This document provides guidelines for managing cardiovascular diseases during pregnancy. It discusses physiological changes during pregnancy that impact the cardiovascular system. It also outlines a modified WHO classification system to assess maternal cardiovascular risk. Risk is stratified into 4 categories based on disease severity and impact on mortality and morbidity. Predictors of maternal and neonatal cardiovascular events are identified. Guidelines are provided for managing specific conditions like hypertension, as well as for timing and mode of delivery based on maternal risk. Drug therapies for hypertension are also discussed.
1. Pregnancy places significant demands on the cardiovascular system due to increases in blood volume, cardiac output, and heart rate.
2. Common cardiac problems during pregnancy include congenital heart defects, heart failure, and pulmonary hypertension. These conditions can lead to complications for both mother and baby if not properly managed.
3. Testing such as echocardiography and stress testing are used to evaluate cardiac function during pregnancy. Treatment depends on the severity and type of condition, with termination of pregnancy recommended for very high risk cases.
1) Heart disease occurs in 1-4% of pregnancies and poses increased risks to both mother and fetus. Risk assessment evaluates factors like functional class, cardiac lesions, and ventricular function.
2) Congenital heart disease outcomes depend on the specific lesion. Acyanotic lesions usually tolerate pregnancy well while cyanotic lesions have higher fetal wastage and morbidity. Labor requires monitoring to avoid hemodynamic changes.
3) Rheumatic mitral stenosis risks increase maternal morbidity due to heightened symptoms from increased cardiac output but not mortality. Medical management aims to restrict activity and fluids while balloon valvuloplasty or surgery may be needed in severe cases.
Cardiac disease is a leading cause of maternal mortality. During pregnancy, the cardiac output increases by 40% which can worsen existing heart conditions like rheumatic heart disease. Rheumatic heart disease, caused by untreated streptococcal infections, accounts for 90% of heart conditions in pregnancy. It often involves mitral stenosis which carries risks of heart failure, infection, blood clots and fetal loss. Pregnancy also poses risks for other heart conditions like congenital heart defects. Care involves a multidisciplinary approach with cardiologists, focusing on monitoring, limiting activity and weight gain, avoiding anemia and fluid overload to reduce stress on the heart. Vaginal delivery is preferred when possible but C-sections may be needed
The increased cardiac output related to pregnancy can lead to heart failure, and the increased heart rate in the third trimester can lead to ischemic events. The potential obstetrical complications include preeclampsia or other hypertensive related disorders, premature birth, and small-for-gestational-age births
This document discusses cardiac disease in pregnancy. The major causes of cardiac death over the last 10 years are cardiomyopathy, myocardial infarction, and ischemic heart disease. Physiological adaptations to pregnancy include increases in blood volume, stroke volume, heart rate, and cardiac output. Labor further increases cardiac output. Examination may reveal murmurs. Echocardiography is the preferred investigation. Risks are assessed based on factors like pulmonary hypertension and cardiac function. Management involves a multidisciplinary team and monitoring for decompensation. Risks vary for different cardiac lesions and are managed accordingly, such as with endocarditis prophylaxis.
1. Pregnancy places significant demands on the cardiovascular system due to increases in blood volume, cardiac output, and heart rate.
2. Common cardiac problems during pregnancy include congenital heart defects, heart failure, and pulmonary hypertension. These conditions can lead to complications for both mother and baby if not properly managed.
3. Testing such as echocardiography and stress testing are used to evaluate cardiac function during pregnancy. Treatment depends on the severity and type of condition, with termination of pregnancy recommended for very high risk cases.
1) Heart disease occurs in 1-4% of pregnancies and poses increased risks to both mother and fetus. Risk assessment evaluates factors like functional class, cardiac lesions, and ventricular function.
2) Congenital heart disease outcomes depend on the specific lesion. Acyanotic lesions usually tolerate pregnancy well while cyanotic lesions have higher fetal wastage and morbidity. Labor requires monitoring to avoid hemodynamic changes.
3) Rheumatic mitral stenosis risks increase maternal morbidity due to heightened symptoms from increased cardiac output but not mortality. Medical management aims to restrict activity and fluids while balloon valvuloplasty or surgery may be needed in severe cases.
Cardiac disease is a leading cause of maternal mortality. During pregnancy, the cardiac output increases by 40% which can worsen existing heart conditions like rheumatic heart disease. Rheumatic heart disease, caused by untreated streptococcal infections, accounts for 90% of heart conditions in pregnancy. It often involves mitral stenosis which carries risks of heart failure, infection, blood clots and fetal loss. Pregnancy also poses risks for other heart conditions like congenital heart defects. Care involves a multidisciplinary approach with cardiologists, focusing on monitoring, limiting activity and weight gain, avoiding anemia and fluid overload to reduce stress on the heart. Vaginal delivery is preferred when possible but C-sections may be needed
The increased cardiac output related to pregnancy can lead to heart failure, and the increased heart rate in the third trimester can lead to ischemic events. The potential obstetrical complications include preeclampsia or other hypertensive related disorders, premature birth, and small-for-gestational-age births
This document discusses cardiac disease in pregnancy. The major causes of cardiac death over the last 10 years are cardiomyopathy, myocardial infarction, and ischemic heart disease. Physiological adaptations to pregnancy include increases in blood volume, stroke volume, heart rate, and cardiac output. Labor further increases cardiac output. Examination may reveal murmurs. Echocardiography is the preferred investigation. Risks are assessed based on factors like pulmonary hypertension and cardiac function. Management involves a multidisciplinary team and monitoring for decompensation. Risks vary for different cardiac lesions and are managed accordingly, such as with endocarditis prophylaxis.
Here are a few key things we can do:
1. Provide thorough preconception counseling to assess risk and optimize medical condition before pregnancy if possible.
2. Ensure careful multidisciplinary antenatal care involving cardiologists, obstetricians, anesthesiologists to monitor for complications.
3. Plan delivery carefully considering hemodynamic changes, with options for early delivery or C-section if needed.
4. Be vigilant for dangerous periods like labor/delivery when changes in volume and pressure occur abruptly. Have low threshold for ICU admission.
5. Educate patients and families on warning signs and ensure close postpartum follow up as this is a high risk period.
6.
