Pregnancy in patients with pulmonary hypertension carries significant risks to both mother and baby. Key risks include heart failure in the mother from the increased cardiovascular demands of pregnancy, as well as risks of blood clots, need for intensive care admission, and death. Delivery via planned c-section at 34 weeks is typically recommended to minimize risks, with regional anesthesia preferred over general. Strict monitoring during pregnancy and postpartum is important. While new therapies have improved outcomes, pregnancy is still not recommended due to the very high mortality risks. Termination should be considered and patients require extensive contraceptive counseling.
This document discusses updates in venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It describes the risk factors, signs, symptoms, and diagnostic testing for VTE including ultrasonography, CT pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scanning, and magnetic resonance imaging (MRI). It also discusses specific considerations for diagnosing PE during pregnancy.
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 peripartum cardiomyopathy (PPCM), a type of dilated cardiomyopathy that presents with left ventricular systolic dysfunction and heart failure near the end of pregnancy or in the months following delivery. The case is of a 29-year old woman who presented with dyspnea and fatigue two days after an uneventful delivery of her first child. PPCM has an incidence of 1 in 4,000 live births in the United States. While the exact cause is unknown, proposed mechanisms include viral myocarditis, an abnormal immune response, and prolonged use of tocolytics. Diagnosis involves excluding other potential causes and is confirmed by echocardiogram showing reduced left ventricular function. Treatment involves standard heart failure medications,
1) Pulmonary hypertension (PH) is defined as elevated pulmonary artery pressure, while pulmonary arterial hypertension (PAH) is a subtype caused by constriction and remodeling of small pulmonary arteries.
2) PAH is a progressive disease that involves proliferation of cells in the pulmonary arteries leading to increased pulmonary vascular resistance and right heart failure if left untreated.
3) The document reviews classification of PH, diagnostic testing and evaluation algorithms, goals of treatment, and approved therapies for PAH.
Anticoagulation in prosthatic valves with pregnancyShah Abbas
This document discusses anticoagulation management for pregnant women with prosthetic heart valves. It notes that less than 1% of pregnant women have prosthetic valves. Pregnancy causes physiological changes that increase cardiovascular demands. The risks of thrombosis are higher during pregnancy due to hypercoagulability. Options for anticoagulation include warfarin, unfractionated heparin, and low molecular weight heparin. Warfarin carries risks of fetal complications if used in the first trimester, so alternatives like heparin are preferred during that period. Careful anticoagulant management throughout pregnancy and the peripartum period can help reduce risks to both mother and fetus.
1. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial or venous thrombosis or pregnancy morbidity in the presence of antiphospholipid antibodies.
2. The diagnosis requires one clinical criterion of vascular thrombosis or pregnancy complications and one laboratory criterion of positive testing for antiphospholipid antibodies on two occasions at least 12 weeks apart.
3. Treatment during pregnancy involves low-dose aspirin and heparin starting at a positive pregnancy test through 34 weeks gestation to reduce the risk of pregnancy complications like miscarriage, preeclampsia, and intrauterine growth restriction.
This document discusses updates in venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It describes the risk factors, signs, symptoms, and diagnostic testing for VTE including ultrasonography, CT pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scanning, and magnetic resonance imaging (MRI). It also discusses specific considerations for diagnosing PE during pregnancy.
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 peripartum cardiomyopathy (PPCM), a type of dilated cardiomyopathy that presents with left ventricular systolic dysfunction and heart failure near the end of pregnancy or in the months following delivery. The case is of a 29-year old woman who presented with dyspnea and fatigue two days after an uneventful delivery of her first child. PPCM has an incidence of 1 in 4,000 live births in the United States. While the exact cause is unknown, proposed mechanisms include viral myocarditis, an abnormal immune response, and prolonged use of tocolytics. Diagnosis involves excluding other potential causes and is confirmed by echocardiogram showing reduced left ventricular function. Treatment involves standard heart failure medications,
1) Pulmonary hypertension (PH) is defined as elevated pulmonary artery pressure, while pulmonary arterial hypertension (PAH) is a subtype caused by constriction and remodeling of small pulmonary arteries.
2) PAH is a progressive disease that involves proliferation of cells in the pulmonary arteries leading to increased pulmonary vascular resistance and right heart failure if left untreated.
3) The document reviews classification of PH, diagnostic testing and evaluation algorithms, goals of treatment, and approved therapies for PAH.
Anticoagulation in prosthatic valves with pregnancyShah Abbas
This document discusses anticoagulation management for pregnant women with prosthetic heart valves. It notes that less than 1% of pregnant women have prosthetic valves. Pregnancy causes physiological changes that increase cardiovascular demands. The risks of thrombosis are higher during pregnancy due to hypercoagulability. Options for anticoagulation include warfarin, unfractionated heparin, and low molecular weight heparin. Warfarin carries risks of fetal complications if used in the first trimester, so alternatives like heparin are preferred during that period. Careful anticoagulant management throughout pregnancy and the peripartum period can help reduce risks to both mother and fetus.
1. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial or venous thrombosis or pregnancy morbidity in the presence of antiphospholipid antibodies.
2. The diagnosis requires one clinical criterion of vascular thrombosis or pregnancy complications and one laboratory criterion of positive testing for antiphospholipid antibodies on two occasions at least 12 weeks apart.
3. Treatment during pregnancy involves low-dose aspirin and heparin starting at a positive pregnancy test through 34 weeks gestation to reduce the risk of pregnancy complications like miscarriage, preeclampsia, and intrauterine growth restriction.
Management of Cardiovascular Disease during PregnancyM A Hasnat
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.
This document discusses pregnancy and valvular heart disease. It notes that pregnancy places significant strain on the heart and can negatively impact both mother and fetus if the mother has an existing heart condition. It provides details on physiological changes during pregnancy and delivery that impact the cardiovascular system. It then reviews specific valvular conditions like mitral stenosis, aortic stenosis, and mechanical heart valves. It recommends carefully planning and monitoring pregnancies for women with valvular disease, with vaginal delivery preferred in most cases depending on the severity of the condition. Close follow-up is important to monitor for complications.
