Heart Disease & Heart Disease & PregnancyPregnancy

Pregnancy places an additional Pregnancy places an additional strain on the heart due to the strain on the heart due to the cardiovascular changes that occur cardiovascular changes that occur due to the physiological due to the physiological adaptation to pregnancyadaptation to pregnancy..

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There is steady increase in blood volume reaching There is steady increase in blood volume reaching 40% increase by 36 weeks40% increase by 36 weeks..

Parallel with the increase in volume there is an Parallel with the increase in volume there is an increase in cardiac out put due to increase of both increase in cardiac out put due to increase of both stroke volume & heart rate (c.o.p. increases from 3-stroke volume & heart rate (c.o.p. increases from 3-5L to 6-7.5 L)5L to 6-7.5 L)..

Also immediately after delivery there is a transient Also immediately after delivery there is a transient increase after delivery of the placenta & retraction increase after delivery of the placenta & retraction of the uterusof the uterus..

There is marked reduction in peripheral resistanceThere is marked reduction in peripheral resistance..Blood pressure fall rather than increase & reaches Blood pressure fall rather than increase & reaches

its lowest level at the end of the second trimesterits lowest level at the end of the second trimester . .

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Incidence Incidence about 0.5-1% about 0.5-1%

AetiologyAetiology-: -: 11 ) )70%70% of cases are of rheumatic origin of cases are of rheumatic origin

usually causing mitral stenosis with usually causing mitral stenosis with mitral or aortic regurgitation being less mitral or aortic regurgitation being less commoncommon..

22 ) )25%25% are due to congenital defects. in are due to congenital defects. in some developed countries it reaches some developed countries it reaches 50% of cases (decline in rheumatic fever 50% of cases (decline in rheumatic fever & increase survival due to surgery )& increase survival due to surgery )..

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The commonest malformation areThe commonest malformation are-: -: Patent ductus arteriosus, atrial Patent ductus arteriosus, atrial

septal defect, ventricular septal septal defect, ventricular septal defect, coarctation of the aorta, defect, coarctation of the aorta, pulmonary stenosis, fallots tetralogy, pulmonary stenosis, fallots tetralogy, aortic stenosis & eisenmengers aortic stenosis & eisenmengers syndromesyndrome..

33 ) )5%5% due to other causes like due to other causes like disorder of rhythm, cardiomyopathy, disorder of rhythm, cardiomyopathy, thyrotoxicosis, aneamiathyrotoxicosis, aneamia..

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ComplicationsComplications

Cardiac disease is a major cause of Cardiac disease is a major cause of maternal mortality due to heart maternal mortality due to heart failure & increase incidence of failure & increase incidence of venous thrombosis & pulmonary venous thrombosis & pulmonary embolismembolism..

Unless heart failure develop cardiac Unless heart failure develop cardiac disease does not alter the perinatal disease does not alter the perinatal mortality but there is high incidence mortality but there is high incidence of IUGR & preterm labourof IUGR & preterm labour..

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Assessment of cardiac Assessment of cardiac function in pregnancyfunction in pregnancy

The physiological change associated with The physiological change associated with pregnancy give rise to symptoms & sign which pregnancy give rise to symptoms & sign which may cause confusion in the assessment of may cause confusion in the assessment of cardiac disorder such as dyspnoea, tachycardia cardiac disorder such as dyspnoea, tachycardia ,ankle oedema ,soft ejection murmur,ankle oedema ,soft ejection murmur..

The heart of every pregnant women should be The heart of every pregnant women should be auscultated at the first antenatal visitauscultated at the first antenatal visit. .

Any suspicious sign like grade 3 systolic Any suspicious sign like grade 3 systolic murmur any diastolic murmur marked murmur any diastolic murmur marked disturbance of rate & rhythm require further disturbance of rate & rhythm require further investigation preferably by cardiologist ,ECG, investigation preferably by cardiologist ,ECG, echocardiographyechocardiography. .

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The functional capacity or the functional reserve of The functional capacity or the functional reserve of the heart should be assessed because it is usually the heart should be assessed because it is usually more important than the anatomical nature of the more important than the anatomical nature of the lesionlesion..

New york heart disease association proposed four New york heart disease association proposed four gradesgrades..

Class1:- no limitation of physical activityClass1:- no limitation of physical activity..Class2:- slight limitation of activity ordinary activity Class2:- slight limitation of activity ordinary activity

causes fatigue ,palpitation ,dyspnoea ,& anginal paincauses fatigue ,palpitation ,dyspnoea ,& anginal pain..Class3:- marked limitation of physical activity Class3:- marked limitation of physical activity

symptoms occur with less than ordinary activitysymptoms occur with less than ordinary activity. . Class4:- inability to carry any physical activity Class4:- inability to carry any physical activity

without discomfort ( dyspnoea at rest)without discomfort ( dyspnoea at rest)

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Management.Management.Antenatal managementAntenatal management

Aim is to prevent heart failure & to detect obstetric complications Aim is to prevent heart failure & to detect obstetric complications & to minimize them where possible& to minimize them where possible. .

