Heart disease in pregnancy 20-5-10


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Heart disease in pregnancy 20-5-10

  2. 2. Incidence and types of heart diseases in pregnancy <ul><li>Incidence of heart disease in pregnancy is around 1% </li></ul><ul><li>These can be congenital and acquired </li></ul><ul><li>of these, acquired heart diseases are most common in developing countries . These include: </li></ul><ul><li>RHD, cardiomyopathies and ischemic heart disease </li></ul>
  3. 3. <ul><li>Congenital heart diseases can be: </li></ul><ul><li>left to right shunts, stenotic lesions, right to left shunts </li></ul><ul><li>Most common cardiac lesion in pregnancy is RVHD(MS) </li></ul><ul><li>Most common arrhythmia in pregnancy is SVT </li></ul><ul><li>Most common acyanotic heart disease in pregnancy is ASD(ostium secundum ) </li></ul><ul><li>Most common cyanotic heart disease- TOF </li></ul>
  4. 4. HEMODYNAMIC CHANGES DURING PREGNANCY <ul><li>Cardiac output: </li></ul><ul><li>increase in CO starts at ~5wk POG, reaches a maximum at 30-34 wk ( 40% increase over the prepregnant value) and remains elevated till term. During labour, it increases by ~20% with uterine contractions. Immediately following delivery CO increases further by~15-20% </li></ul><ul><li>return to pre labour value= 1 hr after delivery </li></ul><ul><li>return to pre pregnant value= 4 wk after delivery </li></ul>
  5. 5. <ul><li>Mechanism for increase CO </li></ul><ul><li>increase Stroke volume = 27% </li></ul><ul><li>increase heart rate = 17% </li></ul><ul><li>increase in intravascular volume </li></ul><ul><li>Intravascular volume (IVV) </li></ul><ul><li>increase in blood volume starts around 6 wk and gradually reaches a peak of ~30-40% by 32 wk </li></ul><ul><li>plasma volume~ 40-50% </li></ul><ul><li>RBC volume~ 20-30% </li></ul><ul><li>IVV expansion is marked by systolic ejection murmur . </li></ul>
  6. 6. <ul><li>Systemic vascular resistance falls by 21% </li></ul><ul><li>Pulmonary vascular resistance falls by 34% </li></ul><ul><li>Colloid osmotic pressure falls by 14% </li></ul><ul><li>Aortic root – increase in size and compliance </li></ul><ul><li>Venous pressure- </li></ul><ul><li>femoral vein pressure:20cm of water (lying down) and 80 – 100 cm of water on standing. </li></ul><ul><li>BP: mid trimester fall in MAP of 10 -15 mm of Hg, reaching a nadir ~ 24-28 wk </li></ul><ul><li>No change in CVP </li></ul><ul><li>PCWP </li></ul>
  7. 7. NORMAL CARDIAC FINDINGS <ul><li>Raised JVP with prominent pulsations </li></ul><ul><li>Brisk and diffuse apex impulsation </li></ul><ul><li>Loud s1 </li></ul><ul><li>Loud s2 and widely split </li></ul><ul><li>Occasional s3 </li></ul><ul><li>Aortic or pulmonary flow murmurs </li></ul><ul><li>Venous hum </li></ul><ul><li>Mammary souffle </li></ul>
  8. 8. ABNORMAL CARDIAC FINDINGS <ul><li>Progressive dyspnea or orthopnea </li></ul><ul><li>Nocturnal cough </li></ul><ul><li>Hemoptysis </li></ul><ul><li>Syncope </li></ul><ul><li>Chest pain </li></ul><ul><li>Cyanosis </li></ul><ul><li>Clubbing </li></ul><ul><li>Persisstent neck vein distension </li></ul><ul><li>Systolic murmur grade 3 or above </li></ul>
  9. 9. <ul><li>Diastolic murmur </li></ul><ul><li>Cardiomegaly </li></ul><ul><li>Persistent arrhythmia </li></ul><ul><li>Persistent split s2 </li></ul>
  10. 10. PERIODS DURING PREGNANCY WHEN DANGER OF CARDIAC DECOMPENSATION IS HIGH <ul><li>12-16 WK- hemodynamic chngs of pregnancy begin </li></ul><ul><li>28-32 wk- hemodynamic chngs peak </li></ul><ul><li>During labour and delivery </li></ul><ul><li>Immediately following delivery of baby and placental separation( max chances ) </li></ul><ul><li>4-5 days following delivery </li></ul>
  11. 11. NYHA FUNCTIONAL CALSSIFICATION OF CARDIAC DISEASE <ul><li>I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. </li></ul><ul><li>II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. </li></ul><ul><li>III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m).Comfortable only at rest. </li></ul><ul><li>IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. </li></ul>
  12. 12. RISK OF MATERNAL MORTALITY AND MORBIDITY WITH HEART DISEASE <ul><li>Group1( minimal risk) 0-1% </li></ul><ul><li>ASD </li></ul><ul><li>VSD </li></ul><ul><li>PDA </li></ul><ul><li>Corrected TOF </li></ul><ul><li>Corrected congenital heart disease without residual cardiac dysfunction </li></ul><ul><li>MVP </li></ul><ul><li>NYHA class 1,2 </li></ul>
  13. 13. <ul><li>Group 2( moderate risk) 5-15% </li></ul><ul><li>AS </li></ul><ul><li>Marfan’s syndrome with normal aorta </li></ul><ul><li>Uncorrected TOF </li></ul><ul><li>Previous MI </li></ul><ul><li>Artificial valve </li></ul><ul><li>H/o peripartum cardiomyopathy with no residual ventricular dysfunction </li></ul><ul><li>NYHA class 3,4 </li></ul>
  14. 14. <ul><li>Group3 (major) 25-50% </li></ul><ul><li>Pulmonary hypertension </li></ul><ul><li>Marfan’s syndrome with aortic valve involvement </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Complicated coarctation of aorta </li></ul>
  15. 15. PREDICTORS OF CARDIAC EVENTS DURING PREGNANCY (Sui and Coleman 2004) <ul><li>N : NYHA grade 3,4 or cyanosis </li></ul><ul><li>O : obstructive lesion of left heart </li></ul><ul><li>MV area < 2 cm sq </li></ul><ul><li>Aortic valve area< 1.5 cm sq </li></ul><ul><li>pressure gradient > 30 mm of Hg </li></ul><ul><li>P : prior cardiac event </li></ul><ul><li>stroke/ arrythmia/TIA/stroke </li></ul><ul><li>E : EF< 40% </li></ul>
  16. 16. <ul><li>Heart disease and none of above, risk of adverse cardiac event during pregnancy~ 5% </li></ul><ul><li>Heart disease with any one of above- 25% </li></ul><ul><li>Heart disease with 2 or more of above- 75% </li></ul>
  17. 17. Thank you