This document discusses cardiac diseases in pregnancy, including normal pregnancy physiology, symptoms of cardiac disease, preconception counseling, contraindications to pregnancy for certain heart conditions, genetic inheritance of cardiac conditions, and management of specific diseases. It covers topics like dilated cardiomyopathy, peripartum cardiomyopathy, congenital heart diseases involving left-to-right shunts or obstructive lesions, rheumatic heart disease including mitral stenosis, mitral valve prolapse, and Marfan syndrome. Pregnancy risks and management approaches are described for each condition. A team-based approach involving multiple specialists is recommended.
Pregnancy places an additional burden on the heart due to significant hemodynamic changes. The incidence of heart disease during pregnancy has increased due to more women with congenital heart disease surviving to reproductive age. Hemodynamic changes during pregnancy and labor like increased blood volume, heart rate and cardiac output can exaggerate the symptoms of heart conditions. Close monitoring and management of heart conditions and risks is needed before, during and after pregnancy to support a healthy pregnancy outcome.
This document discusses the approach to cardiac disease in pregnancy. It begins by outlining the normal physiological changes in pregnancy that place additional strain on the cardiovascular system. It then describes a systematic approach to evaluating and monitoring different types of cardiac lesions during pregnancy based on how well they are tolerated by the increased cardiovascular demands. High-risk cardiac conditions that require close monitoring and individualized treatment plans are also outlined.
This document discusses heart disease in pregnancy. It notes that 0.4-5.0% of pregnant women have heart disease, which is a leading cause of maternal mortality. The most common heart disorders seen in pregnancy are rheumatic valve disease, congenital heart disease, and cardiomyopathy. Physiological changes in pregnancy like increased blood volume, cardiac output, and heart rate are described. Guidelines for assessing risk, managing specific conditions, determining delivery timing/location, and optimizing outcomes for mothers and babies with heart disease are provided. The importance of pre-conception counseling and a multidisciplinary approach to care is emphasized.
This document discusses cardiovascular diseases in pregnancy. Some key points:
- Risk factors for heart disease in pregnancy are increasing and include diabetes, hypertension, and obesity. The number of women with congenital heart disease reaching childbearing age is also rising.
- Hemodynamic changes during pregnancy place additional strain on the heart, increasing cardiac output and blood volume. These changes begin in the first trimester and peak in the second.
- Women with preexisting heart conditions like pulmonary hypertension face higher risks during pregnancy and delivery. Those with severe disease may require termination of pregnancy for safety. Close monitoring is important for women with heart conditions throughout their pregnancy.
This document discusses cardiac disease in pregnancy. It notes the physiological changes of increased cardiac output during pregnancy and describes common cardiac conditions like rheumatic heart disease and congenital heart defects. It provides details on managing specific conditions like mitral stenosis. Guidelines are presented for monitoring high-risk patients and minimizing cardiac stress during labor and delivery. The importance of a multidisciplinary approach between obstetricians and cardiologists is emphasized.
This document discusses the cardiovascular changes that occur during pregnancy and how they impact women with underlying heart disease. It notes that the incidence of heart disease complicating pregnancy is approximately 1% globally. The most common types seen in India are rheumatic heart disease (78%) and congenital heart disease (18.7%). The document outlines the normal anatomical and physiological changes pregnancy has on the cardiovascular system. It then discusses how certain heart conditions are classified based on their risk during pregnancy, from WHO class 1 (lowest risk) to WHO class 4 (highest risk). The document provides guidance on evaluating and managing women with heart disease throughout their pregnancy.
New ESC guideline on cardiovascular disease in pregnancyArunSharma10
New ESC Guideline on Cardiovascular Disease in Pregnancy
Management of Cardiovascular Diseases During Pregnancy
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Pregnancy is complicated by maternal disease in 1–4% of cases
This document discusses cardiac disease in pregnancy. It notes that cardiac disease affects 1-2% of pregnancies and is a leading cause of maternal mortality. Rheumatic heart disease is the most common in many countries. Physiological changes in pregnancy like increased cardiac output place extra burden on the heart. Close monitoring and management of cardiac patients is needed before, during and after pregnancy to optimize outcomes for both mother and baby. A multidisciplinary team approach is important for treating women with heart disease through pregnancy.
This document discusses cardiac diseases in pregnancy. It begins with the epidemiology and classification of heart diseases. It then covers the normal cardiovascular alterations in pregnancy, the effects of pregnancy on heart diseases and vice versa. It provides details on diagnosing and managing heart diseases in pregnancy, including specific cardiac conditions and complications like arrhythmias and heart failure. Close monitoring is needed during pregnancy for women with cardiac issues due to risks of maternal mortality, preterm delivery, fetal growth problems, and congenital heart defects in the baby.
This document discusses heart disease in pregnancy. It notes that rheumatic valvular heart disease is the most common cause of cardiovascular disease in pregnancy in developing countries. The most common rheumatic lesion is mitral stenosis. Congenital heart disease is the most frequent cardiovascular disease present during pregnancy in industrialized countries, with shunt lesions being predominant. Pregnancy can exacerbate pre-existing heart conditions and lead to complications like heart failure, arrhythmias, and pulmonary edema due to the increased cardiovascular demands. Careful management and monitoring during pregnancy and delivery are important for women with heart disease.
ESC guidelines on Cardiovascular diseases during pregnancyAinshamsCardio
Pregnancy poses risks for women with cardiac conditions due to physiological changes that increase cardiac output and blood pressure. Careful pre-pregnancy evaluation and individualized management plans are needed to minimize risks which can include arrhythmias, heart failure, and aortic dissection. Medical therapy aims to control symptoms while minimizing risks to both mother and fetus, and mode of delivery depends on maternal cardiac status and obstetric factors.
Rivaroxaban is contraindicated in breastfeeding women. The other options - fondaparinux, LMWH, daltaparin and warfarin - can be used during breastfeeding.
Peripartum cardiomyopathy is a form of heart failure that develops in the final month of pregnancy or within 5 months after delivery. It is defined as left ventricular systolic dysfunction without other identifiable causes. Risk factors include age over 30, multiparity, African descent, cocaine use, long term tocolytic therapy, multiple gestation, preeclampsia history, and nutritional deficiencies. Diagnosis involves excluding other causes by EKG, echocardiogram, labs, and symptoms matching criteria. Treatment is similar to other heart failures with diuretics, beta-blockers, digoxin, and anticoagulants considering pregnancy risk classifications. Prognosis shows 50-60% recovery within 6 months but high
This document discusses liver disease in pregnancy, specifically chronic hepatitis B and C. It notes that pregnancy is generally well-tolerated by women with chronic hepatitis B or C. The main concern is risk of transmission to the infant during childbirth. Screening pregnant women for hepatitis B and universal vaccination of newborns can interrupt transmission in over 90% of cases. Continuing lamivudine treatment during pregnancy may further reduce risk of transmission to 100%. Close monitoring is recommended for women with cirrhosis or portal hypertension due to risk of complications.