1) The patient requires careful management of anticoagulation for her mechanical heart valve during pregnancy and delivery. She should receive adjusted-dose low molecular weight heparin throughout pregnancy.
2) A regional anesthetic technique could be used for her planned c-section, but her coagulation status and platelet count must be checked closely both before and after the procedure due to her anticoagulation.
3) After delivery, she will need to resume anticoagulation while monitoring closely for any signs of spinal hematoma due to her recent regional block and anticoagulated state.
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
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.
Cardiovascular diseases during pregnancy, european guidlines 2011Basem Enany
This document discusses cardiac signs, symptoms, and management during pregnancy. Some normal signs include palpitations, edema, and dizziness due to increased blood volume and heart rate. Abnormal signs like anasarca and syncope require evaluation. Testing like echocardiograms are generally safe in pregnancy but radiation exposure should be minimized. Conditions like pulmonary hypertension carry high risks, while repaired defects usually pose little risk. Medical management of valvular issues and heart failure aims to support volume and avoid hypotension.
Lecture by Dr Sujoy Dasgupta in BOGSCON 2015, the Annual Conference of Bengal Obstetric and Gynaecological Society, held at Hotel Novotel, Kolkata in January, 2015; where he had been invited as FACULTY to deliver his lecture
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.
Pulmonary hypertension is elevated pressures in the pulmonary vascular bed defined as a mean pulmonary artery pressure of ≥20 mmHg. The document discusses the pathophysiology, categorization, risk stratification, diagnosis and treatment of pulmonary hypertension. Risk stratification considers a mPAP ≥25 mmHg, PVR >3 Woods Units and PAWP ≤15 mmHg to determine who warrants treatment. Treatment includes vasodilator therapy targeting the prostacyclin, endothelin, and nitric oxide pathways.
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.
This document discusses critical care for obstetric patients. It begins with an introduction and epidemiology section noting that while the proportion of obstetric patients in ICUs is low, the most common reasons for admission are postpartum hemorrhage and hypertensive disorders. It then covers obstetric critical care, basic principles for obstetric emergencies, transfer to critical care settings, the role of obstetricians, resuscitative hysterotomy, and supportive care. It provides recommendations including prioritizing maternal stabilization, consulting obstetricians, and not withholding necessary treatments due to fetal concerns. The document aims to guide management of critically ill obstetric patients.
Thromboprophylaxis in pregnancy and puerperiumManju Puri
This presentation is about thromboprophylaxis in pregnancy and puerperium and describes the risk assessment , indications, drugs to be used, when to start, for how long to continue.
The document discusses the pathophysiology of cardiac tamponade and constrictive pericarditis. It describes the anatomy and functions of the pericardium. Cardiac tamponade occurs when fluid rapidly accumulates in the pericardial sac under pressure, compressing the heart and impairing ventricular filling. Constrictive pericarditis results from a thickened, rigid pericardium that restricts ventricular filling. Key differences in hemodynamics between the two conditions are outlined. Diagnosis relies on identifying features on echocardiogram and cardiac catheterization findings.
Pregnancy is associated with a 30-50% increase in cardiac output and blood volume that can exacerbate mitral stenosis symptoms. Women with mitral stenosis should be evaluated before pregnancy to determine if valvuloplasty or surgery is needed. Mild to moderate mitral stenosis can often be managed during pregnancy with diuretics and beta blockers, while those who fail medical management may require valvuloplasty between 22-26 weeks. Close monitoring is important during labor and delivery due to further increases in cardiac output.
Pulmonary atresia with intact interventricular septum Ramachandra Barik
PA/IVS is a rare congenital cardiac defect that consists of atresia of the pulmonary valve resulting in an absent connection between the right ventricular outflow tract (RVOT) and pulmonary arteries, and an intact ventricular septum that allows no connection between the right and left ventricles
This document discusses guidelines for the treatment of heart disease in pregnancy. It covers topics like pre-conception counseling, cardiovascular drug therapy in pregnancy, contraceptive methods for women with heart disease, and future perspectives. The guidelines recommend counseling women with cardiac conditions who want to get pregnant. They also provide guidance on the use of specific drugs in pregnancy like aspirin, amiodarone, ACE inhibitors, beta blockers, and discuss alternatives to warfarin. Management strategies are discussed for various heart conditions according to guidelines from ACC/AHA.
This document discusses peripartum cardiomyopathy (PPCM), defined as an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery. It affects 1 in 1,000-4,000 births in the US. Risk factors include age over 30, African descent, multiple pregnancies, preeclampsia, cocaine use, smoking, and selenium deficiency. Treatment involves diuretics, vasodilators, beta-blockers, anticoagulation, and in severe cases inotropes, bromocriptine, IVIG, or mechanical circulatory support. The cause is multi-factorial involving genetic, inflammatory, autoimmune and
1) The incidence of heart disease during pregnancy is around 1% with acquired heart diseases like rheumatic heart disease, cardiomyopathies, and ischemic heart disease being more common in developing countries.
2) Hemodynamic changes during pregnancy include a 40% increase in cardiac output by week 30-34 and a 30-40% increase in intravascular volume by week 32.
3) Peripartum cardiomyopathy has an incidence of 1 in 4,000 pregnancies and can result in severe congestive heart failure, often presenting in the third trimester or within 5 months postpartum.
Management of Pre-eclampsiaand eclampsia Case discussionsMouafak Alhadithy
The document discusses the management of pre-eclampsia and eclampsia, defining the conditions and outlining diagnostic criteria and treatment approaches. It provides case studies of patients presenting with hypertension in pregnancy and describes how to evaluate and treat the patients, including through antihypertensive medication, magnesium sulfate administration, and decisions around delivery timing and method. The goal of management is to terminate the pregnancy safely while restoring the health of both the mother and newborn.
