HEART DISEASES IN PREGNANCY

DR. TAILA AMBER

PHYSIOLOGICAL CHANGES IN PREGNANCY

Cardiac output 30-50%

Stroke volume 30-50%

Heart rate 10-20bpm

Systemic Peripheral resistance 30%

Decrease in both systolic(3-5mmHg) &diastolicblood pressure (5-10mmHg) .

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Gradient between colloid oncotic pressure and

Pulmonary Capillary wedge pressure 28%

Turning from left lateral to supine position, CO

25%

PHYSIOLOGICAL CHANGES IN PREGNANCY

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PHYSIOLOGICAL CHANGES DURING LABOUR Rapid increase in HR and BP Increase in Cardiac Output

15% in 1st stage 50% in 2nd stage

Uterine contractions -> auto-transfusion of 300-500ml 3rd Stage: 1L blood returns to circulation Hence, risk of pulmonary edema in 2nd stage and immediately

post-partum Changes revert ---

Rapidly in 1st week Slowly in 6 weeks Some may persist for 1 year

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Decreased exercise capacity Tiredness Dyspnea Palpitations Light headedness

SYMPTOMS DURING NORMAL PREGNANCY THAT MAY MIMIC CARDIAC DISEASE

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SUSPECT HEART DISEASE

Previous history Orthopnea and PND Excessive fatigue Palpitations with sweating/syncope Chest pain

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SIGNS that mimic CARDIAC DISEASE

Loud S1 Exaggerated splitting of S2 Physiological S3 at the apex Systolic ejection murmur at LSB ( up to Grade 3/6) (96%) Continuous murmurs ( mammary soufflés, cervical

venous hum) Bounding pulse Ectopic beats

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SUSPECT HEART DISEASE Low volume pulse Tachycardia, Irregular pulse - Atrial

fibrillation Cyanosis, clubbing, Splinter

hemorrhages Signs of cardiac failure

– Raised JVP, hepatomegaly, pedal edema Pan-systolic murmurs (VSD,MR,TR)

with Thrill Late systolic murmurs (MR, MVP) Ejection systolic murmur (Grade > 3/6) Diastolic murmur Dr. Taila Amber

TYPES OF CARDIAC DISEASES

CONGENITAL ACQUIRED

PDAASD/VSDPULMONARY STENOSISTOFCONGENITAL AORTIC / MITRAL VALVE DISEASEEISENMENGER’S SYNDROMEPRIMARY PULMONARY HTNCOARCTATION OF AORTAMARFAN’S SYNDROMECONGENITAL HEART BLOCKTRICUSPID ATRESIA

RHEUMATIC HEART DISEASE MS (90%) MR (6.6%) AS (1%) AR (2.5%) TR/TSMICARDIOMYOPATHY HOCM Puerperal cardiomyopathyENDOMYOCARDIAL FIBROSISPERICARDIAL DISEASE

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CLASS I No functional limitation of activity. No symptoms of cardiac de-compensation with activity.

CLASS II Patients are asymptomatic at rest. Ordinary physical activity results in symptoms.

CLASS III Limitation of most physical activity. Asymptomatic at rest Minimal physical activity results in symptoms.

CLASS IV Severe limitation of physical activity results in symptoms.

Patients may be symptomatic at rest /heart failure at any point of pregnancy.

NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE

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SIGNIFICANCE OF HEART DISEASEIN PREGNANCY

MATERNAL : Restricted physical

activity MM : 2.3/100,000 CAUSES:

• MS (in our country)• Cardiomyopathy• Pulmonary vascular

disease / HTN• MI• Dissecting aneurysm• Endocarditis

FETAL: Miascarriages IUGR IUD Premature delivery Increased PMR Risk of CHD = 2-4%

Cardiac disease affects 3-3.5% of all pregnancies

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INITIAL MANAGEMENT

• ASSESSMENT OF PREGNANT PATIENT

• FETAL ASSESSMENT

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ASSESSMENT OF PREGNANT PATIENTS

HISTORY

• Dyspnea : NYHA classification, onset • Fever with arthralgia• Prior events : (HF ,TIA ,STROKE). • Recurrent Cyanosis • Associated diseases : (anemia ,thyrotoxicosis ,Htn).• Drugs : (kind ,compliance ,education) • Past History• Arrhythmia • Family history

EXAMINATION

• Murmurs.• Signs of heart failure• Signs of endocarditis

ECG&ECHO

• ECG: arrhythmia.• ECHO• CXR, MRI• Angiography

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ECGAxis deviation to the left 15-20Small Q wavesT wave inversion in lead IIISinus tachycardia

