Heart disease in pregnancy
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1. Patients with heart disease require careful intrapartum management including monitoring of vital signs, fluid balance, and fetal heart rate. Epidural analgesia is preferred to avoid hemodynamic changes from pain. Vaginal delivery is preferred for most, and antibiotics are given before procedures to prevent endocarditis. 2. NYHA classification stratifies heart disease severity from Class I (no limitation) to Class IV (severe limitation even at rest).
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Heart disease in pregnancy
- 2. 1% of all pregnancies One of the leading indirect causes of maternal mortality
- 3. Increase in cardiac output by 40% Incr in stroke vol by 10% Incr in heart rate by 10% (15 bpm) Incr in blood volume by 40% Decrease in peripheral resistance & diastolic BP
- 4. Rheumatic - more in dev countries, 90% MS Congenital – ASD commonest
- 5. Progressive dyspnoea Orthopnoea Paroxysmal nocturnal dyspnoea Hemoptysis Palpitations Syncope Nocturnal cough Chest pain
- 6. Cynosis Clubbing Persistent distension neck veins Thrill Parasternal heave Diastolic murmur A grade 3 systolic murmur AF, persistent arrythmias Cardiomegaly Persistent split 2nd sound, Loud P2
- 7. Echocardiography ◦ Structural lesion, ◦ Valve area & severity ◦ Valve gradient ◦ Ventricular function Safe, non invasive ECG diagnoses arrythmias only
- 8. Collapsing pulse – wide pulse pressure in preg Increase in HR, ectopic beats JVP waves more prominent Heart size increases Apex beat displaced up & laterally Loud S1,third heart sound Ejection systolic murmurs(gr 2 & 3) Venous hums in neck & mammary souffle ov breast Peripheral edema ECG – left axis deviation, mild ST changes
- 9. NYHA Classification Class I Uncompromised/no limitation in physical activity Class II Slight limitation of physical activity/dyspnoea on severe exertion Class III Marked limitation of physical activity/dyspnoea on mild exertion Class IV Severely compromised/Dyspnoea at rest
- 10. Myocardial dysfunction(Ejection fraction <40% or cardiomyopathy) Prior heart failure, arrythmia or stroke Previous arrythmia needing treatment NYHA class 3 or 4 or cyanosis L sided obstruction(mitral area <2sq.cm/peak LV outflow tract gradient above 30mm Hg/Aortic valve <1.5sq cm)
- 11. Based on risk stratification Given intrapartum to women at high & moderate risk only in presence of suspected bacteremia or active infection Optional in women at high risk undergoing uncomplicated delivery & not for mod risk gp
- 12. High risk Moderate risk Prosthetic valves Most other congenital cardiac malformations Previous endocarditis Rheumatic valvular heart disease Complex cyanotic heart disease Hypertrophic cardiomyopathy Surgically constructed shunts or conduits Mitral valve prolapse with regurgitation or thickened leaflets
- 13. Given 30 – 60 min before the procedure Ampicillin 2 g or cefazolin/ ceftriaxone 1gm IV If sensitive to penicillin, clindamycin 600mg IV Oral – 2gm amoxycillin Vancomycin also if enterococcus suspected
- 14. Isolated atrium septum secondum Surgical repair of ASD, VSD & PDA Prev coronory bypass graft surgery Mitral valve prolapse without regurgitation Previous Kawasaki disease without valvular dysfunction Cardiac pacemaker
- 15. Eisenmenger syndrome Primary pulmonary hypertension Uncorrected severe coarctation Marfans with aorta dilated >45mm Severe MS with complications Severe symptomatic aortic stenosis Prev peripartum cardiomyopathy with residual LV dysfunction
- 16. Preconceptional counselling V imp in artificial valves on oral anticoagulants Cong lesions & MS better corrected surgically first Mild MS, complete family early
- 17. Combined clinic, tertiary care centre, cardio+obst Two issues ◦ ?need for termination ◦ ? Need for surgery ◦ If surgery needed best in 2nd trimester Fetal surveillance with growth scans
- 18. Mostly uneventful No need of early hospitalisation Physical activity to be kept within the pt’s cardiac reserve Adequate rest, frequent follow ups Look out for nocturnal cough & persistent basal crepitations heart failure Sudden reduction in ability to carry out usual duties and dyspnoea Prevent respiratory infections