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.
Management of Cardiovascular Disease during PregnancyM A Hasnat
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.
This document discusses pregnancy and valvular heart disease. It notes that pregnancy places significant strain on the heart and can negatively impact both mother and fetus if the mother has an existing heart condition. It provides details on physiological changes during pregnancy and delivery that impact the cardiovascular system. It then reviews specific valvular conditions like mitral stenosis, aortic stenosis, and mechanical heart valves. It recommends carefully planning and monitoring pregnancies for women with valvular disease, with vaginal delivery preferred in most cases depending on the severity of the condition. Close follow-up is important to monitor for complications.
1) The patient requires careful management of anticoagulation for her mechanical heart valve during pregnancy and delivery. She should receive adjusted-dose low molecular weight heparin throughout pregnancy.
2) A regional anesthetic technique could be used for her planned c-section, but her coagulation status and platelet count must be checked closely both before and after the procedure due to her anticoagulation.
3) After delivery, she will need to resume anticoagulation while monitoring closely for any signs of spinal hematoma due to her recent regional block and anticoagulated state.
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
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.
Cardiovascular diseases during pregnancy, european guidlines 2011Basem Enany
This document discusses cardiac signs, symptoms, and management during pregnancy. Some normal signs include palpitations, edema, and dizziness due to increased blood volume and heart rate. Abnormal signs like anasarca and syncope require evaluation. Testing like echocardiograms are generally safe in pregnancy but radiation exposure should be minimized. Conditions like pulmonary hypertension carry high risks, while repaired defects usually pose little risk. Medical management of valvular issues and heart failure aims to support volume and avoid hypotension.
Lecture by Dr Sujoy Dasgupta in BOGSCON 2015, the Annual Conference of Bengal Obstetric and Gynaecological Society, held at Hotel Novotel, Kolkata in January, 2015; where he had been invited as FACULTY to deliver his lecture
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.
Pulmonary hypertension is elevated pressures in the pulmonary vascular bed defined as a mean pulmonary artery pressure of ≥20 mmHg. The document discusses the pathophysiology, categorization, risk stratification, diagnosis and treatment of pulmonary hypertension. Risk stratification considers a mPAP ≥25 mmHg, PVR >3 Woods Units and PAWP ≤15 mmHg to determine who warrants treatment. Treatment includes vasodilator therapy targeting the prostacyclin, endothelin, and nitric oxide pathways.
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.
This document discusses critical care for obstetric patients. It begins with an introduction and epidemiology section noting that while the proportion of obstetric patients in ICUs is low, the most common reasons for admission are postpartum hemorrhage and hypertensive disorders. It then covers obstetric critical care, basic principles for obstetric emergencies, transfer to critical care settings, the role of obstetricians, resuscitative hysterotomy, and supportive care. It provides recommendations including prioritizing maternal stabilization, consulting obstetricians, and not withholding necessary treatments due to fetal concerns. The document aims to guide management of critically ill obstetric patients.
Thromboprophylaxis in pregnancy and puerperiumManju Puri
This presentation is about thromboprophylaxis in pregnancy and puerperium and describes the risk assessment , indications, drugs to be used, when to start, for how long to continue.
The document discusses the pathophysiology of cardiac tamponade and constrictive pericarditis. It describes the anatomy and functions of the pericardium. Cardiac tamponade occurs when fluid rapidly accumulates in the pericardial sac under pressure, compressing the heart and impairing ventricular filling. Constrictive pericarditis results from a thickened, rigid pericardium that restricts ventricular filling. Key differences in hemodynamics between the two conditions are outlined. Diagnosis relies on identifying features on echocardiogram and cardiac catheterization findings.
Pregnancy is associated with a 30-50% increase in cardiac output and blood volume that can exacerbate mitral stenosis symptoms. Women with mitral stenosis should be evaluated before pregnancy to determine if valvuloplasty or surgery is needed. Mild to moderate mitral stenosis can often be managed during pregnancy with diuretics and beta blockers, while those who fail medical management may require valvuloplasty between 22-26 weeks. Close monitoring is important during labor and delivery due to further increases in cardiac output.
Pulmonary atresia with intact interventricular septum Ramachandra Barik
PA/IVS is a rare congenital cardiac defect that consists of atresia of the pulmonary valve resulting in an absent connection between the right ventricular outflow tract (RVOT) and pulmonary arteries, and an intact ventricular septum that allows no connection between the right and left ventricles
This document discusses guidelines for the treatment of heart disease in pregnancy. It covers topics like pre-conception counseling, cardiovascular drug therapy in pregnancy, contraceptive methods for women with heart disease, and future perspectives. The guidelines recommend counseling women with cardiac conditions who want to get pregnant. They also provide guidance on the use of specific drugs in pregnancy like aspirin, amiodarone, ACE inhibitors, beta blockers, and discuss alternatives to warfarin. Management strategies are discussed for various heart conditions according to guidelines from ACC/AHA.
This document discusses peripartum cardiomyopathy (PPCM), defined as an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery. It affects 1 in 1,000-4,000 births in the US. Risk factors include age over 30, African descent, multiple pregnancies, preeclampsia, cocaine use, smoking, and selenium deficiency. Treatment involves diuretics, vasodilators, beta-blockers, anticoagulation, and in severe cases inotropes, bromocriptine, IVIG, or mechanical circulatory support. The cause is multi-factorial involving genetic, inflammatory, autoimmune and
1) The incidence of heart disease during pregnancy is around 1% with acquired heart diseases like rheumatic heart disease, cardiomyopathies, and ischemic heart disease being more common in developing countries.
2) Hemodynamic changes during pregnancy include a 40% increase in cardiac output by week 30-34 and a 30-40% increase in intravascular volume by week 32.
3) Peripartum cardiomyopathy has an incidence of 1 in 4,000 pregnancies and can result in severe congestive heart failure, often presenting in the third trimester or within 5 months postpartum.