General managementGeneral management--:--:11 ) )ideally should be seen at a joint clinic by cardiologist and an ideally should be seen at a joint clinic by cardiologist and an

obstetricanobstetrican. . 22 ) )visit need to be more frequent at least fortnightly in the first visit need to be more frequent at least fortnightly in the first

half of pregnancy and weekly in the second halfhalf of pregnancy and weekly in the second half..33 ) )in each visit she should be asked aboutin each visit she should be asked about. .

----any increase in her shortness of breathany increase in her shortness of breath. . ----any increase in exercise toleranceany increase in exercise tolerance. .

-- --tachycardiatachycardia. . ----any marked increase in tirednessany marked increase in tiredness. .

-- --fetal movementfetal movement..Examination should always include pulse rate, rhythm, blood Examination should always include pulse rate, rhythm, blood

pressure jvp lung base ,increased sacral or ankle oedema pressure jvp lung base ,increased sacral or ankle oedema liver ,fundal hieght and fetal growthliver ,fundal hieght and fetal growth..

A careful watch of pregnancy complications like PIH ,UTI, chest A careful watch of pregnancy complications like PIH ,UTI, chest infection, bacterial endocarditis atrial fibrillation and anaemiainfection, bacterial endocarditis atrial fibrillation and anaemia

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44 ) )out patient management is used but if there out patient management is used but if there are any signs of heart failure ,infection ,grade3 are any signs of heart failure ,infection ,grade3 &4 disease ,obstetric complications indicate &4 disease ,obstetric complications indicate admission to hospitaladmission to hospital..

55 ) )adequate rest is essential with at least 9 hours adequate rest is essential with at least 9 hours at night & rest in bed in the afternoonat night & rest in bed in the afternoon..

66 ) )dietary supervision ensuring reasonable dietary supervision ensuring reasonable protein ,vitamin ,& iron intake & because of the protein ,vitamin ,& iron intake & because of the additional cardiac strain imposed by anaemia additional cardiac strain imposed by anaemia prophylactic iron & folic acid is indicatedprophylactic iron & folic acid is indicated..

77 ) )infection must be avoided . The onset of any infection must be avoided . The onset of any intercurrent infection even corysa is an intercurrent infection even corysa is an indication of hospital treatment . Complete indication of hospital treatment . Complete dental care & tooth extraction should be under dental care & tooth extraction should be under antibiotic coverantibiotic cover

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Specific managementSpecific managementSimilar to that for the non pregnantSimilar to that for the non pregnant. .

11 ) )digoxin:- indicated primarily in patient with digoxin:- indicated primarily in patient with atrial fibrillation & acute heart failure. atrial fibrillation & acute heart failure. Prophylactic therapy is sometime advocated but Prophylactic therapy is sometime advocated but evidence infavour of this is not strongevidence infavour of this is not strong..

22 ) )diuretics:- thiazide diuretics can be used in diuretics:- thiazide diuretics can be used in chronic congestive failure with k chronic congestive failure with k supplement .frusemide is required for acute heart supplement .frusemide is required for acute heart failurefailure..

33 ) )beta adrenargic blocker may be required for beta adrenargic blocker may be required for dysrhythmiadysrhythmia. .

44))aminophylline is of considerable value in aminophylline is of considerable value in alleviation of broncho spasm & pulmonary oedemaalleviation of broncho spasm & pulmonary oedema

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55 ) )heparin is indicated in patient with prosthetic heparin is indicated in patient with prosthetic valve, atrial fibrillation & pulmonary hypertensionvalve, atrial fibrillation & pulmonary hypertension. .

66 ) )in acute pulmonary oedema morphine, oxygen, in acute pulmonary oedema morphine, oxygen, digoxin, lasix, & aminophyllinedigoxin, lasix, & aminophylline..

77))cardic surgery:- with close surgery (mitral cardic surgery:- with close surgery (mitral valvotomy) there is little increase risk for the fetus valvotomy) there is little increase risk for the fetus but open surgery involving cardio pulmonary by but open surgery involving cardio pulmonary by pass result in increase incidence of fetal losspass result in increase incidence of fetal loss..

Indication of surgery is recurrent pulmonary Indication of surgery is recurrent pulmonary oedema in association with predominant mitral oedema in association with predominant mitral stenosis occuring early in pregnancy and with stenosis occuring early in pregnancy and with failure to respond to medical treatmentfailure to respond to medical treatment. .

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--mitral stenosis ---mitral valvotomymitral stenosis ---mitral valvotomy..--ligation of patent ductus arteriosusligation of patent ductus arteriosus..

--closure of atrial & ventricular septal defects are difficult closure of atrial & ventricular septal defects are difficult during pregnancy. Best result of surgery is obtained during pregnancy. Best result of surgery is obtained between 16 & 20between 16 & 20thth week of pregnancy week of pregnancy..

