Cardiac illness in pregnancy

1. CARDIAC ILLNESS IN
PREGNANCY

2. INTRODUCTION
• Many symptoms may mimic normal symptoms of pregnancy
See( physiological changes in pregnancy ) section of cardiovascular changes

3. ANTENATAL MANAGEMENT OF A
PATIENT WITH CARDIAC ILLNESS
• First MDT should be involved
• Second classify the disease regarding the severity and the risk

4. HIGH RISK CONDITIONS
i. Systemic ventricular dysfunction (ejection fraction <30%, NYHA Class III– IV).
ii. Pulmonary hypertension
iii. Cyanotic congenital heart disease.
iv. Aortic pathology (dilated aortic root >4 cm, Marfan syndrome).
v. Ischemic heart disease.
vi. Left heart obstructive lesions (aortic, mitral stenosis).
vii. Prosthetic heart valves (metal).
viii. Previous peripartum cardiomyopathy
• Anticoagulation : pulmonary hypertension (PH) or artificial valve replacements, and
in those in or at risk of atrial fibrillation

5. FETAL RISKS OF
MATERNAL CARDIAC
DISEASE
• congenital heart disease
• fetal hypoxia
• Iatrogenic prematurity
• FGR
• Effects of maternal drugs (teratogenesis, growth restriction, fetal loss)

6. DELIVERY IN CARDIAC PATIENTS
• In most cases we wait for spontaneous vaginal delivery
• CS done in case of sever or unstable disease (cannot tolerate vaginal
delivery )
• Induction maybe needed in high risk illness and for the usual obstetric
indications (avoid it )
• Epidural is recommended (watch out hypotension )

7. DELIVERY IN CARDIAC PATIENTS
• Prophylactic antibiotics should be given to any woman with a structural heart defect
to reduce the risk of bacterial endocarditis ??
• Balance fluid infusion
• Consider shortening of the second stage (elective instrumental delivery )
• Avoid supine position during labor
• Active management of third stage of labor using oxytocin, low dose, slow infusion
(ergometrine should not be used )

8. SPECIFIC CARDIAC CONDITIONS
MYOCARDIAL INFARCTION
Risk in Parous women more than 35 years
More in the third trimester and postpartum period
percutaneous transluminal coronary angioplasty (PTCA) an option in the second half of
pregnancy
Thrombolytic therapy : NOT teratogenic , maternal and fetal hemorrhage
The diagnosis is often missed

9. SPECIFIC CARDIAC CONDITIONS
Pulmonary hypertension
• Symptoms : fatigue, breathlessness and syncope, and clinical signs are those of right heart
failure
• Treatment by endothelin inhibitors (bosentan)
• Pregnancy carries 30-50 % maternal mortality
• Women may deteriorate early (second trimester) or in the immediate postpartum period
• Pregnancy should be discouraged

10. SPECIFIC CARDIAC CONDITIONS
MARFAN SYNDROME
• Connective tissue disease
• Autosomal dominant
• mitral valve prolapse and aortic regurgitation, aortic root dilatation and aortic rupture
or dissection
• Pregnancy increases the risk of aortic rupture or dissection

11. SPECIFIC CARDIAC CONDITIONS
MARFAN SYNDROME
Serial Echocardiogram :
Aortic root dilatation more than 4 cm ------ 50% mortality, if pre-pregnancy, discourage
pregnancy, if already pregnant, serial monitoring and ceserean section is needed
Complications in marfan :
early pregnancy loss
preterm labour
cervical weakness
uterine inversion
postpartum haemorrhage.

12. SPECIFIC CARDIAC CONDITIONS
MITRAL AND AORTIC STENOSIS
• Left sided lesions are usually a high risk during pregnancy
• Aortic stenosis (AS) is usually congenital and mitral stenosis usually rheumatic in
origin
• The Risk in mitral is more than aortic stenosis

13. MITRAL STENOSIS
• mitral stenosis, 40% worsening symptoms in the pregnancy (pulmonary edema )
• The aim of treatment is to reduce the heart rate: bed rest, oxygen, beta-blockade
and diuretic therapy
• Balloon mitral valvotomy is the treatment of choice after delivery, but can be considered
in pregnancy
• Maternal mortality is reported at 2%
• Mitral stenosis less than 1 (cm2) is contraindication for pregnancy.

14. AORTIC STENOSIS
• Pregnancy is usually tolerated in mild and moderate AS
• In sever AS mortality rate is 17 % in the mother and 30 % in the fetus
• Same treatment aim and options as mitral stenosis

15. PERIPARTUM CARDIOMYOPATHY
• It’s a heart failure due to left ventricular systolic dysfunction toward term or
postpartum period
• Presents with breathlessness and signs of heart failure
• Diagnosis of exclusion , echo shows EF less than 45 % anfd dilataion of all
chambers
• Risk factors : advanced maternal age , multiparity , multiple pregnancy ,
hypertension

16. PERIPARTUM CARDIOMYOPATHY
• Treatment as any heart failure
• high recurrence
• High resolution rate
• If recurrent , persistent low EF , or recovery took more than 6 months;
pregnancy is usually discouraged