Management of Pre-eclampsiaand eclampsia Case discussionsMouafak Alhadithy
The document discusses the management of pre-eclampsia and eclampsia, defining the conditions and outlining diagnostic criteria and treatment approaches. It provides case studies of patients presenting with hypertension in pregnancy and describes how to evaluate and treat the patients, including through antihypertensive medication, magnesium sulfate administration, and decisions around delivery timing and method. The goal of management is to terminate the pregnancy safely while restoring the health of both the mother and newborn.
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.
UPDATES ON HPT DISORDERS OF PREGNANCY by dr yahya.pptxMaryamYahya8
This document provides an overview of hypertensive disorders in pregnancy. It defines the main categories of hypertensive disorders such as chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. It discusses the pathophysiology, risk factors, diagnosis, and management of these conditions. Hypertensive disorders are a major cause of maternal and fetal morbidity and mortality worldwide. Accurate classification is important for optimizing care and reducing health risks.
This document discusses respiratory issues that can occur during pregnancy, including common causes of acute respiratory failure in pregnant women. Some key points include:
- Respiratory failure accounts for 40-50% of ICU admissions of pregnant women and has a 12% mortality rate.
- Hormonal and anatomical changes during pregnancy can affect the upper respiratory tract, lungs, and diaphragm.
- Common causes of respiratory failure mentioned include asthma, pneumonia, pulmonary edema, pulmonary embolism, aspiration, anemia, and peripartum cardiomyopathy.
- Management of conditions like asthma and cardiac arrest during pregnancy requires special considerations due to the risks to both mother and fetus. Fetal monitoring and timely delivery
Peripartum cardiomyopathy (PPCM) is heart failure that develops in the final month of pregnancy or within 5 months after delivery. It is defined by the presence of left ventricular systolic dysfunction without an identifiable cause. The cause is unknown but may involve hormonal and genetic factors. Symptoms include those of heart failure like shortness of breath. Treatment focuses on heart failure management. Prognosis is generally good, with around 70% of patients recovering heart function within 6 months though those with more severe dysfunction have a lower recovery rate.
Peripartum cardiomyopathy is defined as heart failure occurring in the last month of pregnancy or within 5 months after delivery without an identifiable cause. It results in left ventricular systolic dysfunction and signs of heart failure. While the cause is unknown, risk factors include age over 30, malnutrition, hypertension, and multiple births. Treatment involves managing heart failure symptoms along with anticoagulation. Prognosis varies, with 50-60% recovering within 6 months but risks of relapse remain if further pregnancy occurs.
The document discusses management of rheumatic diseases during pregnancy. It notes that remission of the rheumatic disease leads to healthy child in over 90% of cases. It provides screening recommendations and lists medications that are generally considered safe during pregnancy like hydroxychloroquine and low-dose aspirin. Specific rheumatic diseases like SLE, APS, and vasculitis are discussed in terms of risks during pregnancy and monitoring recommendations. Male fertility is also briefly covered.
This document discusses two placental factors - placenta previa and abruptio placenta. Placenta previa occurs when the placenta implants in the lower uterine segment, covering all or part of the internal cervical os. It commonly causes bleeding in the second half of pregnancy. Abruptio placenta is the premature separation of the placenta from the uterine wall, also commonly causing bleeding in the third trimester. Both conditions require careful monitoring and management to control bleeding and deliver a viable fetus. Maternal and fetal prognoses depend on gestational age, blood loss amount, and promptness of medical intervention.
This document discusses several medical disorders that can occur during pregnancy including hypertension, preeclampsia, chronic essential hypertension, gestational hypertension, renal disease, and cardiac disease. It provides details on the pathophysiology, diagnosis, risk factors, treatment and management of these conditions. Medical care has advanced to allow more women with serious medical problems to become pregnant, but these disorders can increase risks for both mother and fetus. Careful monitoring and treatment are important to balance health risks.
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 hypertension in pregnancy. It begins by defining hypertension as a systolic blood pressure of 140 mmHg or higher and/or a diastolic blood pressure of 90 mmHg or higher, measured at least twice 4 hours apart. It then notes that hypertension complicates 14.8% of pregnancies and is a leading cause of maternal death. The document covers classification of hypertension in pregnancy, prediction and prevention strategies like aspirin and calcium supplementation, management of different types of hypertension during pregnancy including chronic hypertension and preeclampsia, and postnatal care.
Postpartum management of hypertensive disorders in pregnancychaimingcheng
This document discusses postpartum hypertension, which remains a challenge even after childbirth. It notes that hypertension was the fourth leading cause of maternal death in Malaysia from 2006-2008, accounting for 15.4% of deaths. It emphasizes the need for close monitoring and treatment of postpartum hypertension to prevent complications like cerebral hemorrhage. Effective treatment and management both in the hospital and after discharge are important to reduce maternal morbidity and mortality from postpartum hypertensive disorders.
Hypertensive disorder in pregnancy - DIAGNOSIS AND MANAGEMENTAhmadShukri48
This document discusses hypertensive disorders in pregnancy. Some key points:
- Hypertensive disorders in pregnancy (HDP) include pre-eclampsia, gestational hypertension, chronic hypertension, and pre-eclampsia superimposed on chronic hypertension.
- Risk factors for HDP include maternal age <20 or >35, primigravidity, obesity, multiple gestation, and chronic medical conditions.
- Mild HDP can often be managed as outpatients with close monitoring if blood pressures are below 160/100 mmHg and there is no proteinuria or other complications. Inpatient admission is indicated for more severe cases or if complications develop.
- Management involves frequent monitoring of blood pressures,
CVS Drugs in pregnancy-Dr. Swapan Sur.pptxhakimnasir3
This document discusses cardiovascular drug use and management of cardiovascular conditions during pregnancy. It notes that ACE inhibitors, ARBs, renin inhibitors, statins, warfarin in the 1st trimester, and amiodarone are FDA Category X drugs and should be avoided during pregnancy. Warfarin in the 2nd/3rd trimester, heparin, and LMWH are preferred anticoagulants. Conditions such as pulmonary hypertension and severe heart failure carry a high risk of pregnancy. Medical management focuses on afterload reduction, rate control, and diuretics when possible.
