Patofisiologi dalam kehamilan, persalinan

dan nifas

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 Heart Failure in Pregnancy

Population of Europe of childbearing age

• EU population 2008 499

million total
• 105 million women in
childbearing age
• 5 million live births

• 1% of pregnancies are
complicated by heart diseases

European Heart Journal 2011

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Major Causes of Maternal Death
UK 2003 – 2005
Overall Death Rates per Million Maternities

European Heart Journal 2011

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 Cardiovascular Disease :
- Valvular Heart Disease
- Congenital Heart Disease

Hear
t
Cardiovascular Disease
Failu due to Pregnancy :
Peripartum

re Cardiomyopathy

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 • Breathlessness at
rest / on exercise
• Fatigue
Symptoms of HF • Tiredness
• Ankle swelling
•Tachycardia
•Tachypnoea
•Pulmonary rales
•Pleural Effusion
HEART •↑ JVP
Clinical Syndrome Signs of HF
FAILURE •Peripheral
Oedema
•Hepatomegaly
•Cardiomegaly
Objective Evidence of •Third heart sound
•Cardiac murmurs
Structural/ Functional of
•Abnormality on
the Heart at Rest Echo
•↑ NPs

ESC Guidelines for the Diagnosis and Treatment of Acute & Chronic Heart Failure 2008
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New York Heart Association Classification of Congestive Heart Failure

General Guide
Functional Class Description (Estimated Mets Equivalent)
I Dyspnea occurs with greater Climbs ≥ 2 flights of staors
than ordinary physical activity with ease (≥ 7 Mets)
II Dyspnea occurs with ordinary Can climb 2 flight of stairs but
physical activity with difficulty (5-6 Mets)
III Dyspnea occurs with less than Can climb ≤ 1 flight of stairs
ordinary physical activity (2-4 Mets)
IV Dyspnea may be present even Dyspnea at rest (0-1 Mets)
at rest

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 Framingham Criteria for Heart Failure

Major Criteria Minor Criteria

Paroxysmal nocturnal dyspnea Bilateral ankle edema

Neck vein distention.
Rales
Radiographic cardiomegali
Acute pulmonary edema
S3 Gallop
Increased CVP > 16 cm H2O
Hepatojugular reflux
Nocturnal cough
Dyspnoe on ordinary exertion
Hepatomegaly
Pleural effusion
Tachycardia ( ≥ 120 x/minute)

The criteria for heart failure were based on fulfillment of at least two
major criterias or 1 major and 2 minors criteria
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 History and physical examination

Normal pregnancy : Suggesting heart disease :

⮊ Dyspnea and orthopnea
⮊ Fatique
⮊ Chest discomfort
⮊ Visible neck pulsation
⮊ 3rd heart sound
⮊ Systolic murmur
⮊ Basilar pulmonary rales
⮊ Pedal edema
⮊ Dyspnea and orthopnea🡩
⮊ Hemoptysis
⮊ Syncope with exertion
⮊ Chest pain (related to effort)
⮊ Cyanosis
⮊ Cardiomegaly
⮊ Loud systolic murmur (3/6)
⮊ Fixed split 2nd heart sound
⮊ Pulmonary HT
⮊ Clubbing finger

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Electrocardiography
Echocardiography
Transthoracal echocardiography
Transesophageal echocardiography
Magnetic resonance imaging

All X-ray (particularly early in

pregnancy)
Radionuclide imaging
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• Valvular Heart Disease in Pregnancy

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 Valvular heart disease

Most common cause of heart disease during pregnancy

The cause of 🡪 almost all mitral stenosis,
🡪 some mitral regurgitation,
aortic regurgitation
tricuspid regurgitation
🡪 Some double and triple-valve disease
Recognition of rheumatic fever as the cause of heart
disease is important 🡪 need antibiotic prophylaxis to
prevent reccurence of the disease

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 Mitral stenosis (MS)

♀ > ♂ (due almost exclusively to RF)

Resting pressure gradient across
stenotic mitral valve 🡩
Pulmonary vasc. Congestion
🡪 25% of pts
🡪 Apparent : about 20th week
🡪 Aggravated at the time of labor & delivery
Atrial fibrilation is particular concern
Therapy :
🡪 Ballon valvuloplasty
🡪 Mitral valve surgery

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 Mitral regurgitation (MR)

Causes :
⮊ Rheumatic fever
⮊ Myxomatous changes in the valve,
with prolapse
MR is generally well tolerated

Recognized congestive heart failure 🡪 should be

treated earlier :
⮊ Afterload reduction
⮊ ACE inh & ARBs 🡪 should not be used
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 Prosthetic valve disease
Prosthetic heart valve

Complications :
⮊ Thromboemboli
⮊ Bleeding (from anticoagulation)
⮊ Endocarditis
⮊ Valve dysfunction
⮊ Reoperation

Pregnancy🡪 risk of these complications 🡩

Prosthetic valve : relative contraindication to pregnancy
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• Congenital Heart Disease in Pregnancy

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 Congenital heart disease (CHD)

Maternal Corrected prior

morbidity to pregnancy
Maternal mortality
Residual/inoperable lesions
Fetal death 🡪 Careful understanding
before pregnancy undertaken

Cardiac & congenital Surgical 🡪 doesn’t alter

abn. in the fetus the incidence of CHD
in the offspring

Antibiotic prophylaxis against

endocarditis is as appropriate
during pregnancy
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 Congenital heart disease…
L-to-R shunts

ASD VSD PDA

Well tolerated during

Well tolerated during
Well tolerated during
pregnancy
pregnancy
pregnancy
Chance of PHT 🡩
Chance of PHT 🡩
Chance of PHT 🡩

