3. Heart diseases in pregnancy
They complicate more than 1% of all
pregnancies.
They are now the leading cause of indirect
maternal deaths accounting to 20% of all cases.
Cardiovascular diseases also accounts for
significant maternal morbidity and are a leading
cause of obstetric ICU admission
The increasing prevalence , is likely due to; high
rates of obesity , HTN, DM others ; delayed child
bearing, congenital heart disease
4. Normal Cardiac changes in
Pregnancy
CO; increases by 40% from 8wks and is maximal
by mid pregnancy.
Blood Volume; The mean plasma volume
increase is 50% over the pre pregnancy volume.
This maintains a dilated sytemic vasculature.
Venous pressure increase, esp. In the lower
extremities, occurs in pregnancy.
Slight heart enlargement, due to upward and
leftward anatomic displacement of the heart.
Systolic ejection murmur is present due to
increased CO passing thru the aortic and pul.
valves
5. Pre-pregnancy Counselling
Women with CVD should be aware of their
conditions prior to pregnancy and they should be
also assessed by the Cardiologist, managed or
treated according to situation.
Issues related to that;
Risk of maternal death
Possible reduction of maternal life expectancy
Effects of pregnancy on cardiac diseases
Risk of fetus developing CHD
Risk of preterm labour and FGR
Intensive maternal and fetal monitoring during
labor
6. Clinical indicators of Heart disease
during pregnancy
Symptoms include;
Progressive dysnea or Orthopnea or PND
Nocturnal cough
Hemoptysis
Syncope
Chest pain
10. Rheumatic Heart Disease
Is now distinctly uncommon in developed
countries
Women are at risk of developing HVHD 10-20
years after initial episode of RF.
The most common lesion is mitral stenosis
Pts are at high risk for developing HF, subacute
endocarditis and thromboembolic diseases.
Increased risk for fetal wastage
Onset of pul. Edema: 40 WOG
Severe MS leads to atrial fib. Which can lead to
CHF.
11. Congenital Heart Diseases
Include atrial and ventricular septal defects,
primary hypertension and cyanotic heart
disease.
Pts with complete surgical correction can tolerate
pregnancy.
Pts with persistent septal defect generally tolerate
pregnancy
Pts with PH (primary or as a result of cyanotic
heart disease) should not get pregnqnt.
PH can lead to pul. Congestion, HF and
hypotension, all of which can lead to sudden
death.
12. Cardiac arrhythmia
Supraventricular tachycardia is the most
common type
occurs as a result of birth defects and changes in
heart structure.
Atrial fibrillation and flatter are more serious
forms, associated with underlying cardiac
diseases.
13. cardiomyopathy
DCM
Cardiac chambers are severely dilated and left ventricle is
diffusely hypokinetic, LV wall tension is increased and
systolic pump fxn progressively declines. Consequently
CO falls and filling pressure increases.-> progressive
dyspnea, edema and fatigue.estsblished DCM even in a
compansated HF , is a contraindication to pregnancy
. Peripartum Cardiomyopathy. Specific to pregnancy or
postpartum women.
pt has no underlying HD, Symptoms appear in the last wk of
preg. Or within 6 months after delivery.
RF; older maternal age, Htn, multiple gestation
Mortality rate:20% , persistence: 30%-50%, recurrence: 20-
50%
15. Management
Principles;
Early diagnosis and evaluation of anatomical type
and functional grade of the case.
To detect the high risk factors and to prevent
cardiac failure
Optimise care (Obstetrician and Cardiologist) and
ensure mandatory hospital delivery.
16. Indications for termination of
pregnancy
Absolute
Primary pulmonary hypertension
Eisenmenger’s syndrome
Pulmonary veno-occlusive disease
Relative
Parous woman with grade III and IV cardiac
lesion
Grade I or II with previous h/o cardiac failure in
early months or in between pregnancy
17.
18. Management (cont’d)
Risk for classes i and ii is minimal
Risk for classes iii and iv is marked
Risk increases if cyanosis is present
Risk also depends on the type of defect
Mitral and aortic stenosis (obstructive diseases)
carry a high risk for decompensation
Regurgitant diseases carry a lower risk
Other high risk conditions: PH, marfan syndrome,
mechanical valve, ventricular ejection fraction
less than 40%, or a previous history of cardiac
event during pregnancy.
19. Management: Antenatal
Pregnancy with significant HD should be
managed in a joint obstetriccian/cardiologist care.
Physicians have to distinguish between normal
pregnancy changes and impending heart failure.
This is achieved by asking the pregnant woman
about breathlessness esp at night, changes in
heart rate or rhythm, increased tiredness or
decreased exercise tolerance.
Routine physical exam: PR ,BP JVP and sacral
and ankle edema, presence of basal crackles
20. These women should be advised to reduce their
normal physical activities
Echocardiography is good to assess fxn and valves,
echocardiogram is usually done around 28wks
Avoidance of excessive weight gain and edema
Avoidance of anemia
The use of anticoagulant during pregnancy is a
complicated issue this is because warfarin is
tetratogenic in the 1st trimester and linked with fetal
intracranial hemorrhage in 3rd trimester
Anticoagulation is essential in patients with congenital
heart disease who have pulmonary hypertension or
artificial valve replacement or for those at risk of atrial
fib.
21.
22. Management: Labor and Delivery
The aim of management is to await the onset of
spontaneous labour.
Induction of labour should be considered for the
usual obstetrical indications and in high risk mothers.
Epidural anesthesia is often recommended
This regional anesthesia has some risk in some
cardiac conditions as it causes hypotension
Anesthetist should document an anesthetic
management plan
Prophylactic antibiotics should be given to any woman
with cardiac defects to reduce risk of endocarditis
2nd stage of normal labour should be shortened
CS should only be done on obstetrical indications
sinceit inreases the risk og haemorrhage, thrombosis
and sepsis/infections
23. PPH in particular can lead to major
cardiovascular instability
3rd stages of labour is managed actively by
oxytocin ONLY not with ergometrine
As oxytocin is a vasodilator, it should b
administered slowly to patients with significant
heart disease
High level maternal surveillance is requirex until
the main hemodynamic changes following
delivery have passed
24. In summary
Avoid induction of labour if possible
Use prophylactic antibiotics
Ensure fluid balance
Avoid the supine position
Discuss the type of anesthesia with senior
anethetist
Keep the 2nd stage Short
Use oxytocin judiciously