This document discusses obstetric embolism, including amniotic fluid embolism (AFE) and venous thromboembolism (VTE). It provides data on maternal deaths in Malaysia from these causes from 2006-2012. It also outlines risk factors for VTE in pregnancy, signs and symptoms, diagnostic methods, and treatment guidelines involving low molecular weight heparin, unfractionated heparin, or warfarin. Strategies to reduce VTE risk include modifying risks factors before pregnancy, awareness and guidelines, and risk-based management during pregnancy and postpartum.
Antepartum hemorrhage (APH) is bleeding from the genital tract during pregnancy before labor. It affects 4% of pregnancies and can cause complications for both mother and fetus. The main causes are placenta previa, placental abruption, and local infections. Management depends on severity, with minor bleeding monitored but major bleeding requiring delivery to stabilize the mother or fetus. Expediting delivery preserves the health of both.
Thromboprophylaxis need of hour for indian womenLifecare Centre
This document discusses thromboprophylaxis (prevention of blood clots) during pregnancy and the postpartum period for Indian women. It notes that while blood clots are generally not thought to occur often in Indian women, they can and do sometimes happen. Two case examples are described where women died of pulmonary embolisms after delivery despite appearing to recover well. The document emphasizes the need for thromboprophylaxis, especially for women at higher risk. It provides guidance on assessing risk factors and managing prophylaxis during pregnancy, delivery, and postpartum. Low molecular weight heparin is recommended over unfractionated heparin for safety and ease of use.
Hypertensive disorders in pregnancy remain a common cause of maternal death worldwide. In Malaysia, it is the third most common cause of maternal death. The goals of managing preeclampsia are to prolong pregnancy for fetal maturity while preventing complications, effectively prevent and manage eclampsia, and ensure optimal preeclampsia treatment. Risk factors for preeclampsia include primigravida, age over 40, previous preeclampsia, chronic hypertension, diabetes, and family history. Low dose aspirin and calcium supplements can help prevent preeclampsia in high risk women.
This document summarizes the case of a 42-year-old, 137 kg female patient at 38 weeks gestation with severe aortic stenosis and chronic hypertension admitted for induction of labor due to increasing shortness of breath. Key issues include managing the patient's comorbidities during labor and delivery while maintaining hemodynamic stability given her fixed cardiac output from aortic stenosis. Anesthetic plans focus on careful titration of regional techniques or general anesthesia to prevent rapid hemodynamic changes.
This document summarizes hypertension and hypertensive disorders in pregnancy. It discusses normal hemodynamic changes in pregnancy, classification and treatment of hypertension, preeclampsia and eclampsia. Conditions like acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura-hemolytic uremic syndrome and systemic lupus erythematosus flares are also mentioned as they can present similarly to preeclampsia/eclampsia. First line antihypertensive agents during pregnancy include methyldopa, labetalol and nifedipine. Delivery is the only cure for preeclampsia.
Similar to Pregnancy with pulmonary hypertension (20)
Maternal collapse is a life-threatening medical emergency defined as an acute event involving the cardiorespiratory systems and brain in a pregnant or recently pregnant woman, resulting in a reduced or absent level of consciousness. Prompt resuscitation is essential, beginning with shaking and shouting to assess responsiveness, calling for help, providing oxygen, and performing CPR with manual left uterine displacement. If there is no return of spontaneous circulation after 4 minutes of CPR, perimortem cesarean section should be performed within 5 minutes. Thorough documentation, incident reporting, training, and debriefing are important for clinical governance following maternal collapse. Outcomes depend on the underlying cause, location, speed of response, and provider skills
1) The document discusses guidelines for pregnant women with cardiac diseases fasting during Ramadan.
2) It notes that Islamic law exempts pregnant and breastfeeding women from fasting if it could harm their health or the baby's health.
3) The document outlines factors to consider before fasting such as gestation, nutrition status, pre-existing conditions, and outlines symptoms that require breaking the fast.
This document provides information on urinary catheterization including the types, parts, indications, procedures, and complications of catheterization. It discusses the different types of catheters including intermittent, external, and indwelling catheters. It describes how to properly insert a transurethral catheter and notes key steps like explaining the procedure to the patient, gathering supplies, cleaning the area, lubricating the catheter, and inflating the balloon. Potential complications of catheterization like urinary tract infections are also reviewed.
This document discusses maternal collapse during pregnancy and the postpartum period. It begins by defining maternal collapse as an acute event involving the cardiorespiratory and central nervous systems that results in a reduced or absent level of consciousness. Prompt resuscitation is important for outcomes. Incidence is estimated at 0.14-6 per 1,000 births. The ABCDE approach and basic life support are emphasized, including chest compressions, assisted ventilation, defibrillation if needed, and consideration of perimortem cesarean section if no return of spontaneous circulation after 4 minutes of resuscitation efforts. Training, documentation, incident reporting and debriefing are important aspects of clinical governance following a maternal collapse.
The document discusses the concept of hijab in Islam. It defines hijab as meaning "to hide from view, conceal, or cover something" and that it includes the complete modest dress of a woman. It outlines six criteria for hijab, such as loose fitting clothes that do not reveal figure and do not resemble clothing of non-believers. The document provides verses from the Quran and sayings of Prophet Muhammad to explain that hijab is more than just a headscarf and involves modest conduct and speech.
This document discusses anemia in pregnancy. It defines anemia and provides prevalence rates. It describes physiological changes in blood during pregnancy. It discusses severity of anemia and classifications. Iron deficiency anemia is the most common type and the document outlines iron absorption, requirements, and prevention. Signs, effects, diagnosis and treatment of anemia in pregnancy are also summarized.
Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that can cause long-term complications if not treated promptly. It is usually caused by bacteria spreading from the vagina or cervix, such as Chlamydia trachomatis and Neisseria gonorrhoeae. Left untreated, PID can lead to infertility, ectopic pregnancy, chronic pelvic pain, and increased risk of HIV transmission. Treatment involves a combination of antibiotics to cover common causative organisms, with hospitalization recommended for severe cases. Prompt treatment is important to prevent long-term complications.
An obstetric history should include details of the current pregnancy, past obstetric and medical history, family history, social history, and review of systems. The examination involves evaluation of vital signs, general appearance, breast and abdominal exams to assess size and position of the uterus and fetus. Fetal heart rate and engagement should be determined. [/SUMMARY]
The document discusses intrauterine fetal demise (IUFD), defined as the death of a fetus weighing over 500g or over 24 weeks gestation before the onset of labor. It notes that the cause is unknown in 25-60% of cases. Identifiable causes include maternal conditions like diabetes or hypertension, fetal conditions like birth defects or infections, and placental conditions like abruption or insufficiency. Evaluation of an IUFD involves examining the mother's medical history and current pregnancy, evaluating the stillborn infant, investigating the placenta, and certain laboratory tests. Management depends on factors like gestation, number of fetuses, and the parents' wishes regarding expectant or active management such as labor induction. Complications can
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
1. PREGNANCY WITH PULMONARY HYPERTENSION
PROFESSOR SHABNAM NAZ
MBBS (MEDALIST)MCPS,FCPS
OBGYN
CMC,SMBB MEDICAL UNIVERSITY LARKANA
2. WHAT THE OBSTETRICIAN
KNOW ABOUT THE PULMONARY
HYPERTENSION IN PREGNANCY
• WHAT IS PULMONARY HYPERTENSION
• CLINICAL FEATURES SUGGESTIVE OF DIAGNOSIS
• INVESTIGATIONS HELP FUL IN DIAGNOSIS
• MORTALITY RATE AND WHY HIGH MORTALITY
• WHICH CONTRACEPTION IS SAFE
• SAFETY OF DRUGS IN PREGNANCY
• TIME OF DELVERY
• MODE OF DELVERY
• WHICH ANALGESIA / ANESTHESIA IS USED
• BRESTFEEDING
• FOLLOW UP
OBJECTIVES
3. You are registrar Incharge of high
risk opd you received a women
who is 7 weeks pregnant with
one paper which shows she is K/C
of pulmonary HTN , NYHA class ii
and on bosentan and warfarin
DANGER
CASE
4. Q ASKING. FROM HER
IS THIS UR PLANNED PREGNANCY?
IF NO ---ARE YOU HAPPY TO CONTINUE THIS PREGNANCY?
DID U RECEIVED PRE-PREGNANCY COUNSELING?
HAVE U STARTED FOLIC ACID?
CAN YOU TELL ME MORE ABOUT YOUR HEART PROBLEM
WHEN DID YOU SEE YOUR DOCTER LAST TIME ,
WHAT DID HE SAY ABOUT YOUR CONDITION,
ANY RECENT TEST HAD DONE HEART TRACE AND ULTRASOUND OF
HEART ( ECG ECHO ,) R THEY NORMAL ,
WHAT MEDICATIONS ARE U TAKING . R U TAKING IT REGULARY
ANY RECENT ADMISSION TO HOSPITAL ?
HOW ARE YOU NOW, R U ABLE TO DO ROUTINE HOUSE CHORE, ANY
SOB, ANY SLEEP DISTRUBANCE DUE TO SOB, R U ABLE TO CLIMBS
STAIRS COMFORTABLY ?
DO U FEEL PAIN IN CHEST OR IN TUMMY , ANY FAINTING OR LIGHT
HEADEDNES DO U NOTICE ANY CHANGE IN HEART BEAT OR
APPETITE
ANY LEG AND ANKLE SWELLING.
Past obstetrical history
Menstrual history lmp , cervical smear ,
contraception
Medical history apart from this heart problem
other medical problem ,any blood clot in leg
Surgical history any surgery in past
Family history --- family history of concerns
( especially heart disease in family ,blood clot )
Drug history a part from bosentan and
warfarin are you taking any other medications
are u allergic to drug F.A/MV/ASPIRINE
Social history (support)
do you smoke, drink, recreational drugs
5. she need termination of preg -----tell in her own
language so she understand
actually I have to give some serious information before you take
this decision about this pregnancy
Pulmonary hypertension (PH) means high blood
pressure in the lungs,.
Every pregnant women who are completely healthy there heart —
becomes overloaded with work during pregnancy and even more so
during labor and delivery.
In a patient who suffers from pulmonary hypertension and whose heart is
already under stress, the risks are particularly high and could result in the
death of the mother.
we strongly recommend to end this pregnancy ,how ever its up to
you ,decision is yours , and we will support you whether you want
to continue the pregnancy or you want to go for termination,
6. maternal risk ------she may have problems with her and her baby, like,
heart failure ,
icu admission
Increase need of ,oxygen ,
Increased chances of blood to clot ,
long term hospital admission ,
early delivery, high risk of death during pregnancy
we care about your life we don't want to lose you , we may decide to end
pregnancy if your health is compromised at any stage
fetal risk u may miscarry or
ur baby may not grow well
there is small increase risk of early delivery and problems of early
delivery
7. antenatal care Look if you want to continue with this pregnancy we will
support you in all the way ,
your ANC will be in consultant led unit clinic ,
your care will be shared by MDT group of specialist team includes,heart doctor,
consultant obstetrician , icu consultant,anesthetist ,paediatrician
I would recomand you to refer u urgently to cardiologist he will review your
condition and review ur drugs u may need change of drugs
bcs boseton and warfarin are not safe for baby , you may need blood thinning
injections inspite of warfarin ,its unlikely that baby is effected by warfarin. if you
continue we will refer you to FMU for anomaly scan,
I will arrange an urgent appointment with consultant cardiologist
These are some patient information leaflets it will be helpful
8. PULMONARY HYPERTENSION
• Pulmonary hypertension is a challenging disease to diagnose, accurately
classify, and treat.
