HEART DISEASE IN PREGNANCY

Decreased blood viscosity . Decreased peripheral resistance 4. Causes for increased cardiac output are 1.Cardiac output begins to rise in the first trimester and continues as steady increase to peak at 32 weeks gestation by 30% to 50% of pre pregnancy level. Increase in heart rate (late pregnancy) 3. Increases in stroke volume (early pregnancy) 2.

This fall is due to 1. the placental bed serves as a large arteriovenous shunt causing lowered systemic vascular resistance 2.The fall in the peripheral resistance is about 20-30% at 2124 weeks & returns to normal at term. . Due to the trophoblastic erosion of endometrial vessels. There is physiological vasodilatation which is believed to be secondary to endothelial prostacyclin and circulating progesterone.

Table 1: Normal Hemodynamic Changes During Pregnancy Hemodynamic Parameter Change During Normal Pregnancy Change During Labor and Delivery Change During Postpartum Blood volume Heart rate Cardiac output Blood pressure Stroke volume Systemic vascular resistance ↑ 40%-50% ↑ 10-15 beats/min ↑ 30%-50% above baseline ↓ 10mmHg ↑ ↑ ↑ Additional 50% ↑ ↓ (auto diuresis) ↓ ↓ ↓ ↓ ↓ ↑ First and second trimesters. ↓ third trimester ↓ ↑ (300500mL/contracti on) ↑ .

due to hyperventilation. Jugular veins may be distended and JVP raised.The clinical features in a normal pregnancy which can mimic a cardiac disease are 1. Systolic ejection murmurs along the left sternal border occur in 96% of pregnant women and are believed to be caused by increased flow across the aortic and pulmonary valves. Cardiac impulse. . Pedal Edema 3. Dyspnea . elevated diaphragm. 5. 4. 2.Diffused and shifted laterally from elevated diaphragm..

NYHA.5 cm2. Adapted from Siu SC. 27%. . and 75%.104:515-521. respectively. et al: Prospective multicenter study of pregnancy outcomes in women with heart disease. or left ventricular outflow tract peak gradient > 30 mm Hg 1 Myocardial dysfunction LVEF < 40%. Colman JM. LVEF. transient ischemic attack. Sermer M. New York Heart Association. restrictive cardiomyopathy. left ventricular ejection fraction. or hypertrophic cardiomyopathy 1 *Maternal cardiac event rates for 0. Circulation 2001. stroke before current pregnancy Symptomatic sustained tachyarrhythmia or bradyarrhythmia requiring treatment Points * 1 Prior arrhythmia NYHA III or IV or cyanosis Valvular and outflow tract obstruction 1 1 Aortic valve area < 1.Table 2: Predictors of Maternal Risk for Cardiac Complications Criteria Prior cardiac events Example Heart failure. mitral valve area < 2 cm2. 1. and >1 points are 5%.

Marked limitation of physical activity Severe limitation of physical activity Symptoms with extra ordinary physical work. Symptoms with ordinary physical work Symptoms with less than ordinary physical work Symptoms at rest CLASS II CLASS III CLASS IV .The New York Heart Association (NYHA) Grading of functional capacity of the heart: CLASS I No functional limitation of activity Mild limitation of physical activity.

Low risk of maternal mortality (less than 1%). (b) Pulmonary hypertension. (c) Marfan’s syndrome with abnormal aortic root. (b) Aortic stenosis. (d) Uncomplicated coarctation of aorta. High risk of maternal mortality (25-50%). (c) Marfan’s syndrome with normal aorta. (e) Past history of myocardial infarction. 1. 2. . (c) Patent ductus arteriosus. (a) Septal defects. (a) NYHA classes III and IV mitral stenosis.Mortality associated with specific cardiac lesions. (b) New York Heart Association classes I and II. 3. (a) Eissenmenger’s syndrome. (d) Pulmonary / tricuspid lesions. (d) Peripartum cardiomyopathy. Moderate risk of maternal mortality (5-15%).

