HEART DISEASE IN PREGNANCY

! ! ! The commonest cause of heart disease in pregnancy: ! - Rheumatic Heart Disease 55% ! - Congenital Heart Disease 40%

Normal Physiological Changes in CVS during Pregnancy

Parameter
Blood volume Cardiac output Stroke volume Heart rate Systolic blood pressure Diastolic blood pressure Pulse pressure Systemic vascular resistance

1st Trimester ↑ ↑ ↑ ↑ ↔ ↓

2nd Trimester ↑↑ ↑↑ to ↑↑↑ ↑↑↑ ↑↑ ↓ ↓↓

3rd Trimester ↑↑↑ ↑↑ to ↑↑↑ ↑, ↔ or ↓ ↑↑ to ↑↑↑ ↔ ↓
       

Normal changes in heart sounds during pregnancy

↑ ↓

↑↑ ↓↓↓

↔ ↓↓

Increase loudness of both S1 and S2 Increase splitting of mitral and tricuspid component of S1 No constant change in S2 Loud S3 by 20 weeks gestation <5% develop S4 >95% develop a systolic murmur that disappears after delivery 20% have transient diastolic murmur 10% develop continuous murmur d/t increased mammary blood flow

During labour, anxiety, pain and uterine contraction will lead to more cardiac output....

Smoking 9. Assessment and stratification of maternal and fetal risks 3. Pre-conceptual counseling 2. Left ventricular and right ventricular function 4. Management of the pregnancy and complications of heart disease 4. Presence of arrythmias 8. mode and place of delivery 5. dyspnoea Progressive orthopnoea PND Syncope with exertion Chest pain related to effort/ emotion Risk assessment: 1. systolic murmur) Signs of Left heart failure  gallop rhythm  basal crepitation  pleural effusion Signs of Right heart failure  congested neck veins  enlarged tender liver  Ascites  oedema CLASS II CLASS III: CLASS IV: .The effect of maternal drugs on the fetus . Determining the timing. Not impossible to diagnose heart disease in pregnancy Pregnant women must be examined at least once by a doctor during ANC PMH & PSH Screen for cardiac signs and symptoms NYHA Functional Class CLASS I: - SIGNS TO LOOK FOR: Clubbing Central cyanosis Displaced apex beat Murmurs (esp Diastolic. Presence of valve/conduit stenosis (left heart obstruction) 6. Presence of conduction defects 7.The effect of the cardiac disorder on fetal development . NYHA Functional Class 2. Severity of pulmonary hypertension 5. Antibiotic prophylaxis during procedure/labour SYMPTOMS: Pre conceptual counseling      Severe.The risk of genetic transmission to the fetus Patients with heart disease should be encouraged to complete their family early and be discouraged from having too many pregnancies.The effect of the haemodynamic changes on the patient . progressive. Presence of cyanosis 3.Management Principles: 1. High-risk patients should be advised on permanent contraceptive measures. Multiple gestation .

Atrial Fibrillation associated with structural heart disease 4. Stroke volume rises by 10% in the first 48 hours of delivery and then reduces over next 2-4 weeks 4. Unfractionated heparin a. Complex CHD Drugs given: 1. Closely vital signs monitoring: 1. Eisenmenger’s Syndrome.risk of DVT is 5x 3. Primary Pulmonary HPT. Mechanical heart valves 2.0 gm over 1 hour+ IV or IM Gentamycin 1. Blood Pressure 3. LMWH : Fewer complications of thrombocytopenia and osteoporosis .5 mg/kg (not to exceed 80 mg) 30 mins before procedure. Arterial saturation with pulse oximeter 2. osteoporosis 3. Complications: abcess. hematomas. Misc cond: Peripartum Cardiomyopathy. Oxygen therapy 3. Second stage must be shortened 9. then 1. Fetal monitoring (CTG) 6.0 gm + IV or IM Gentamycin 1.5 gm orally 6 hours after initial dose or repeat parenteral regime 8 hours after initial dose 1. Fetal complications seen in dose >5mg daily 2. Careful haemodynamic monitoring is important in these patients for about 48-72 hours. Left lateral position 2. Requires monitoring with APTT c. Encouraged patient to breast feed Penicillin Allergic Patient Vancomycin Gentamicin IV Vancomycin 1.5 mg/kg (not to exceed 80 mg) 1 hour before procedure and repeat 8 hours later Alternative Low Risk Regime Amoxicillin 3gm orally 1 hour before procedure. followed by: Amoxicillin 1. Pain and anxiety relief vital to reduce tachycardia 8. Does not cross placenta b. 5. CVP (occasionally) 4.5gm 6 hours later ANTICOAGULATION IN PREGNANCY: Indications: 1. Antibiotic prophylaxis against endocarditis at onset of labour or induction of labour POSTPARTUM 1. Assoc with warfarin embryopathy 4-10% b.INTRAPARTUM MANAGEMENT Standard Regimen ANTIBIOTIC PROPHYLAXIS REGIME Ampicillin Gentamicin Amoxicillin IV or IM Ampicillin 2. Systolic BP rises in first 24 hours of delivery 3. DVT and Thromboembolism . Remain in hospital for atleast a week 6. Continuous ECG monitoring for mother (to detect arrythmias) 5. Fluid therapy to be carefully monitored to avoid pulmonary oedema 7. Warfarin a. Increase in venous return: due to the relief of caval compression and auto transfusion from the contracting uterus 2. thrombocytopenia.