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Heart Disease in Pregnancy

Dr Wan Md Hafizi bin Wan Mohamad

Outlines

Epidemiology

Hemodynamic changes

Maternal risk

Complication Clinical Approach

- Sign and symptoms

- Physical examination Management -Preconception

  • - Antenatal mangement

  • - Intrapartum management

  • - Postpartum management

Epidemiology in Malaysia

Accounts for 12% of maternal disease in 1996. Commonest cause of indirect maternal death in Malaysia

In Sarawak there were a total of 9 maternal deaths from hearth diseases in the 3 years period between 2010-2012

How comman?

Coronary artery disease is uncomman in pre- menopausal women of child-bearing age

Most common; congenital heart disease or rheumatic valvular heart disease

Cardiac complications result from hemodynamic changes that occur during

pregnancy

CVS adaptation in pregnancy

Cardiac output: increased by 45% Stroke volume: increased Heart rate: increase by 10-20bpm

Blood pressure: reduced in the 1 st and 2 nd trimester

Hemodynamic during pregnancy

Peripheral resistant decrease increase uterine blood flow

Blood volume increase 40-45% Heart rate increase10-20%

Hemodynamic during pregnancy • Peripheral resistant decrease increase uterine blood flow • Blood volume increase 40-45%

Cardiac output increase 30%

Venous pressure in lower extremities increase pedal edema

Maternal Risk

High risk heart disease

Pulmonary hypertension (>60% systemic pressure)

Dilated cardiomyopathy, ejection fraction <40%

Symptomatic obstructive lesions (delay pregnancy until the obstruction has been corrected)

-aortic stenosis

-Mitral stenosis -Pulmonary stenosis

-Coarctation of the aorta

Marfan syndromes with aortic root >40mm diameter

Cyanotic lesions

Moderate risk - COA

- Prosthetic valve on coagulation

Low Risk

  • - Pulmonary stenosis

  • - Uncomplicated AR/MR

  • - Uncomplicated septal defect (ASD/VSD)

Cilical Approach

Symptoms :

  • - fatigue at rest

  • - exertional chest pain

  • - exertional sveer dyspnea

  • - orthopneia (progressively)

  • - PND

  • - syncope

Cilical Approach Symptoms : - fatigue at rest - exertional chest pain - exertional sveer dyspnea
  • - palpitation (dysaryytmia, if tacycardia may normal for pregnant women)

General

  • - anemia

  • - clubbing

Signs

  • - Pulses (arrhythmias)

  • - Blood pressure

  • - JVP increase

  • - cyanosis

  • - ankle edema

Chest examination :

  • - shifted apex beat

  • - loud diastolic murmur

  • - cardiomegaly

  • - basal crepitation

Management

1. Precontraception counselling regarding :

effect of hemodynamic changes and maternal risk Effect of fetal growth Effect of materanl drug and complicance Genetic transmission Need for frequent admission and long stay Encourage for complete family earlier and discourage from multiple pregnancy

Contraception

Barrier method: compliance issue Spermicides: high failure rate

COCP: avoid in IHD, valvular heart disease and plmonary hypertension

Implanon: very useful

IUCD: contraindicated in prostatic valve, endocarditis

Antenatal Management

1. Booking

all mother should examine CVS properly if suspected, refer to cardiologist for ECHO

2. Antenatal Clinic

History: look for any heart failure symptoms with access of NYHA

PE :look any sign of heart failure Investigation: Hb,ECG, ECHO (if sx suggestive)

3. Factor aggravate heart failure identified and treat

  • - Anemia

  • - HPT

  • - Infection(UTI or URTI)

  • - Hyperthyroidism

  • - Arrhythmias

  • - Multiple gestation

4. Advice about :

  • - Rest

  • - Smoking cessation

  • - Compliance of hematinic

5.

Anticogulant

  • - anticoagulant theraphy is indicated if patient had previous valve replacement and severe heart disease

  • - 3 types regime can be used :

    • - continue warfarin throughout preganancy, replace heparin for

delivery ( 1-2 weeks prior for delivery)

  • - replacement warfarin with heparin in 1 st trimester

  • - use heparin throughout pregnancy

  • 6. Time and mode of delivery:

Mild and moderate heart disease :

  • - aim for SVD, avoid induction of labour

Severe heart disease /develop acute heart failure

  • - admit patient early

  • - prepare for preterm labour for sever heart disease patient

Intrapartum Management

Aim for deliver within 6 hours

Stop heparin before pregnancy

Prop up left lateral

Continue CTG, ECG and Sp02

Give 02 (3L/min)

Give epidural anesthesia

Antibiotics epidural given in severe cases:

- IV ampicillin 2gr STAT and 8hr later (2 doses)

- IV gentamicin 800mg and 8hr later ( 2doses)

Avoid fluid overload

Shortened 2 nd stage 3 good maternal push / by using instrumental delivery

For 3 rd stage, give syntocinon (don’t give ergometrine)