TROPONIN Not affected by pregnancy, useful in IHD TRANSTHORACIC ECHOCARDIOGRAPHY-Cornerstone of

evaluation­ LV / RV / LA / RA dimensions, pericardial effusion, Small Functional TR /

PR / MR/ AR CXR MRI , CT scan ANGIOGRAPHY

INVESTIGATIONS

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FETAL ASSESSMENT

• 1st Trimester USG: sensitivity=85%, Specificity = 99%• 2nd Trimester (18-20wk): Optimal time• When fetal cardiac anomaly suspected:

– Full fetal Echocardiography– Detailed anomaly scan– Family history– Maternal medical history– Fetal karyotype– Referral to maternal-fetal medicine specialist ,pediatric

cardiologist, geneticist, neonatologist– Delivery where NNU facilities are available

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SUBSEQUENT MANAGEMENT

1. Pre-conceptional counseling, Risk stratification

2. Antepartum management

3. Peripartum management

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PRE-CONCEPTIONAL COUNSELLING

Obstetrician and cardiologist

Prevent an unwanted pregnancy and asses the risks associated with pregnancy

Continuation OR Termination

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RISK SCORE (CARPREG Study)

1. Preconception history of adverse cardiac events or arrhythmia

2. Poor functional class before pregnancy(NYHA class >II)

3. Left heart obstruction -MVA < 2 sqcm AVA <1.5sqcm Aortic valve gradient >30mmHg4. LV Ejection Fraction <40%5. Cyanosis

Estimated risk of adverse cardiac event 0 ------- 5% 1 ------- 27% >1 ------- 75%

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TERMINATION OF PREGNANCY

TERMINATION - <12wks OF PREGNANCY Eisenmenger's syndrome Marfan syndrome with aortic involvement Severe Pulmonary hypertension Coarctation of aorta Symptomatic severe AS, MS Severe left ventricular dysfunction EF<40% Metallic prosthetic valve –complications

1st and 2nd trimester : suction evacuation safe If medical management : Mifepristone in 1st

PG E1,2 , misoprostolDr. Taila Amber

ANTEPARTUM MANAGEMENT

• MEDICAL MANAGEMENT

• SURGICAL MANAGEMENT

• OBSTETRICAL MANAGEMENT

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MEDICAL MANAGEMENTMultidisciplinary Team – cardiologist, obstetricians,

fetal medicine specialists, pediatrician

NYHA CLASS I or II 1. Limit strenuous exercise2. Adequate rest3. Iron and Vitamins to minimize anemia 4. Low salt diet if ventricular dysfunction5. Regular cardiac and obstetric evaluation

Identify and treat early - infections, anemia, hypertension, hyperthyroidism & arrthymias

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NYHA CLASS III or IV

1. Hospitalisation for bed rest2. Intensive Close monitoring3. Cardiac intervention, surgery4. Termination of pregnancy

Treat precipitating events – infections, arrhythmia, anemia, hyperthyroidism

DISEASE SPECIFIC

MEDICAL MANAGEMENT

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SURGICAL MANAGEMENT

• Rarely required, in certain cases of acquired heart disease

• Open heart surgery avoided (10-30% Risk of fetal loss)

• Closed valvotomy or valvuloplasty preferred for valvular lesions

• Optimal time -> 2nd trimester

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OBSTETRICAL MANAGEMENT

Frequency of visits: 2 weeklyAssessment of cardiac status, fetal size, liquor, FM

USGAnomaly scan2 weekly growth scan

Hospital admissionLow threshold

Time and mode of delivery Labour

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TIME OF DELIVERY

• Multidisciplinary Approach

• TIMING OF DELIVERY:Individualized on– Cardiac status– Bishop score– Fetal well-being– Lung maturity

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MODE OF DELIVERY

Normal vaginal delivery - in patients hemodynamically stable (ESC guidelines)– Less risk of blood loss, infections, VTE