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 Congenital heart disease…

R-to-L shunt
(Cyanotic heart disease

Pulmonary vasc. resistance Obstruction to pulmonary flow

Exceeds systemic vasc. resist
Eisenmenger’s syndrome
⮊ Advisable to avoid or
interrupt pregnancy
Normal pulmonary vasc. Resist.
Tetralogy of Fallot (TOF)
⮊ Most common form
⮊ Successful pregnancy can be
achieved although the lesion is
uncorrected, but maternal
mortality is high

Cyanosis; Hb 🡩 High fetal loss

High maternal mortality Low birth weight
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 Congenital heart disease…

Coarctation aorta
♂ >♀
With bicuspid aortic valve
Maternal mortality: 3-8%
Tx : Blood pressure control
Ballon dilatation
Surgery

Hypertrophic obstructive cardiomyopathy

An autosomal dominant trait
Dyspnea 🡩, chest discomfort 🡩,
palpitation 🡩 during pregnancy
Avoid hypovolemia
Tx : Beta blockers (at the time of
labor & delivery) 23

Complex congenital lesion
Transposition of
Great vessels
Maternal & fetal outcome 🡫
If corrected transposition
Isn’t complicated by :
⮊ cyanosis
⮊ ventricular dysfunction
⮊ heart block
🡪 pregnancy should be well
tolerated
Congenital heart disease…
Ebstein’s anomaly Marfan’s syndrome
Avoid pregnancy :
Maternal risk🡩 if : +
⮊ Right ventricular 1. Risk of aortic rupture 🡩
2. Women life’s span 🡫
dysfunction
3. Half of the offspring
⮊ RVOT obstruction
will be affected
⮊ R to L shunt
🡪 If recognized during
(avoid pregnancy) pregnancy :
⮊ Activity 🡫
⮊ HT prevented
⮊ Sectio cesarian 24
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• Peripartum Cardiomyopathy

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 Definition PPCM
• Demakis et al. (1971) : 4 criteria

Pearson et al, 2000 29

 Risk Factor PPCM
• Pregnant in > 30th • Geographic
• Multiparous • Prolonged use of
• Black race tocolytic
• Multiple gestation
• Obese
• Preeclampsia Beta agonist
• Chronic
hypertension
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• Stratification Risk State in Pregnancy

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 Cardiovascular abnormalities placing
a mother and infant at extremely high risk

Advise avoidance or Pregnancy counseling and

Interruption of pregnancy :
⮊ Pulmonary hypertension
⮊ Dilated cardiomyopathy
with CHF
⮊ Marfan’s syndrome with
dilated aortic root
⮊ Cyanotic congenital heart
disease
Close clinical follow up
required :
⮊ Prosthetic valve
⮊ Coartation of the aorta
⮊ Marfan’s syndrome
⮊ Dilated cardiomyopathy in
asymptomatic women
⮊ Obstructive lesions

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• Management HF in Pregnancy

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 Nearly all
cardiac drugs

Placenta Breast milk

Information about all of them is incomplete

When possible, to avoid their use
If required for maternal safety, they should be used
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 Congestive heart failure (CHF)
Management of CHF during pregnancy should not
differ greatly from that at other times,

ACE inhibitors and ARBs 🡪 should not be used

Supine position 🡪 preload reduction

with obstruction of return of blood from
the inferior vena cava to the heart

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 At Risk for Heart Failure Heart Failure

STAGE A STAGE B STAGE C

At high risk for HF but STAGE D
Structural heart disease Structural heart disease
without structural heart Refractory HF requiring
but without signs or with prior or current
disease or symptoms of specialized interventions
symptoms of HF symptoms of HF
HF

eg; Patients with:

-Hypertension eg; Patients with:
eg; Patients with: -Who have marked
-Atherosclerosis
-Previous MI eg; Patients with: symptoms at rest despite
disease -Known structural
-Diabetes Structural Heart -LV remodelling Development of Refractory symptoms of
maximal medical therapy
-Obesity disease symptoms of HF heart disease and HF at rest (eg; those who are
including LVH & -Shortness of breath & recurrently hospitalized
-Metabolic syndrome
low EF fatigue, reduced or can not be solely
or
Patients:
-Asymptomatic exercise tolerance discharged from the
-Using cardiotoxins valvular disease hospital without
-With FHx CM specialized interventions

THERAPY GOALS
-Treat hypertension THERAPY GOALS
THERAPY GOALS -Appropriate measures
-Encourage smoking THERAPY GOALS -All measures under Stage A & B under Stage A, B,C
cessation -All measures -Dietary salt restriction -Decision re: appropriate
-Treat lipid disorders DRUGS FOR ROUTINE USE
-Encourage regular
under Stage A -Diuretics for fluid retention level of care
exercise DRUGS -ACEI OPTIONS
-Compassionate end-of-
-Discourage alcohol -ACEI or ARB in -Beta-blockers
DRUGS IN SELECTED PATIENTS life care hospice
intake, illicit drug use appropriate -Extraordinary measures:
-aldosterone antagonist
-Control metabolic
syndromes
patients -ARBs - Heart transplant
-Beta-blockers in -Digitalis - Chronic inotropes
DRUGS -Hydralazine nitrates - Permanent
- ACEI or ARB in appropriate DRUGS IN SELECTED PATIENTS mechanical support
appropriate patients patients -Biventricular pacing - Experimental
(see text) for vascular -Implantable defibrillators
surgery or drugs
disease or diabetes

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The AHA Guidelines & Scientific Statements Handbook,2009.
THANK YOU

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