Venous Thromboembolism (VTE) refers to deep vein thrombosis (DVT) and pulmonary embolism (PE). Pregnancy is a risk factor for VTE due to physiological changes in the coagulation system that promote clotting. The risk is highest in the first trimester through 6 weeks postpartum. Management involves risk assessment, diagnosis, anticoagulation therapy like heparin, prevention through prophylaxis for high risk women, and consideration of risk factors when stopping treatment.
25. CARDIAC DISEASE IN PREGNANCY obgy.pptjacobntanga
Cardiac disease in pregnancy can complicate about 1% of all pregnancies. It includes both congenital heart disease and acquired conditions like rheumatic heart disease. The physiological changes of pregnancy like increased blood volume, stroke volume and heart rate place an additional burden on the heart. Care during pregnancy involves classifying the cardiac lesion's risk level, monitoring for heart failure, preventing its triggers like infection and anemia, and managing pain relief to reduce stress on the heart. Termination of pregnancy may be indicated for high risk lesions like Eisenmenger's syndrome and Marfan's syndrome with aortic involvement due to their high maternal mortality rates.
Heart disease complicates around 2% of pregnancies in developing countries like India. Rheumatic heart disease is the most common cause. Pregnancy leads to hemodynamic changes that increase cardiac output and blood volume. This can precipitate heart failure in patients with cardiac disease. Risk periods are early pregnancy when changes begin, late pregnancy when changes peak, and delivery. Care involves screening, counseling, monitoring, treating underlying conditions, careful fluid management during labor, and advising contraception after delivery. Outcomes depend on functional classification and severity of disease at baseline.
Here are a few key things we can do:
1. Provide thorough preconception counseling to assess risk and optimize medical condition before pregnancy if possible.
2. Ensure careful multidisciplinary antenatal care involving cardiologists, obstetricians, anesthesiologists to monitor for complications.
3. Plan delivery carefully considering hemodynamic changes, with options for early delivery or C-section if needed.
4. Be vigilant for dangerous periods like labor/delivery when changes in volume and pressure occur abruptly. Have low threshold for ICU admission.
5. Educate patients and families on warning signs and ensure close postpartum follow up as this is a high risk period.
6.
This document discusses cardiac diseases in pregnancy, including normal pregnancy physiology, symptoms of cardiac disease, preconception counseling, contraindications to pregnancy for certain heart conditions, genetic inheritance of cardiac conditions, and management of specific diseases. It covers topics like dilated cardiomyopathy, peripartum cardiomyopathy, congenital heart diseases involving left-to-right shunts or obstructive lesions, rheumatic heart disease including mitral stenosis, mitral valve prolapse, and Marfan syndrome. Pregnancy risks and management approaches are described for each condition. A team-based approach involving multiple specialists is recommended.
Pregnancy places an additional burden on the heart due to significant hemodynamic changes. The incidence of heart disease during pregnancy has increased due to more women with congenital heart disease surviving to reproductive age. Hemodynamic changes during pregnancy and labor like increased blood volume, heart rate and cardiac output can exaggerate the symptoms of heart conditions. Close monitoring and management of heart conditions and risks is needed before, during and after pregnancy to support a healthy pregnancy outcome.
This document discusses the approach to cardiac disease in pregnancy. It begins by outlining the normal physiological changes in pregnancy that place additional strain on the cardiovascular system. It then describes a systematic approach to evaluating and monitoring different types of cardiac lesions during pregnancy based on how well they are tolerated by the increased cardiovascular demands. High-risk cardiac conditions that require close monitoring and individualized treatment plans are also outlined.
This document discusses heart disease in pregnancy. It notes that 0.4-5.0% of pregnant women have heart disease, which is a leading cause of maternal mortality. The most common heart disorders seen in pregnancy are rheumatic valve disease, congenital heart disease, and cardiomyopathy. Physiological changes in pregnancy like increased blood volume, cardiac output, and heart rate are described. Guidelines for assessing risk, managing specific conditions, determining delivery timing/location, and optimizing outcomes for mothers and babies with heart disease are provided. The importance of pre-conception counseling and a multidisciplinary approach to care is emphasized.
This document discusses cardiovascular diseases in pregnancy. Some key points:
- Risk factors for heart disease in pregnancy are increasing and include diabetes, hypertension, and obesity. The number of women with congenital heart disease reaching childbearing age is also rising.
- Hemodynamic changes during pregnancy place additional strain on the heart, increasing cardiac output and blood volume. These changes begin in the first trimester and peak in the second.
- Women with preexisting heart conditions like pulmonary hypertension face higher risks during pregnancy and delivery. Those with severe disease may require termination of pregnancy for safety. Close monitoring is important for women with heart conditions throughout their pregnancy.
This document discusses cardiac disease in pregnancy. It notes the physiological changes of increased cardiac output during pregnancy and describes common cardiac conditions like rheumatic heart disease and congenital heart defects. It provides details on managing specific conditions like mitral stenosis. Guidelines are presented for monitoring high-risk patients and minimizing cardiac stress during labor and delivery. The importance of a multidisciplinary approach between obstetricians and cardiologists is emphasized.
This document discusses the cardiovascular changes that occur during pregnancy and how they impact women with underlying heart disease. It notes that the incidence of heart disease complicating pregnancy is approximately 1% globally. The most common types seen in India are rheumatic heart disease (78%) and congenital heart disease (18.7%). The document outlines the normal anatomical and physiological changes pregnancy has on the cardiovascular system. It then discusses how certain heart conditions are classified based on their risk during pregnancy, from WHO class 1 (lowest risk) to WHO class 4 (highest risk). The document provides guidance on evaluating and managing women with heart disease throughout their pregnancy.
New ESC guideline on cardiovascular disease in pregnancyArunSharma10
New ESC Guideline on Cardiovascular Disease in Pregnancy
Management of Cardiovascular Diseases During Pregnancy
Women with CVD
LMWH
Drugs during pregnancy and breastfeeding
Valvular heart disease
Coronary artery disease
Pregnancy is complicated by maternal disease in 1–4% of cases
This document discusses cardiac disease in pregnancy. It notes that cardiac disease affects 1-2% of pregnancies and is a leading cause of maternal mortality. Rheumatic heart disease is the most common in many countries. Physiological changes in pregnancy like increased cardiac output place extra burden on the heart. Close monitoring and management of cardiac patients is needed before, during and after pregnancy to optimize outcomes for both mother and baby. A multidisciplinary team approach is important for treating women with heart disease through pregnancy.