These patients should be advised against becoming pregnant. v Patients in NYHA classes III and IV may have a mortality rate of 5% to 15%. . women in NYHA classes I and II lesions usually do well during pregnancy and have a favorable prognosis with a mortality rate of <1%.Prognosis depending on the functional status v In general.

causing increase in cardiac output & can cause reflex bradycardia. 3. Decrease cardiac output. 2. Uterine contractions increases venous return . Cardiac output increases by15%.Physiological changes during labour and puerperium.First stage. . 1.Third stage Normal blood loss during delivery (around 250-350 ml). It leads to a.Second stage Increase in intra abdominal pressure (valsalva’s) causes decrease in venous return and cardiac output. Decrease blood volume b.

• Criteria to diagnose cardiac disease during pregnancy: 1.Systolic murmurs of severe intensity (grade 3). 3. 2.Unequivocal enlargement of heart (X-ray).Presence of severe arrythmias. 4. atrial fibrillation or flutter .Presence of diastolic murmurs.

MVP (isolated or with mild or moderate MR and normal LV function) 7. Mild or moderate PS 10. mean gradient < 5 mm Hg) without severe pulmonary hypertension 9. MR with normal LV function and NYHA Class I or II 8. Repaired acyanotic congenital heart disease without residual cardiac dysfunction .Box 1: Maternal Cardiac Lesions and Risk of Cardiac Complications During Pregnancy Low Risk 1. 4. AR with normal LV function and NYHA Class I or II 6. Atrial septal defect Ventricular septal defect Patent ductus arteriosus Asymptomatic AS with low mean gradient (<50 mm Hg) and normal LV function (EF > 50%) 5.5 cm2. 2. Mild or moderate MS (MVA > 1. 3.

mitral valve area. 4. aortic stenosis. aortic regurgitation. TA. mitral valve prolapse. Eisenmenger's syndrome 2. EF. Severe AS with or without symptoms 6. with moderate or severe LV dysfunction (EF < 40%) 7. TOF. tricuspid atresia) 4. 3. AS. or both (stenosis or regurgitation). New York Heart Association. truncus arteriosus. . MS. LV. Complex cyanotic heart disease (TOF. TA. pulmonary stenosis. 5.Intermediate Risk 1. mitral stenosis. TGA. MVP. Severe pulmonary hypertension 3. TGA. NYHA Class III or IV symptoms associated with any valvular disease or with cardiomyopathy of any cause 8. Marfan syndrome with aortic root or valve involvement 5. History of prior peripartum cardiomyopathy AR. PS. ejection fraction. left ventricular. NYHA. Large left to right shunt Coarctation of the aorta Marfan syndrome with a normal aortic root Moderate or severe MS Mild or moderate AS Severe PS High Risk 1. 6. transposition of the great arteries. Ebstein's anomaly. MVA. Aortic or mitral valve disease. tetralogy of Falot. 2.

MTP is indicated in: 1. .The indications for Termination of pregnancy. 2. Termination should be done before 12 weeks of pregnancy.Pulmonary hypertension.Marfan’s syndrome with aortic involvement 3. Because of high maternal risks.Coarctation of aorta with valvular involvement.Eisenmenger’s syndrome. 4.

Warfarin use in first trimester can be teratogenic and can cause fetal embryopathy (15 to 25 % ) which includes : – Nasal cartilage hypoplasia. – Stippling of bones. – IUGR and – Brachydactyly .

Risk factors for cardiac failure during pregnancy Infection Anemia Obesity Hypertension Hyperthyroidism Multiple pregnancy .

5mg per kg gentamicin /IV prior to the procedure .Antibiotic prophylaxis consists of a. b. followed by one more dose of ampicillin 8 hours later. 2 gm ampicillin IV/plus 1. . In the event of penicillin allergy 1 gm vancomycin IV can be substituted.

3. IUCD can cause infection. 2. 4. Medroxy progesterone 150mg IM every 3 months. . OC pills are not ideal as they can cause thrombo embolism.Contraception 1.200 mg every 2 months 5. b.endocarditis.Desogestrel INJECTABLES a. Barrier contraceptives – Have high failure rates. Norethisterone. Sterilization is best. Progestin only pills or Long acting injectable progesterone are better PILL .

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