88 ) )therapeutic abortiontherapeutic abortion-:-:With increase sophistication of cardiac surgery the need With increase sophistication of cardiac surgery the need

for therapeutic abortion has been reduced . It should be for therapeutic abortion has been reduced . It should be reserved for those women in the first 20reserved for those women in the first 20thth week of week of pregnancy who remain in grade 3&4 despite medical pregnancy who remain in grade 3&4 despite medical treatment & who are assessed as unsuitable for surgerytreatment & who are assessed as unsuitable for surgery..

Termination is also may be indicated for patient with Termination is also may be indicated for patient with cynotic heart disease ,primary or secondary pulmonary cynotic heart disease ,primary or secondary pulmonary

hypertension , or eisemmengers syndromehypertension , or eisemmengers syndrome

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Management of labourManagement of labour--vaginal delivery is preferable to caesarian section except vaginal delivery is preferable to caesarian section except

in cases of coarctation of the aorta . However if there is in cases of coarctation of the aorta . However if there is obstetric indication for caesarian section it is not obstetric indication for caesarian section it is not contraindicatedcontraindicated. .

--there is no place for trial of labourthere is no place for trial of labour..--labour is managed like in healthy womenlabour is managed like in healthy women..

--oxygen should be availableoxygen should be available. . --adequate sedation and analgesia are important by adequate sedation and analgesia are important by

pethidine but epidural is the best method of pain reliefpethidine but epidural is the best method of pain relief. . --assisted delivery by forceps or ventouse is indicated assisted delivery by forceps or ventouse is indicated

unless the second stage of labour is very rapidunless the second stage of labour is very rapid..--third stage it is usual to give only syntocinon as third stage it is usual to give only syntocinon as

ergometrine is contraindicated as it may precipitate heart ergometrine is contraindicated as it may precipitate heart failurefailure..

--antibiotic prophylaxis is commonly given to guard against antibiotic prophylaxis is commonly given to guard against the risk of bacterial endocarditisthe risk of bacterial endocarditis

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Management of the Management of the puerperiumpuerperium

- -the high risk of acute cardiac failure the high risk of acute cardiac failure persist for 24 hours after delivery & persist for 24 hours after delivery & careful observation during this period is careful observation during this period is essentialessential. .

--breast feeding is not contraindicatedbreast feeding is not contraindicated..--although adequate rest essential early although adequate rest essential early

ambulation is desirable to minimize the ambulation is desirable to minimize the risk of thrombo embolic disordersrisk of thrombo embolic disorders..

The use of anticoagulant is contraversialThe use of anticoagulant is contraversial..

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Future pregnancyFuture pregnancy--if the patient wants more children she can if the patient wants more children she can

safely become pregnant provided that she is safely become pregnant provided that she is grade 1or2 & her heart is well compensated grade 1or2 & her heart is well compensated . Grade 3&4 should be discouraged from . Grade 3&4 should be discouraged from being pregnant until cardiac surgery has being pregnant until cardiac surgery has been performedbeen performed..

If the patient desire no further children If the patient desire no further children contraception can be used oral pills & contraception can be used oral pills & condom are preferable to IUCDcondom are preferable to IUCD..

Tubal ligation is best deferred until the Tubal ligation is best deferred until the patient has overcome the burden of patient has overcome the burden of

pregnancy & puerperiumpregnancy & puerperium www.doctor.sd

Cardiomyopathy of Cardiomyopathy of pregnancypregnancy

11 ) )hypertrophic obstructive hypertrophic obstructive cardiomyopathy characterized by cardiomyopathy characterized by hypertrophy & disorganization of cardiac hypertrophy & disorganization of cardiac muscle particularly the left ventricle and muscle particularly the left ventricle and septumseptum..

--cause is unknowncause is unknown. . --the patient present with chest the patient present with chest

pain ,syncope ,arrhythmia ,or the pain ,syncope ,arrhythmia ,or the symptoms of heart failure. treatment is symptoms of heart failure. treatment is by B-blockersby B-blockers

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22))Pregnancy Pregnancy cardiomyopathycardiomyopathy

--occurs in the last quarter of pregnancy & puerperiumoccurs in the last quarter of pregnancy & puerperium. . --the heart is growthly dilatedthe heart is growthly dilated. .

Usually in multiparous Usually in multiparous ––black-relatively elderly women of black-relatively elderly women of low social classlow social class..

--pulmonary ,peripheral ,and cerebral embolism is a major pulmonary ,peripheral ,and cerebral embolism is a major cause of morbidity & mortalitycause of morbidity & mortality..

--the condition recurthe condition recur..--cause unknown. It is considered to be a form of congestive cause unknown. It is considered to be a form of congestive

cardiomyopathycardiomyopathy. . --treatment is with anti failure drugs & anticoagulant until treatment is with anti failure drugs & anticoagulant until

the heart size return to normalthe heart size return to normal..--assuming that the patient recover from the initial episode assuming that the patient recover from the initial episode

the long term prognosis is goodthe long term prognosis is good.. - -

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