• (PH) is defined at cardiac catheterization as a mean pulmonary artery
pressure (mPAP) of at least or >25 mmHg at rest
• IPAH is a severe, progressive disease with an incidence of 1–2 cases per
million of population / year
• and is three times more common in women.
• With “conventional” treatment, it has a median survival time of 2.8 years
from diagnosis; however, with new therapies there has been a doubling of
the survival time.
• Younger patients have seen the greatest improve-ment in outcome, with 5-
year survival approximating 80% in patients with IPAH
9. Classification of pulmonary
hypertension
Group 1, pulmonary arterial
hypertension (PAH);
Group 2, PH owing to left heart
disease (PH-LHD);
Group 3, PH owing to lung disease
and or hypoxia;
Group 4, chronic thromboembolic
pulmonary hypertension (CTEPH)
and
Group 5, unclear or multifactorial
aetiologies
10. HOW DO I MAKE THE DIAGNOSIS?
• The majority of patients with PH who are pregnant will
have an established diagnosis.
• However, this diagnosis should be considered in pregnant
patients with increasing breathlessness in the first
trimester, particularly if significant and associated with
syncope.
• The classic symptoms of PH include fatigue and
progressive exertional breathlessness. As the disease
progresses, patients may develop exertional pre-syncope
and syncope, which are usually indicators of severe
disease.
• Exertional chest tightness similar to angina may occur
but
• ankle oedema is a late feature.
Signs
Tachycardia
Elevated jugular venous pressure
Right ventricle heave
Loud P2
Pansystolic murmur from tricuspid regurgitation
Pulmonary diastolic murmur from pulmonary
regurgitation
Hepatomegaly ± pulsation
Ascites
Peripheral edema
11. Investigations
• It is absolutely essential that if a diagnosis of PH is suspected, patients are referred to
specialists experienced in the assessment of PH to confirm or refute the diagnosis.
• Electrocardiogram (ECG) and chest X-ray (CXR) may be abnormal in up to 90% of cases
with severe disease but cannot be used in clinical practice to exclude PH.
• Echo--The diagnosis is usually suggested by echocardiography--- mPAP of at least
25 mmHg, dilated right ventricle with reduced function and may identify a cause of PH such
as LHD. In patients with IPAH, the sPAP is often in excess of 70 mmHg.
• CT pulmonary angiography (CTPA) performed for other reasons such as suspected
pulmonary embolism.
• Review of the CT may show evidence of pulmonary artery enlargement and dilated right-
sided chambers,
12. Investigation
Imaging
Chest X-ray
Ventilation perfusion scanning
Lung hypofractionated conformal radiotherapy
Contrast helical CT pulmonary arteries
Cardiac magnetic resonance imaging and angiography
Pulmonary
Pulmonary angiogram (in selected cases)
Arterial blood gases
Lung function
Nocturnal oxygen saturation monitoring
Exercise test (6-min walk/shuttle)
Cardiology
Electrocardiogram
Echocardiography
Cardiac catheterization
Cardiology blood
Routine hematology and biochemistry
Thrombophilia screen
13. risk of maternal death patient
with P.H
• So the risk of maternal death
remains very high.
• For those with severe P.H and
poorly controlled disease, the
risk will be significantly higher.
•
Before2004,the mortality of P.H
in pregnancy was estimated at
30–50%, but studies since then
suggest that improved therapy
may have reduced it to 20–30%.
Women with pulmonary arterial
hypertension—irrespective of
etiology—should be advised of
the very high risks of pregnancy
and be given clear advice
about contraception
14. WHY IS THE RISK OF MATERNAL
DEATH SO HIGH?
this is bcs of interplay between cardiovascular stresses
with complex physiological changes occurring during
pregnancy and the compromised right ventricular
function and abnormal vasculature seen in these
patients.
1. increase Cardiovascular demands
2. Direct effects on the pulmonary vasculature
3. Acute changes in blood volume around delivery
and effects on compromised right ventricular
function. The third stage of labour with delivery of
the placenta and uterine contraction can release up
to 500 ml of blood into the circulation.Delivery also
results in decompression of the aorta and venous
system, with an increase in venous return.
4. Thrombosis
5 Other factors
The stress of coping with a normal
pregnancy is exacerbated in patients and
their families by the presence of any
medical condition where the risk of
maternal death is high.
A number of issues may affect compliance,
often with complex therapies and
management plans. The need for
assessments by experienced physicians
able to understand subtle changes and a
lack of randomised controlled trial data on
how to manage these pregnancies
contribute to a cocktail that may have
disastrous consequences.
15. • What forms of contraception can be used
in patients with pulmonary hypertension?
• Progesterone-only contraceptives ( cerazette ),
• nexplanon (implant) FOR 3 YEARS
• depot-provera (every 3 months)
• Nexplanon has the advantage that the individual does not
need to remember daily medication or 3-monthly
injections. These drugs can be taken in patients prescribed
warfarin although care needs to be taken with
intramuscular injections.
• The Mirena intra-uterine system is highly effective and
helpful in women with heavy periods. The risk of vasovagal
events, which can be dangerous in PH, mandates that these
devices be inserted in a hospital.
16. • Periodic abstinence and condoms are not
recommended as a sole form of
contraception,
• . Female sterilization is generally not
recommended as it requires an
anesthetic although for appropriately
counselled patients, it can be performed
at the time of Caesarean section.
• Importantly the endothelin receptor
blocker bosentan (but not ambrisentan)
is an enzyme inducer so that for patients
taking cerazette or nexplanon, we
recommend an additional tablet of
cerazette.
• Emergency hormonal contraception is
safe for unprotected intercourse but a
double dose is required in patients taking
bosentan.
18. When should I deliver a pt with pulmonary hypertension / TOD
• This is primarily dependent on the health of the
mother and also the health of the foetus.
