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Cardiorespiratory Distress in Pregnancy

By Mohamad Masykurin Mafauzy

Heart Disease in Pregnancy

Introduction
It is rare, but potentially serious and complicates approximately 1 per cent of all pregnancy
Prevalence depends on the incidence of rheumatic heart disease and undiagnosed or uncorrected congenital heart disease

Heart Disease in Pregnancy

Rheumatic heart disease remains an important cause of heart disease In developing countries. Congenital heart disease accounts for approximately 50% of heart disease in pregnant women in the UK.

Acquired ishaemic heart disease is more common due to smoking amongst women

Maternal Risks

Pulmonary hypertension & mitral stenosis is most likely condition that restrict an increase in pulmonary blood flow. 40-50% maternal mortality rate amongst women with pulmonary hypertension & Eisenmengers syndrome In cases of Fallots tetralogy, the maternal mortality is much lower (5%) because there is no pulmonary hypertension Other causes of heart disease that can cause maternal morbidity are cardiomyopathy, rupture or dissection of aorta & ischaemic heart disease Infective endocarditis is rare since the use of antibiotics become routine

Fetal Risks

At risks of growth restriction & preterm delivery in pregnancies complicated by cyanotic congenital heart disease. Uncorrected coarctation of the aorta is associated with fetal growth restriction in > 40% of cases due to reduced placental perfusion The incidence of CHD in population is 0.08%. If a parent is affected, the risk increased to 5%. Therefore all pregnant women with CHD should be referred for expert fetal cardiology scanning

Pre-pregnancy Management

To women with heart disease Pre-pregnancy counselling


Contraceptive plan for certain cases Explain the maternal and fetal risks Need for frequent hospital attendance and possible admission Intensive maternal and fetal monitoring during labor Maternal echocardiography Treat current medical problems Optimize medical therapy Do surgical correction (for certain cases) before pregnancy

Cardiologist involvement

Counselling on Contraceptive
Pregnancy

is not recommended in these women and contraception is mandatory, especially until corrective surgery can be accomplished. Several uncorrected lesions (mortality of up to 25% to 50%)
Eisenmengers syndrome Primary pulmonary hypertension Cardiomyopathy Congestive heart failure Marfans syndrome with aortic involvement

Contraceptive Device
Contraindications

of using combined oral contraceptive in woman with heart diseases Contraindications of using IUCD in prosthetic valves and endocarditis. Effective alternatives

Surgical method (best option): vasectomy, tubectomy Implantable progesterone-only contraceptive Barrier method condom but higher failure rate

Antenatal Management
Managed

in joint obstetric/cardiac clinic Risk factor for the development of heart failure
Respiratory / urinary infections Anemia, obesity, hypertension, arrhythmias Pain-related stress, fluid overload

Anticoagulation

in pregnancy

Warfarin teratogenic in 1st trimester Essential in patient with pulmonary hypertension, artificial valve replacement and in/at risk of atrial fibrillation 3 options depend on degree of thrombotic risk womans choice

Anticoagulation therapy
1st

option :

Warfarin throughout pregnancy Replace with heparin (for delivery only)

2nd

option :

1st trimester : heparin 2nd / 3rd trimester : warfarin

3rd

option

Heparin throughout pregnancy Labour warfarin, FFP, vitamin K

Signs and symptoms indicative of significant CV disease


Medical

history Physical examination Laboratory examinations


ECG Chest radiograph Echocardiography Exercise stress testing

Medical history

Progressively worsening SOB Cough with frothy pink sputum Paroxysmal nocturnal dyspnea Chest pain with exertion Syncope preceded by palpitation on exertion Hemoptysis NYHA classifications Patient with heart disease

Therapeutic regimens Echocardiogram test Corrective/palliative surgery

Family history

Class I : patients have no limitation of physical activity. Ordinary physical activity does not cause fatigue, palpitation, dyspnea or anginal pain.

Class II : patients have slight limitation of physical activity. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.

NYHA classification of heart disease

Class III : Patients have marked limitation of physical activity.

Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain

Class IV : Patients have inability to carry on any physical activity without discomfort symptom of cardiac insufficiency or anginal syndrome may be present, even at rest.
If any physical activity is undertaken, discomfort is increased

Physical examinations
Inspection

Clubbing, cyanosis, pallor Pectus excavatum, precordial bulge Sustained right/left ventricular heave

Palpation

Auscultation

Loud systolic murmur, any diastolic murmur Ejection clicks, late systolic clicks, opening snaps

Lab examinations
ECG

Significant arrhythmias Heart blocks

Chest

radiograph

Cardiomegaly Pulmonary edema

Exercise

stress testing

Indicated for preconception work-up for estimation of myocardial reserve to determine if a woman can safely carry a pregnant to term

Risk Stratification
Low risk generally tolerate pregnancy well
Uncomplicated septal defect Pulmonary stenosis Aortic and mitral regurgitation Hypertropic cardiomyopathy Acyanotic ebstein anomaly Corrected transposition without other defects

Moderate risk in pregnancy


Coarctation of aorta Univentricular circulation Prosthetic valves on anticoagulants

High maternal & fetal risk 50% mortality


Pulmonary hypertension Eisenmengers syndrome Cyanotic heart disease Severe aortic/mitral stenosis Poor left ventricular function (LVEF < 40%) Marfans syndrome (aortic diameter > 40 mm)

Treatment of HF in Pregnancy

The principles of treatment are the same as in the non-pregnant women Drug therapy:

Diuretics Vasodilator Digoxin Oxygen and morphine Fetal ultrasound to assess fetal growth Regular cardiotocography Consider premature delivery if there is evidence of fetal compromise

Assessment of fetal well-being


Prophylactic Antibiotics (Rheumatic Heart Disease)


Benzathine

PNC 1.2 U IM every 4 week PNC V 250 mg 12 hourly (preferable) Erythromycin 250 mg 12 hourly (for those sensitive to PNC)

Management of Labour and Delivery


To await the onset of spontaneous labour Consider IOL Epidural anesthesia Prophylactic antibiotics structural heart defect ADDITIONAL POINTS To monitor the O2 saturation, continuous arterial blood presure monitoring

Aim

Additional points

Avoid IOL if possible Use prophylactic antibiotic Ensure fluid balance Avoid supine position Keep 2nd stage short(forcep/ventouse) Use syntocinon

Asthma in Pregnancy

Definition
Asthma

is a chronic inflammatory disease that causing reversible bronchial airway obstruction. Most common respiratory disease encountered in pregnancy and affects 14% of women of child-bearing age. Pregnancy outcomes in women with asthma are usually good.

Effect of Asthma on Pregnancy


Pregnancy itself does not increase the frequency or severity of asthma in most women. Problems may occur if :

Poorly controlled asthma Not compliant to medication Told not to continue medication Failure of the clinicians to recognize the severity of the asthma

If the asthma is effectively treated and controlled no risk Severe asthma high risk

Classification of asthma by level of control


Characteristics Daytime symptoms Limitation of activities Controlled none none Partly controlled Uncontrolled >2x/week Any >2 features of partly controlled asthma present in any week

Nocturnal symptoms
Need for reliever Lung function (PEF/FEV1)

none
None (twice/less/wee k) normal

Any
>2x/week

<80% predicted or personal best (if known)

Treatment in General

Main goal of therapy is to maintain normal or nearnormal maternal pulmonary function to : Allow adequate fetal oxygenation Prevent exacerbations Allow the patient to maintain her usual activities To improve asthma management by giving educational interventions : Learn the proper use of portable peak flow meter to objectively evaluate asthma severity Monitor the patient inhalation technique Avoidance of potential asthma trigger is extremely important Smoking cessation

Treatment (prenatal)
Current

therapy should continue in pregnancy. Educate and reassure mother the safety of the medication and warn the patient not to stop their treatment Usually well controlled with :

Inhaled beta-2-agonist (salbutamol) Corticosteroids (betamethasone)

If

in severe exacerbation:
Hospital admission Bronchodilator Oxygen Steroid

Medication

to avoid :

Prostaglandin F2 bronchospasm. Use prostaglandin E2 , oxytocin. General anesthesia atelectasis, chest infection. Use epidural anesthesia. Ergometrine bronchospasm. Use syntocinon. Aspirin and NSAIDs (eg : indomethacin) severe bronchospasm and ocular, nasal, dermal, gastrointestinal inflammation

Treatment (intrapartum)
Adequate

control :

Adequate hydration status Pain relief as necessary Continuous O2 monitoring. O2 saturation >95% at all times If exacerbation neb hydrocort (hydrocortisone)

Treatment (post-partum)
Continue

usual therapy and follow-up Breastfeeding is not contraindicated Inhaled beta2 agonist, cromolyn sodium, steroids (inhaled), ipratropium safe while breast feeding. Systemic steroids may enter into breast milk but only in small amounts if the total daily dosage contains < 40 mg of prednisone

Complications (severe asthma)


Maternal
Hyperemesis gravidarum Pneumonia Pregnancy-induced hypertension Preeclampsia Vaginal bleeding More complicated labours More cesarian section

Fetal
IUGR Preterm birth Low birthweight Neonatal hypoxia Increased overall perinatal mortality

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