This document discusses cardiac diseases in pregnancy. It begins with the epidemiology and classification of heart diseases. It then covers the normal cardiovascular alterations in pregnancy, the effects of pregnancy on heart diseases and vice versa. It provides details on diagnosing and managing heart diseases in pregnancy, including specific cardiac conditions and complications like arrhythmias and heart failure. Close monitoring is needed during pregnancy for women with cardiac issues due to risks of maternal mortality, preterm delivery, fetal growth problems, and congenital heart defects in the baby.
This document discusses heart disease in pregnancy. It notes that rheumatic valvular heart disease is the most common cause of cardiovascular disease in pregnancy in developing countries. The most common rheumatic lesion is mitral stenosis. Congenital heart disease is the most frequent cardiovascular disease present during pregnancy in industrialized countries, with shunt lesions being predominant. Pregnancy can exacerbate pre-existing heart conditions and lead to complications like heart failure, arrhythmias, and pulmonary edema due to the increased cardiovascular demands. Careful management and monitoring during pregnancy and delivery are important for women with heart disease.
ESC guidelines on Cardiovascular diseases during pregnancyAinshamsCardio
Pregnancy poses risks for women with cardiac conditions due to physiological changes that increase cardiac output and blood pressure. Careful pre-pregnancy evaluation and individualized management plans are needed to minimize risks which can include arrhythmias, heart failure, and aortic dissection. Medical therapy aims to control symptoms while minimizing risks to both mother and fetus, and mode of delivery depends on maternal cardiac status and obstetric factors.
Rivaroxaban is contraindicated in breastfeeding women. The other options - fondaparinux, LMWH, daltaparin and warfarin - can be used during breastfeeding.
Peripartum cardiomyopathy is a form of heart failure that develops in the final month of pregnancy or within 5 months after delivery. It is defined as left ventricular systolic dysfunction without other identifiable causes. Risk factors include age over 30, multiparity, African descent, cocaine use, long term tocolytic therapy, multiple gestation, preeclampsia history, and nutritional deficiencies. Diagnosis involves excluding other causes by EKG, echocardiogram, labs, and symptoms matching criteria. Treatment is similar to other heart failures with diuretics, beta-blockers, digoxin, and anticoagulants considering pregnancy risk classifications. Prognosis shows 50-60% recovery within 6 months but high
This document discusses liver disease in pregnancy, specifically chronic hepatitis B and C. It notes that pregnancy is generally well-tolerated by women with chronic hepatitis B or C. The main concern is risk of transmission to the infant during childbirth. Screening pregnant women for hepatitis B and universal vaccination of newborns can interrupt transmission in over 90% of cases. Continuing lamivudine treatment during pregnancy may further reduce risk of transmission to 100%. Close monitoring is recommended for women with cirrhosis or portal hypertension due to risk of complications.
Venous Thromboembolism (VTE) refers to deep vein thrombosis (DVT) and pulmonary embolism (PE). Pregnancy is a risk factor for VTE due to physiological changes in the coagulation system that promote clotting. The risk is highest in the first trimester through 6 weeks postpartum. Management involves risk assessment, diagnosis, anticoagulation therapy like heparin, prevention through prophylaxis for high risk women, and consideration of risk factors when stopping treatment.
25. CARDIAC DISEASE IN PREGNANCY obgy.pptjacobntanga
Cardiac disease in pregnancy can complicate about 1% of all pregnancies. It includes both congenital heart disease and acquired conditions like rheumatic heart disease. The physiological changes of pregnancy like increased blood volume, stroke volume and heart rate place an additional burden on the heart. Care during pregnancy involves classifying the cardiac lesion's risk level, monitoring for heart failure, preventing its triggers like infection and anemia, and managing pain relief to reduce stress on the heart. Termination of pregnancy may be indicated for high risk lesions like Eisenmenger's syndrome and Marfan's syndrome with aortic involvement due to their high maternal mortality rates.
Heart disease complicates around 2% of pregnancies in developing countries like India. Rheumatic heart disease is the most common cause. Pregnancy leads to hemodynamic changes that increase cardiac output and blood volume. This can precipitate heart failure in patients with cardiac disease. Risk periods are early pregnancy when changes begin, late pregnancy when changes peak, and delivery. Care involves screening, counseling, monitoring, treating underlying conditions, careful fluid management during labor, and advising contraception after delivery. Outcomes depend on functional classification and severity of disease at baseline.
Impaired to physiological chnages in pregnancy in preexisting medical disorderNurul Azlan
1. Pregnancy causes significant cardiovascular changes including increased cardiac output, decreased systemic vascular resistance, and a hypercoagulable state.
2. Respiratory changes include decreased lung volumes due to the gravid uterus pushing up the diaphragm and increased minute ventilation and oxygen consumption due to hormonal effects.
3. Common medical conditions affected by pregnancy include asthma, heart disease, diabetes, and thyroid disorders. Proper management involves multidisciplinary care and treatment of underlying conditions while minimizing risk to the mother and fetus.
1. Cardiac disease complicates around 2% of pregnancies worldwide and is a leading cause of maternal mortality, especially in developing countries where rheumatic heart disease is most common.
2. Pregnancy places additional strain on the heart and can cause cardiac failure, especially for those with preexisting heart conditions or risk factors like hypertension, infection, anemia.
3. Management involves careful prenatal monitoring and treatment to prevent cardiac failure, with multidisciplinary care and delivery in a hospital for high-risk patients. Conditions requiring termination or corrective surgery prior to pregnancy include pulmonary hypertension and severe aortic stenosis.
1. Heart disease occurs in less than 1% of pregnancies, with rheumatic heart disease being the most common, followed by congenital heart disease.
2. Pregnancy places additional strain on the heart through increased blood volume, cardiac output, and pressure on the vena cava. Women with preexisting heart conditions or risk factors like hypertension are susceptible to heart failure during pregnancy.
3. Care involves a multidisciplinary team, supervision in hospital, managing infections and other risk factors, and modifying cardiac medications during pregnancy and delivery to reduce risk of complications for both mother and baby.
The increased cardiac output related to pregnancy can lead to heart failure, and the increased heart rate in the third trimester can lead to ischemic events. The potential obstetrical complications include preeclampsia or other hypertensive related disorders, premature birth, and small-for-gestational-age births.
