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Cardiac Diseases in Pregnancy - 1
Cardiac Diseases in Pregnancy - 1
Maternal mortality related to heart disease has decreased remarkably over the past 50 years (from 5.6 to 0.3/100 000 live birth)
Heart disease are still the second most common non obstetrical cause of maternal mortality.
Cardiac Diseases
Rheumatic heart disease Congenital heart disease Hypertensive heart disease Coronary Thyroid Syphilitic Kyphoscoliotic cardiac disease Idiopathic cardiomyopathy Corpulmonale Constrictive pericarditis Heart block Isolated myocarditis
Stroke volume
cont
Later in pregnancy COP is higher when women is in the lateral recumbent position than when she is in the supine
During labor COP increase moderately in the first stage of labor and appreciably greater in the second stage COP also increase in the immediate post partum period
cont
Heart: The heart is displaced upward and to the left with lateral rotation on its long axis Resting pulse increase by about 10 bpm There is some changes in the cardiac sounds include: An exaggerated splitting of the first heart sound with increase loudness of both components, no definite changes in the aortic and pulmonary elements of the second sound, and aloud easily heard third sound
conti.
Systolic murmur is heard in 90 % of cases Soft diastolic murmur transiently in 20 % Continuous murmur arising from the breast vasculature in10 % of cases
Clinical findings
Cyanosis Clubbing of fingers persistent neck vein distension Systolic murmur grade 3/6 or greater Diastolic murmur Cardiomegaly Persistent arrhythmia Persistent split-second sound Criteria for pulmonary hypertension
Diagnostic studies
Electrocardiography
An average 15 degree left axis deviation in the ECG , and mild ST changes may be seen in the inferior leads, Atrial and ventricular premature contractions are relatively frequent
Echocardiography:
Normal changes include : Tricuspid regurgitation , Significantly increase left atrial size and left
ventricular outflow cross sectional area.
Clinical clssification
The New York Heart Associations Functional Classification [ NYHA] First published in 1928 Class 1 : Uncompromised , no limitation of physical activity Class 2 : Slightly compromised , slight limitation of physical activity Class 3 : Markedly compromised , marked limitation of physical activity Class 4 : Severely compromised , inability to perform any physical activity without discomfort
Preconceptional counseling
Maternal mortality generally varies directly with functional classification at pregnancy onset; However this relationship may change as pregnancy progresses Patient with pulmonary hypertension, primary or secondary are in danger of undergoing decompensation during pregnancy
cont
Life threatening cardiac abnormalities can be reversed by corrective surgery and subsequent pregnancy is less dangerous In other cases fetal consideration predominate, for example the teratogenic effect of warfarin
Mortality %
Group 2 Moderate Risk 2A : Mitral stenosis , NYHA classes 3 & 4 Aortic stenosis Aortic coarctation without valvar involvement Fallot tetralogy , uncorrected Previous myocardial infarction Marfan syndrome , normal aorta 2B : Mitral stenosis with atrial fibrillation Artificial valve
5 -15 %
Group 3 Major Risk Pulmonary hypertension Aortic coarctation with valvar involvement Marfan syndrome with aortic involvement
25 -50 %
NYHA = New York Heart Association. From the American College of Obstetrics and Gynecologists (1992a ) , with permission .
Management
In assuring an optimal outcome , management should be a team approach involving ;obstetrician, cardiologist and anesthesiologist Risk to patient of : Heart failure, subacute bacterial endocarditis, and thromboembolic disease will be identified and minimized
Management
Four concepts that affect management are emphasized by the American College of Obs /Gyn :1) the 50% increase in blood volume and COP by the early 3rd trimester 2) further fluctuation in volume and COP in the peripartum period 3) a decline in systemic vascular resistance, reaching a nadir in the 2nd trimester, and then rising to 20% below normal by late pregnancy 4) hyprcoagulability of special importance in women requiring anticoagulation in the non pregnant state
management cont..
signs of heart failure: persistent basilar rales nocturnal cough a sudden diminution in ability to carry out usual duties increasing dyspnea on exertion attacks of smothering with cough hemoptysis, progressive edema and tachycardia
Management cont..
* fluid balance and antibiotic prophylactic * semi recumbent position with lateral tilt * intensive medical management for any signs of impending ventricular failure
[ pulse > 100 , RR > 24 , dyspnea ]
* delay the procedure of tubal sterilization until it is obvious that the mother is a febrile, not anemic and can ambulate without evidence of distress
caesarian section delivery should be with the availability of experience anesthetic support in a facility with experience with complicated cardiac disease
Peripartum cardiomyopathy : this is a diagnosis of exclusion , it describe women with peripartum heart failure with no apparent etiology, symptoms of cardiac decompensation appear during the last weeks of pregnancy or 1 to 6 months postpartum obstetrical complications such as : preeclampsia, anemia from blood loss , and infection either contribute or precipitate heart failure
Prognosis : favorable outcome for the mother with heart disease depends upon the :
_ functional cardiac capacity _ other complications that further increase cardiac load _ quality of medical care provided _ psychological and socioeconomical factors