moderate or severe MS is poorly tolerated during
pregnancy
The risk of fetal morbidity include fetal growth
restriction, preterm birth and these rises with a
severity of MS from 14% with mild MS to 28%-33%
with moderate to severe MS.
10. Percutaneous mitral commissurotomy is preferably
performed after 20 weeks gestation
It should only be considered in NYHA Class-III or
IV.
Surgical Intervention
13. Defects corrected in childhood with no residual
damage pregnancy progresses without
complication.
Atrial and ventricular septal defects + tetralogy
of fallot tolerated pregnancy well after surgical
correction.
16. Peripartum & Postpartum
Cardiomyopathy
No etiological factor found.
No underlying cardiac disease.
Symptoms of cardiac decompensation appear
during last weeks of pregnancy or ( 2-20wks)
postpartum.
Rare
17. Women prone to this condition gives h/o
Pre-eclampsia
Hypertension
Malnutrition
18. Cause Of Death in cardiac pts.
Overload
Pulmonary Congestion
Hypotension
Hypoxia
Sudden death
19. Management
CLASS I No limitation of activity. Ordinary physical
activity does not precipitate fatigue,
dyspnoea etc.
CLASS II No symptoms at rest but minor
limitation of physical activity.
CLASS III No symptoms at rest but marked
limitation of physical activity.
CLASS IV Symptoms present at rest increases
discomfort with any kind of physical
activity.
New York Heart Association Functional Classification (NYHA)
of Heart Disease
20. With I and II Maternal and fetal small risk
With III and IV Increases risk in both
21. ANTENATAL MANAGEMENT
Management with the help of
cardiologist.(multidisciplinary approach)
Patient should be booked in tertiary care hospital
with facilities of CCU
Class I and II cardiac disease patients usually have
very less morbidity
Frequent antenatal visits and admissions in class
III and IV.
22. GUIDELINES FOR ANTENATAL MANAGEMENT
1. Avoid excessive weight gain and odema
2. Avoid strenuous activity
3. Avoid anemia
4. Early detection of a problem
23. AVOID EXCESSIVE WEIGHT GAIN &
ODEMA
Low sodium diet (2 gm/day)
Rest in left lateral position
Adequate sleep
24. AVOID STERNUOUS ACTIVITY
Unable to increase CO to meet demand of
exercise
Extract more oxygen from arterial blood large AV
difference uteroplacental circulation suffer
26. EARLY DETECTION OF A PROBLEM
On each visit look for:-
Infection
Cardiac decompensation
Pulmonary congestion
Cardiac arrhythmias
27. On each visit pulse rate BP, JVP, heart sounds ,
ankle and pedal oedema and presense of basal
crepitations is to be noted
Echocardiography is helpful in assessing the
function of valves and it should be done at
booking visit and repeated around 28 weeks of
gestation.
28. MANAGEMENT OF LABOUR
CO increases 40-50% of pre-labour level
80% of pre-pregnancy
due to increase catecholamine release
due to pain and apprehension
due to abdominal and uterine muscle
contractions
29. Wait for spontaneous labour
C section for obstetric reasons only
Left lateral position
decrease risk of supine hypotension
increase oxygen carrying capacity of blood
Epidural analgesia is recommended as it reduces
pain related stress
30. Prophylactic antibiotic (penicilline and gentamycin)
to reduce the risk of bacterial endocarditis
Esp. in high risk patients.
Early labour postpartum
Amoxicilline 2g iv and gentamycin 120mg iv
at onset of labour or prior to c section and then
oral amoxicilline for 5 days
32. OBSTETRICAL MANAGEMENT
Labour and fetal monitoring by using ext.
electrode
Limit number of pelvic examination
Vaginal delivery preferred unless obstetrical
indication for C section
Shorten 2nd stage outlet
vacuum
33. Pushing avoided increase CO due to increase VR
No ergometrine {causes vasoconstriction}
Delivery of placenta increase 500 ml of blood so
lower extremities should kept at lower level
Syntocinon should be used in a slow low dose
infusion.
Avoid excessive fluids
Strict input and output record
34. IN SEVERE CARDIAC DISEASE (III & IV)
Multi disciplinary approach in CCU
Monitoring of CV status is essential with arterial
and swan- ganzcathetors
Fluid intake and urine output
Arterial blood gases
Electrolytes