Pregnancy in women with heart disease carries increased risks for both mother and baby. The risks depend on the type and severity of the heart condition. Management involves careful prenatal monitoring and treatment to prevent worsening of cardiac function and complications. Delivery should take place in a hospital setting with cardiac and anesthesia specialists present. Close postpartum monitoring is also needed as the risk of heart failure is highest in the first 2 weeks after delivery.
This document discusses the management of heart disease during pregnancy. It notes that while pregnancy outcomes are generally favorable for women with heart disease, they remain at risk for complications like heart failure, arrhythmia, and stroke. The document outlines the normal cardiovascular changes during pregnancy, physical exam findings, diagnosis of heart conditions, and management of specific diseases like mitral stenosis, aortic stenosis, and mitral valve prolapse. It emphasizes the importance of a multidisciplinary team, monitoring for risk factors, admitting high-risk patients, administering antibiotics during labor, and managing cardiac failure. The goal is early detection and prevention of complications to optimize outcomes for both mother and baby.
This document discusses various medical and surgical complications that can occur in obstetrics, including diabetes, thyroid disease, hypertension, heart disease, lung disease, kidney disease, and blood clotting disorders. It covers the diagnosis, potential maternal and fetal complications, and management recommendations for each condition.
This document discusses cardiac disease in pregnancy. Key points include:
- Cardiac disease complicates 0.5-1% of pregnancies and is most often rheumatic or congenital in origin.
- Physiological changes in pregnancy like increased blood volume place additional strain on the heart.
- Evaluation of cardiac disease includes assessing symptoms, functional classification, investigations, and fetal risks.
- Management involves pre-conception counseling, monitoring during pregnancy, and planning for delivery and postpartum care depending on the severity of disease. Complications like heart failure, arrhythmias, and thromboembolism require specific treatment approaches.
This document summarizes key information about heart disease in pregnancy:
- Heart disease complicates around 1% of pregnancies on average and mortality has decreased but morbidity has increased in developed countries.
- Normal pregnancy involves significant hemodynamic changes that can mimic or worsen underlying heart conditions. Risk is highest in the first/third trimesters and postpartum.
- Conditions like congenital heart disease, rheumatic heart disease, and cardiomyopathy commonly complicate pregnancy. Risk stratification classifies conditions as low, medium, or high risk.
- Care involves a multidisciplinary team and counseling on maternal/fetal risks. Delivery at a tertiary center is preferred, with careful monitoring during labor/post
This document discusses heart disease in pregnancy. Some key points:
- The incidence of heart disease in pregnancy varies from 0.1-4% on average. Mortality has decreased in developed countries but maternal mortality has increased.
- Pregnancy causes significant hemodynamic changes like increased cardiac output and plasma volume. These changes peak around 30 weeks and can mimic heart disease symptoms.
- Women with conditions like Eisenmenger's syndrome or severe valvular lesions have a high risk of maternal mortality. Close monitoring and management is needed for safe outcomes.
- Medical termination of pregnancy may be advised in early pregnancy for very high risk cases like pulmonary hypertension.
- Antenatal care involves careful monitoring, treatment compliance and
- Pregnancy can place significant strain on a woman's heart and is a leading cause of maternal mortality. The most common cardiac issues in pregnancy are rheumatic heart disease in developing countries and corrected congenital heart diseases in developed countries.
- Precise monitoring and management of cardiac patients during pregnancy is required due to significant hemodynamic changes that occur. Risk is highest during labor/delivery and postpartum. Functional classification, echocardiogram, and risk score can help determine risk level.
- Management involves multidisciplinary care with focus on prevention of heart failure through activity restriction, salt/fluid control, medications if needed. Delivery plan depends on cardiac status and risk level, with caesarean
This document discusses heart diseases in pregnancy. It covers changes in cardiac output and volume that occur during pregnancy, critical periods of risk, symptoms of heart disease, and management of common conditions like heart failure, valvular diseases, congenital heart diseases and pulmonary hypertension. Evaluation involves monitoring for signs of decompensation. Management is focused on optimizing maternal cardiac status through measures like bed rest, diuretics, and controlling heart failure if it occurs. Delivery planning considers fetal wellbeing and maternal cardiac status.
This document discusses cardiac illness in pregnancy. It notes that many cardiac symptoms mimic normal pregnancy symptoms. It recommends involving a multidisciplinary team to classify disease severity and risk. High risk conditions include ventricular dysfunction, pulmonary hypertension, cyanotic heart disease, aortic pathology, and valvular issues. Fetal risks include congenital heart defects, hypoxia, prematurity, and growth restriction. Vaginal delivery is preferred when safe, with epidural recommended. Specific conditions discussed in more detail include myocardial infarction, pulmonary hypertension, Marfan syndrome, mitral stenosis, aortic stenosis, and peripartum cardiomyopathy.
This document discusses cardiac illness in pregnancy. It notes that many cardiac symptoms mimic normal pregnancy symptoms. It recommends involving a multidisciplinary team to classify disease severity and risk. High risk conditions include ventricular dysfunction, pulmonary hypertension, cyanotic heart disease, aortic pathology, and valvular issues. Fetal risks include congenital heart defects, hypoxia, prematurity, and growth restriction. Vaginal delivery is preferred when safe, with epidural recommended. Specific conditions discussed in more detail include myocardial infarction, pulmonary hypertension, Marfan syndrome, mitral stenosis, aortic stenosis, and peripartum cardiomyopathy.
This document discusses features of pregnancy and childbirth management in women with extragenital pathology. It notes that only 20% of pregnancies proceed without complications, while 30-40% involve extragenital pathology (EGP) such as cardiovascular, kidney, or blood diseases. Pregnancy termination risks are 12% and can affect fetal development. The most common EGP in women ages 21-29 is cardiovascular disease, observed in 7% of cases. Management of pregnancy involves frequent hospitalizations and selecting delivery methods based on the severity of the woman's condition.
Heart Disease In Pregnancy During The Pandemicahvc0858
Heart disease in pregnancy during the pandemic
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Management of Cardiovascular Disease during Pregnancy
1. Management of Cardiovascular Diseases During
Pregnancy – ESC Guideline 2018
Dr. M A Hasnat
MBBS, FCPS (Medicine), MD (Cardiology), FESC
Member Indian Academy of Echocardiography (IAE)
Consultant (Cardiology)
Kurmitola General Hospital
2. Aim of this guideline
• To know
– Pregnancy is indicated or Contraindicated?