- 19. Antiobiotics at first sign of infection Look for asymptomatic bacteriuria & treat Dental hygiene Prevent anaemia Hypertension to be managed incr pre load Arrythmias to be treated Fetal echo especially in congenital heart diseased pts
- 20. Anaemia Tachycardia & arrythmias Hypertension Hyperthyroidism Multiple pregnancy Respiratory infections Stress
- 21. At high risk Ideally should be pregnant only after surgical correction If seen in 1st trimester adv MTP If continuing preg, counsel regarding risks Hospitalised for the rest of the pregnancy Delivery in an experienced unit
- 22. Vaginal delivery preferred except ◦ Coarctation of aorta ◦ Marfan’s with aortic diameter 45mm or more Spontaneous labour best EAS,Oxytocin, ARM if Cx favourable PGs theoretical risk of coronary vasospasm & arrythmias
- 23. Analgesia Position - semi recumbent Fluid management(not more than 75 ml/hr) Monitoring ◦ BP, Heart rate ◦ Pulse oxymetry ◦ Continuous ECG?arrythmias ? Swan Ganz catheter in some cases Continuous electronic fetal heart monitoring
- 24. Outlet forceps Frusemide 40 mg IV soon after baby born THIRD STAGE Ergometrine & Methergin contra indicated Oxytocin IV/IM can be used
- 25. Can decompensate Observed in labour ward 48 hours Fluid balance to be monitored Look out for PPH, Infection & Thrombo embolism Thrombo prophylaxis with heparin Early ambulation Lactation
- 26. Barrier preferred LNG IUS(MIRENA) safe & effective COCs not preferred in pts prone for thrombosis(MS, Artificial valves) Progesterone injectables & Minipills may be used but fluid retention problem Vasectomy for male partner Interval sterilisation GA, not laparoscopic
- 27. Congestive cardiac failure Acute pulmonary edema Arrythmias Subacute bacterial endocarditis
- 28. Previously, closed mitral valvotomy, Now, Balloon valvuloplasty, if valve pliable & not calcified & minimal regurgitation Radiation exposure Safest time after 20 wks Indications in pregnancy 1. Failure of medical T/T in intractable heart failure 2. Recurrent episodes of ac pulmonary edema
- 29. Maternal Factors affecting NYHA functional class Presence of pulmonary hypertension Cyanotic heart disease Type of lesion Fetal outcome Prematurity IUGR Risk of congenital heart disease
- 30. Mitral stenosis 90% Critical stenosis- valve area <1cm2(N=4cm2) Moderate stenosis – 1 – 2.5cm2 Mortality high in NYHA class III & IV L atrial presspulm HT ventricular failure,pulm edema Cardiac surgery best before pregnancy Or balloon valvuloplasty after 20 wks
- 31. Limited physical activity Na restricted, diuretics,β blockers If new onset atrial fibrillation – verapamil,electroversion Digoxin, β blockers for chr fibrillation If persistant fibrillation/L atrial thrombus – heparin Vaginal delivery preferred Epidural analgesia, avoid overload Bacterial endocarditis prophylaxis
- 32. Thromboembolism & infective endocarditis Warfarin safe for mother but embryopathy ◦ Chondrodysplasia punctata, ◦ Nasal hypoplasia ◦ Optic atrophy ◦ Microcephaly ◦ Miscarriage, IUGR, SB
- 33. Discontinue warfarin at 6 wks In high risk,IV heparin infusion,low risk,SC heparin Restart warfarin at 14 wks 34 – 36 wks – restart IV heparin infusion Labour to be planned Stop heparin 6 hrs before delivery Restart heparin 6 hrs after vaginal, 12 hrs after CS Start warfarin after 3days,withdraw heparin once INR adjusted(safe in lactation) Infective endocarditis prophylaxis mandatory
- 34. ASD,corrected VSD, PDA usually safe Eisenmenger syndrome – preg contraindicated Tetralogy of Fallot- high risk if uncorrected Coarctation of aorta – corrected,good prognosis Residual HT in 30%- risk of aortic dissection & paroxysmal HT in 2ndstage rupture aneurysm,ICH Marfan’s – risk of aortic dissection & ao rupture Primary Pulm HT – preg contra indicated
- 35. Cardiac failure in the last month of preg or within 5 mths foll delivery. Absence of another identifiable cause Absence of recognisable heart disease bef last mth of preg ECHO – LV systolic dysfunction(EF <45%, M mode fractional shortening < 30% & L V end diastolic dimension > 2.7cm/m2 Mat outcome not very good, pulm embolism, cereb thrombosis
- 36. 1. What is the intrapartum management of a patient with heart disease in pregnancy? 2. Describe NYHA classification.
Editor's Notes
- Risk of pulmonary edema or death higher with even one of these