• deterioration in the first two trimesters is
associated with a poor outcome and these
patients require termination/delivery to save
the life of the mother.
• If the patient remains stable during pregnancy,
there is an risks of premature Labour at a site
distant from the specialist center, where the
personnel and monitoring facilities may not be
optimal so Our approach is to deliver at around
34 weeks .
• This will be influenced by the mother’s previous
obstetric history, progress in the current preg
foetal growth, geographical issues and the
wishes of the patient and their families.
19. • We recommend elective Caesarean section.
• An elective procedure allows all members of MDT to
be present at a time when circumstances are optimal
and there is access to ICU beds for mother and
neonate.
• It allows experienced surgeons to perform the
procedure, minimizing blood loss and allowing
maneuvers to avoid use of vasoactive drugs by use of
bimanual compression and suture compression of
the uterus as appropriate.
• MDT MEMBERS. a pulmonary vascular physician,
two obstetric anaesthetists, two experienced
obstetricians, a paediatrician, an intensivist, a
midwife in addition to other members of the theatre
team are all present.
What mode of delivery ? Vaginal delivery versus Caesarean section.
20. Vaginal delivery
• is advocated by some but this is accompanied
by a 34% increase in cardiac output when the
cervix is fully dilated.
• This can be ameliorated but not abolished by
the use of regional anesthesia.
• Pushing in the second stage of pregnancy can
significantly reduce cardiac output by reducing
venous return to the right ventricle, which
could have deleterious consequences.
• Given the trend towards pre-term delivery,
induction of pregnancy could result in a long
labour and the prospect of an emergency
Caesarean section in this setting would be a
significant undertaking
21. • Regional versus general anaesthesia
• Single shot spinal should be avoided, given the high
risk of developing significant hypotension.
• Epidural anaesthesia and combined spinal-epidural
anaesthesia are usually advocated, with the latter
providing the advantages of a low spinal block with
a denser sensory block than an epidural, but
avoiding the risk of hypotension with a spinal.
• Regional anaesthesia also has the advantage of
providing post-operative analgesia and importantly
for patients with, for example bleeding
complications, capacity for top up anaesthesia and
ease of return to theatre.
• General anaesthesia has also been used
successfully by a number of centres however, rises
in pulmonary artery pressure are known to occur at
tracheal intubation and positive pressure
ventilation can have negative effects on venous
return.
22. Are there any drugs I should use cautiously in patients with
pulmonary hypertension?
• Anticoagulation is routinely prescribed out with pregnancy in
patients with IPAH
• In pregnancy, the risks and benefits are discussed with
individual patients.
• give prophylactic doses of LMWH in IPAH, full dose twice
daily LMWH in CTEPH with prophylactic doses of LMWH
given the night before surgery and the night after
• Oxytocic drugs can cause hypotension and tachycardia so give
as a low-dose infusion of syntocinon at 5 units over 1 h,
repeated as necessary..
23. How should I follow-up a patient following delivery?
• Patients are usually monitored in an
ITU/HDU setting ------for 5–7 days and if
stable, discharged shortly thereafter.
• stable patients are reviewed usually at
• 1 week,
• then fortnightly,
• then monthly,
• then 3 monthly.
24. IS BREAST FEEDING RECOMMENDED?
• There are no data on drugs
used to treat PH and
whether they cross into
the breast milk.
• Due to uncertainty
regarding this and the
effects on a neonate, we
advise against this.
25. • Patients with pulmonary hypertension should be advised of the high risks of pregnancy with
clear and comprehensive contraceptive advice and if needed be offered termination of
pregnancy.
• Despite being fully counselled regarding the high risk, patients may actively plan to become
pregnant or may present for the first time in pregnancy with a new diagnosis of pulmonary
hypertension.
• The advent of new therapies for specific forms of pulmonary hypertension, improvements in
obstetric care and a multi-professional approach to the management has improved survival
and outcome.
• Despite these advances, patients may have difficulties adhering to management plans and
despite optimal strategies, pregnancy may ultimately result in the death of both the mother
and unborn child.
• The potential impact that this has on family members and staff should not be underestimated.
CONCLUSION
26. 1. Simonneau G, Robbins IM, Beghetti M, et al. Updated
clinical classification of pulmonary hypertension. J Am
Coll Cardiol 2009;
2. Kiely DG, Elliot CA, Sabroe I, et al. Pulmonary
hypertension: diagnosis and management. BMJ 2013; 16,
346:f2028 DOI: 10.1136/bmj.f2028
3. Hurdman J, Condliffe R, Elliot CA, et al. ASPIRE
registry: Assessing the Spectrum of Pulmonary
hypertension Identified at a REferral centre. Eur Respir
J 2012;
4. Peacock AJ, Murphy NF, McMurray JJ, et al. An
epidemiological study of pulmonary arterial
hypertension. Eur Respir J 2007;
5. Condliffe R, Kiely DG, Gibbs JS, et al. Improved
outcomes in medically and surgically treated chronic
thromboembolic pulmonary hypertension. Am J Respir Crit
Care Med 2008;
6. Humbert M, Sitbon O, Chaouat A, et al. Pulmonary arterial
hypertension in France: results from a national registry. Am J
Respir Crit Care Med 2006;
7. Ling Y, Johnson MK, Kiely DG, et al. Changing demographics,
epidemiology, and survival of incident pulmonary arterial
hypertension: results from the pulmonary hypertension registry of
the United Kingdom and Ireland. Am J Respir Crit Care
Med 2012;
8. Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic
thromboembolic pulmonary hypertension after pulmonary
embolism. N Engl J Med 2004; 350: 2257–2264.
9. Kiely DG, Condliffe R, Webster V, et al. Improved survival in
pregnancy and pulmonary hypertension using a multiprofessional
approach. BJOG 2010; 117: 565–574.
10. Gleicher N, Midwall J, Hochberger D, et al. Eisenmenger's
syndrome and pregnancy. Obstet Gynecol Surv 1979; 34(10):
721–741.
REFERENCES