– Pregnancy should continue or not?
– Management during pregnancy, labour and after
delivery.
3. • Pregnancy, a divine blessing of God, is the
fundamental phenomenon for the continuation
of human race.
• Maternal heart disease may discovered first
time during pregnancy due to haemodynamic
overload.
• In the western world, the risk of CVD in
pregnancy has increased due to increasing age
at first pregnancy.
Introduction
4. • In western countries, maternal heart disease is
the major cause of maternal death during
pregnancy.
• Late pregnancies (between ages of 40–50
years) are more frequently associated with an
increasing prevalence of cardiovascular risk
factors, especially diabetes, hypertension, and
obesity.
5. • Hypertensive disorders are the most frequent
cardiovascular disorders during pregnancy,
occurring in 5–10% of all pregnancies.
• Among the other disease conditions,
congenital heart disease is the most frequent
CVD present during pregnancy in the western
world (75–82%).
• Rheumatic valvular disease dominates in non-
western countries, comprising 56–89% of all
CVDs in pregnancy.
6. Physiological adaptations to pregnancy
• Plasma volume and cardiac output (CO) reach
a maximum of 40–50% above baseline at 32
weeks of gestation.
• Atrial and ventricular diameters increase while
ventricular function is preserved.
• Systemic and pulmonary vascular resistances
decrease during pregnancy.
7. • Pregnancy is a hypercoagulable state
associated with increased risk of thrombo-
embolism.
• Increased activity of liver enzyme systems,
GFR, plasma volume, protein binding changes,
and decreased serum albumin levels
contribute to changes in the pharmacokinetics
of many drugs.
8. • Uterine contractions, positioning (left lateral
vs. supine), pain, anxiety, exertion,
haemorrhage, and uterine involution cause
significant haemodynamic changes during
labour and post-partum.
• Anaesthesia, haemorrhage, and infection may
induce additional cardiovascular stress.
• Blood pressure (BP) and CO increase during
labour and post-partum.
9. Cardiac diseases during pregnancy:
• Congenital:
– ASD, VSD, PDA
– TOF, TGV
– Pulmonary stenosis
– Bicuspid Aortic valve
– Coarctation of aorta
– Marfan’s syndrome
11. • Initial diagnosis is sometimes difficult.
• Diagnosis is depends on careful history taking,
clinical examination and investigations.
12. Cardiovascular Investigations in pregnancy
• ECG
• Echocardiography
• Exercise testing
Pregnancy itself is a stress test. So exercise test should be avoided when other
options are available.
– Submaximal exercise testing in asymptomatic patients with suspected heart
disease .
– Stress echocardiography using bicycle ergometry may improve diagnostic
specificity.
– Dobutamine stress is rarely indicated during pregnancy .
• Chest radiography and computed tomography
– Although the foetal dose from chest radiography is <0.01 mGy, it should only
be performed if other methods fail to clarify the cause of symptoms.
• Cardiac catheterization
• MRI
13. Modified World Health Organization
classification of maternal cardiovascular risk
• mWHO I
• mWHO II
• mWHO II–III
• mWHO III
• mWHO IV
14. Modified World Health Organization (mWHO)
classification of maternal cardiovascular risk
• mWHO - I
• Small or mild
– pulmonary stenosis
– patent ductus arteriosus (PDA)
– mitral valve prolapse
• Successfully repaired simple lesions (ASD, VSD, PDA,
anomalous pulmonary venous drainage).
• Isolated atrial or ventricular ectopic beats.
• Risk
– No detectable increased risk of maternal mortality and
no/mild increased risk in morbidity
15. • mWHO - II
– Un-operated atrial or ventricular septal defect
– Repaired TOF
– Most arrhythmias (supraventricular arrhythmias)
– Turner syndrome without aortic dilatation
• Risk
– Small increased risk of maternal mortality or
moderate increase in morbidity
16. • mWHO II-III
– Mild left ventricular impairment (EF >45%)
– HCM
– Native or tissue valve disease not considered WHO I
or IV (mild mitral stenosis, moderate aortic stenosis)
– Marfan or other HTAD syndrome without aortic
dilatation
– Repaired coarctation
– Atrioventricular septal defect
• Risk
– Intermediate increased risk of maternal mortality or
moderate to severe increase in morbidity
17. • mWHO III
– Moderate left ventricular impairment (EF 30–45%)
– Previous peripartum cardiomyopathy without any
residual left ventricular impairment
– Mechanical valve
– Unrepaired cyanotic heart disease
– Moderate mitral stenosis
– Severe asymptomatic aortic stenosis
– Ventricular tachycardia
• Risk
–Significantly increased risk of maternal
mortality or severe morbidity
18. • mWHO IV
– Pulmonary arterial hypertension (PAH)
– Severe left ventricular dysfunction (EF <30% or NYHA
class III–IV)
– Previous peripartum cardiomyopathy with any residual
left ventricular impairment.
– Severe mitral stenosis (MVA <1cm2).
– Severe symptomatic aortic stenosis.
– Severe (re)coarctation of aorta.
– Fontan with any Complication.
• Risk
– Extremely high risk of maternal mortality or severe
morbidity
19. Predictors of maternal cardiovascular events
• Prior cardiac event (HF, TIA, stroke, arrhythmia)
• NYHA class III/IV
• Left heart obstruction (moderate to severe)
• Reduced left ventricular systolic function (ejection fraction <40%)
• Reduced right ventricular function (TAPSE <16 mm)
• Moderate to severe AR and PR
• Pulmonary arterial hypertension (PAH)
• Cardiac medication before pregnancy
• Cyanosis (O2 saturation <90%)
• NT-proBNP >128 pg/mL at 20 weeks predictive of event later in
pregnancy
• Smoking history
• Mechanical valve prosthesis
• Repaired or unrepaired cyanotic heart disease
20. Predictors of neonatal events
• NYHA class III/IV
• Maternal left heart obstruction
• Smoking during pregnancy
• Low maternal oxygen saturation (<90%)
• Multiple gestations
• Use of anticoagulants throughout pregnancy
• Cardiac medication before pregnancy
• Mechanical valve prosthesis
• Maternal cardiac event during pregnancy
• Maternal decline in cardiac output during pregnancy
• Abnormal uteroplacental Doppler flow
21. Management of patient with different risk category:
• mWHO I-II:
Near normal physiology
Pregnancy care in local hospital
• mWHO II-III:
Monitored at referral hospital experience in
managing pregnancy with heart diseases.
• mWHO III-IV:
Counselling against pregnancy
If pregnant:
Therapeutic abortion (early pregnancy)
Intervention/ Cardiac surgery
22. Timing and mode of delivery
• Timing of delivery
– Induction of labour should be considered at 40 weeks of gestation in
all women with cardiac disease;
– Misoprostol, prostaglandin E1 (PGE1) or dinoprostone can be used safely
to induce labour.
• Elective C/S carries no maternal benefit and results in earlier
delivery and LBW.
• Vaginal delivery is associated with less blood loss and lower risk
of infection, venous thrombosis, and embolism, and should be
advised for most women.
• Elective C/S should be considered for obstetric indications and
for patients presenting in labour on
– oral anticoagulants (OACs),
– with aggressive aortic pathology, and
– acute intractable HF.
– severe forms of PH (including Eisenmenger’s syndrome).
23. Hypertensive disorders
• Most common medical complications, affecting 5–
10% of pregnancies worldwide.
• Major cause of maternal, foetal and neonatal
morbidity and mortality.
• Maternal risks include
– placental abruption,
– stroke,
– Multiple organ failure, and disseminated intravascular
coagulation.
• The foetus is at high-risk of IUGR, pre-maturity and
intrauterine death.
24. • The definition of hypertension in pregnancy is based only on
office (or in-hospital) BP values [≥140/ ≥90 mmHg]
– Mild (140–159/ 90–109 mmHg)
– Severely (≥160/110 mmHg) .
• Pre-existing hypertension: develops before 20 weeks of gestation
and usually persists for more than 42 days post-partum. It may
associate with proteinuria.
• Gestational hypertension: develops after 20 weeks of gestation
and usually resolves within 42 days post-partum.
25. • Pre-eclampsia: gestational hypertension with significant
proteinuria (>0.3 g/24 h or ACR ≥30 mg/mmol).
– The only cure is delivery.
• Pre-existing hypertension plus superimposed gestational
hypertension with proteinuria.
• Antenatally unclassifiable hypertension: this term is used
when BP is first recorded after 20 weeks of gestation and
hypertension is diagnosed; re-assessment is necessary after
42 days post-partum.
27. • High risk of pre-eclampsia includes any of the following:
– hypertensive disease during a previous pregnancy
– chronic kidney disease
– autoimmune disease such as SLE or antiphospholipid syndrome
– type 1 or type 2 diabetes
– chronic hypertension.
• Moderate risk of pre-eclampsia includes more than one of
the following risk factors:
– first pregnancy
– age 40 years or older
– pregnancy interval of more than 10 years
– BMI of >_35 kg/m2 at first visit
– family history of pre-eclampsia
– multiple pregnancy.
28. • Women at high or moderate risk of pre-
eclampsia should be advised to take 100–150 mg
of aspirin daily from week 12 to weeks 36–37.
• Calcium supplementation (1.5–2 g/day, orally) is
recommended for the prevention of pre-
eclampsia in women with low dietary intake of
calcium (<600 mg/day).
• Vitamins C and E do not decrease pre-eclampsia
risk.
29. • Methyldopa, beta-blockers (labetalol), and
calcium antagonists (oral nifedipine) are the
drugs of choice.
• Methyldopa should be avoided in post-partum
period because of the risk of post-partum
depression.
30. • All antihypertensive agents taken by the
nursing mother are excreted into breast milk.
• All are at very low concentrations, except for
propranolol and nifedipine, which have breast
milk concentrations similar to those in
maternal plasma.
31. • Atrial Septal Defect (ASD)
• Maternal risk
– Pregnancy is well tolerated.
– In unrepaired ASDs, thromboembolic complications
have been described (5%). Atrial arrhythmias occur
when ASD is unrepaired or closed at an older age.
• Obstetric and offspring risk
– In unrepaired ASD, pre-eclampsia and growth
restriction may occur more frequently.
• Management
– For a secundum defect, catheter device closure can
be performed during pregnancy but is rarely
indicated.
32. • Ventricular septal defect
• Maternal risk
– Small or repaired ventricular septal defects (VSDs)
(without left heart dilatation or ventricular
dysfunction) have a low-risk of complications during
pregnancy (mWHOI and II).
• Obstetric and offspring risk
– There is no evidence of increased obstetric risks.
• Management
– Small VSD- Tolerate pregnancy well
– Large VSD- With PH / Eisemenger syndrome–
• Avoid Pregnancy.
• If pregnant-
– Therapeutic termination
– High mortality if pregnancy is continued
33. • Mitral stenosis
• Maternal risk
– Mild mitral stenosis (MS) is generally well tolerated.
– HF occurs in severe MS (valve area ≤ 1.0 cm2 ) most
often during the second trimester.
– Mortality is higher in low–middle- income countries.
• Obstetric and offspring risk
– The risk of peripartum acute HF depends on symptoms
and PAP.
– Prematurity rates are 20–30%, intrauterine growth
retardation 5–20%, and foetal death 1–5%.
– Offspring risk is higher in women in NYHA class III/IV
during pregnancy.
34. • Management
– Medical therapy: beta-1-selective blockers
(preferably metoprolol or bisoprolol), Diuretics,
Anticoagulation (UFH, LMWH, or VKAVKA),
– All patients with significant MS should be
counselled against pregnancy.
– Intervention should be considered prepregnancy.
– During pregnancy, PTMC or CMC is preferably
performed after 20 weeks of gestation.
35. • Valvular aortic stenosis
• The main cause of AS is bicuspid aortic valve and rheumatic
heart disease.
• Maternal risk
– Related to the baseline severity of AS and symptoms.
– Even in patients with severe AS, pregnancy is often well
tolerated if prior exercise tolerance was normal.
– Mortality is now rare if careful management is provided.
• Obstetric and offspring risk
– Obstetric complications may be increased in patients with
severe AS.
– Pre-term birth, IUGR, LBW occur in 20–25% of the offspring of
mothers with moderate and severe AS, and are increased in
severe AS.
– In bicuspid AV performance of foetal echocardiography is
justified.
36. • Management of valvular AS
– All symptomatic patients with severe AS or
asymptomatic patients with impaired LV function
or a pathological exercise test should be
counselled against pregnancy, and surgery should
be performed prepregnancy.
– Pregnancy should not be discouraged in
asymptomatic patients, even with severe AS,
when LV size and function and the exercise test
are normal
37. • Mitral and aortic regurgitation
• Mitral and aortic regurgitation can be of rheumatic,
congenital or degenerative origin.
• Maternal risk
– Women with severe regurgitation and symptoms or
compromised LV function are at high-risk of HF.
– HF occurs in 20–25% of women with moderate or severe
rheumatic MR. Acute severe regurgitation is poorly
tolerated. In women with congenital heart disease,
significant left AV valve regurgitation is associated with
cardiac complications during pregnancy. A persistent
worsening of regurgitation may occur.
• Obstetric and offspring risk
– No increased risk of obstetric complications.
– Intrauterine growth retardation occurs in 5–10%, and
other offspring complications in <5%, of women with
moderate or severe
38. • Management of MR or AR
– Pre-pregnancy surgery favouring valve repair
should be performed.
– Vaginal delivery with epidural anaesthesia and
shortened second stage is advisable.
39. • Peripartum cardiomyopathy (PPCM)
– Unexplained LV dysfunction which develops during
the last month of pregnancy or within 5 months of
delivery
– Presents with
• heart failure
• embolism
• arrhythmias
– maternal mortality (up to 20%)
– Adverse risk factors include-
• age > 30 yrs
• multiparity
• twin pregnancy
40. • Medical therapy
– Beta blocker
– Diuretics
– Dopamine, if required
– RAAS and aldosterone antagonist should be avoided
during pregnancy.
• Delivery
– NVD if hemodynamically stable
– Early delivery if advance heart failure and
hemodynamic instability despite treatment.
• Prognosis and counselling for repeated pregnancy
41. • AMI in pregnancy
– CAG with a view to PCI with stenting is the
preferred treatment.
– Thrombolytics, although increase the risk of
maternal hemorrhage (8%), can be used where
cardiac catheterization facilities are not available.
– Low-dose aspirin, Nitrates, β-blockers, Clopidogrel
and glycoprotein IIb/IIIa receptor inhibitors - safe
– Short-term heparin administration- safe
– ACEI, ARB & statins are contraindicated
45. Infective endocarditis
• During delivery, the indication for prophylaxis has been
controversial.
• Antibiotic prophylaxis is not recommended during
vaginal or caesarean delivery.
• The diagnosis of IE during pregnancy involves the same
criteria as in the non-pregnant patient.
• IE should be treated in the same way as in the non-
pregnant patient.
• Antibiotics that can be given during all trimesters of
pregnancy are penicillin, ampicillin, amoxicillin,
daptomycin, erythromycin, mezlocillin, oxacillin, and
cephalosporins.
46. Venous thrombo-embolic (VTE) disease during
pregnancy and the puerperium
• VTE, encompassing PE and deep vein
thrombosis (DVT), represents a significant
cause of pregnancy-related morbidity and
mortality.
• The risk of VTE is highest in the immediate
postpertum period.
• All women should undergo a documented
assessment of risk factors for VTE before
pregnancy or in early pregnancy.
47. Drugs during pregnancy and
breastfeeding
• During pregnancy, profound physiological
changes occur that potentially change the
absorption, distribution, metabolism, and
excretion of drugs.
• Beta-adrenergic blocking agents are generally
safe in pregnancy, but may be associated with
increased rates of foetal growth restriction and
also hypoglycaemia. Beta-1-selective drugs are
preferred.
• ACE inhibitors and ARBs are teratogenic and
contraindicated during pregnancy
48. • Spironolactone and Eplerenone are not
advised in humans during pregnancy.
• CCBs do not seem to be associated with an
increased incidence of congenital anomalies in
humans
• Statins should not be prescribed in pregnancy
or during breastfeeding to treat
hyperlipidaemia since their harmlessness is
not proven.
49. Drug category
• Category A: adequate and well-controlled studies have
failed to demonstrate a foetal risk in the first trimester (and
there is no evidence of risk in the later trimesters).
• Category B: either animal reproduction studies have not
demonstrated a foetal risk but there are no controlled
studies in pregnant women, or animal reproduction studies
have shown an adverse effect that was not confirmed in
controlled studies in women.
• Category C: either studies in animals have revealed adverse
effects on the foetus and there are no controlled studies in
women, or studies in women and animals are not available.
Drugs should be given only if potential benefits justify the
potential risk to the foetus.
50. • Category D: there is evidence of human foetal
risk, but the benefits from use in a pregnant
woman may be acceptable despite the risk
(e.g. treatment of life-threatening conditions).
• Category X: The drug is contraindicated in
women who are ormay become pregnant.
51. Take home messages
• It is recommended to perform risk assessment in all women
with cardiac diseases of childbearing age before and after
conception, using the mWHO classification of maternal risk.
• It is recommended that high-risk patients are treated in
specialized centres by a multidisciplinary pregnancy heart
team.
• Foetal echocardiography by experienced specialists is
recommended when there is an elevated risk of foetal
abnormalities.
• Echocardiography is recommended in any pregnant patient
with unexplained or new cardiovascular signs or symptoms.
52. • Vaginal delivery is recommended as the first choice
in most patients.
• Induction of labour should be considered at 40
weeks of gestation in all women with cardiac disease.
• Genetic counselling should be considered in women
with congenital heart disease or congenital
arrhythmia, cardiomyopathies, aortic disease, or
genetic malformations associated with CVD.
• MRI (without gadolinium) should be considered if
echocardiography is insufficient for a definite
diagnosis.
53. • In patients with severe hypertension, vaginal
delivery with epidural analgesia and elective
instrumental delivery should be considered.
• Caesarean delivery should be considered for
obstetrical indications or for patients with
dilatation of the ascending aorta >45 mm,
severe aortic stenosis, pre-term labour while on
oral anticoagulants, Eisenmenger’s syndrome,
or severe heart failure.
54. • A chest radiograph may be considered if other
methods are not successful in clarifying the cause of
dyspnoea.
• Cardiac catheterization may be considered with very
strict indications.
• CT and electrophysiological studies may be considered
in selected patients for vital indications.
• Coronary bypass surgery or valvular surgery may be
considered during pregnancy when conservative and
medical therapy has failed, and in situations that
threaten the mother’s life or that are not amenable to
percutaneous treatment.
• Prophylactic antibiotic therapy to prevent endocarditis
during delivery is not recommended.
In conclusion, the physiological adaptations to pregnancy influence the evaluation and interpretation of cardiac function and clinical status.
Renal or tubular dysplasia, renal failure, oligohydramnios, growth retardation, ossification disorders of the skull, lung hypoplasia, contractures, large joints, anaemia, and intrauterine foetal death have been described.