Cesarean section is indicated in:1. Aortic dissection2. Marfan syndrome with dilated aortic root( >45mm)3. Hemodynamically Unstabillity in particular case of

severe AS.4. Obstetric causes 5. OACs

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INDUCTION OF LABOUR

• BISHOP favorable : ARM & Oxytocin infusion

• BISHOP unfavorable: – Misoprostol : Low risk of coronary vasospasm &

arrhythmias– Dinoprostol: Affects B.P, Contraindicated in active

CVD– Mechanical methods preferred

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LABOUR Intensive Hemodynamic monitoring in severe stenotic lesions

or low EF. Admit few days before labour Pulse, BP, O2 saturation, Left lateral position. Careful attention to volume status NS < 75 ml/hour Inj. Furosemide , Digoxin - Asses pulmonary basal crepts, JVP Treatment of arrhythmias Epidural analgesia to provide analgesia and thus avoid

increase in CO due to pain and anxiety Procedures (ventouse / forceps) to cut short the 2nd stage of

labour

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DELIVERY IN ANTICOAGULATED WOMEN WITH PROSTHETIC VALVES

• ELECTIVE DELIVERY:– OACs shifted to LMWH / UFH from 36 weeks– LMWH shifted to UFH 36 hrs before induction/ C-section– UFH discont. 4-6 hrs before delivery, restarted 4-6 hrs after

delivery• EMERGENCY DELIVERY:

– If on UFH/LMWH --- consider Protamine– If on OACs --- C-section

• FFP & Oral Vit K (0.5-1mg) before C-section• Target INR ≤ 2• FFP & Vit K to newborn

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Warfarin is the favored anticoagulant during the 2nd, 3rd trimesters until the 36th wk

(Class IC ESC guidelines).

Warfarin is favored in the 1st trimester if the dose <5mg /24hrs(Class IIaC ECS guidelines)

ESC GUIDELINES

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POST PARTUM CARE

• Slow IV oxytocin infusion @ <2U/min• PGF analogues in PPH• Methylergometrine contraindicated (10% risk of

vasoconstriction & HTN)• Leg care, elastic stockings, early ambulation to

prevent VTE• Hemodynamic monitoring for 24-72 hours post-

partum

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LACTATION

• Prevents Mastitis, hence Bacteremia

• Diuretic requirement fall

• If severely unwell --- Bottle feed

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SPECIFIC HEART DISEASES

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ARRHYTHMIAS

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• Acute atrial flutter or atrial fibrillation treated promptly

• Ventricular Arrhythmias commonest cardiac complication during pregnancy

• If possible, all antiarrhythmic drugs should be avoided during the first trimester, and those known to be teratogenicity should be avoided throughout pregnancy.

• Because of their safety profiles, preferred drugs include digoxin, beta-blockers and adenosine.

ARRHYTHMIAS

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EISENMENGER’S SYNDROME• MATERNAL RISK: Mortality = 20-50%• NEONATAL OUTCOME: Live birth < 12%• MANAGEMENT:

• If Pregnancy ------ Termination• If pt. choose to continue ---

• Bed rest, O2 saturation• Anticoagulation• Diuretics if heart failure• Oral/ IV Fe, if Iron deficiency

• Delivery --- • C-section if maternal/ fetal condition

deteriorates• Otherwise, timely admission, planned deliveryDr. Taila Amber

MITRAL STENOSIS

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• Responsible for most of morbidity and mortality of RHD in pregnancy• MATERNAL RISK:

• Heart failure (MVA<1.5sqcm), Pulmonary edema • OBSTETRIC/ OFFSPRING RISK:

• Prematurity = 20-30%• IUGR = 5-20%• Still birth = 1-3%

• MANAGEMENT:• Moderate/Severe MS --- counsel against pregnancy• Mild MS: Echo monthly• Medical: β1 blocker, diuretics, anticoagulants• Surgical: Percutaneous mitral commisurotomy after 20 weeks in

NYHA III/IV• MOD:

• Mild --- Vaginal• Moderate/Severe ---- Cesarean section

MITRAL STENOSIS

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• MATERNAL RISK:– VTE in 5%– Arrhythmia

• OBSTETRIC RISK:– Pre-eclampsia– SGA

• MANAGEMENT:– MOD: Vaginal– Catheter device closure if condition deteriorates– Prevention of embolisation

• Compression stockings• Avoiding supine position• Early ambulation after delivery

ASD/VSD

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COARCTATION OF AORTA• MATERNAL RISK:

– Class II WHO– Risk of aortic or cerebral aneurysm rupture

• OBSTETRIC/OFFSSPRING RISK:– HTN– Miscarriage

• MANAGEMENT:– MOD: Vaginal with epidural (ESC) Cesarean section in some references – Follow up in each trimester– Treat HTN, but not to cause hypo perfusion– Percutaneous intervention could be done

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PERIPARTUM CARDIOMYOPATHY

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• Idiopathic CM presenting with heart failure secondary to LV systolic dysfunction towards end of pregnancy or in months following delivery

• EF always reduced to below 45%• PREDISPOSING FACTORS:

– Multiparity, family history, smoking, DM, HTN, Pre-eclampsia, malnutrition

• S/S: of heart failure• INVESTIGATION: Echocardiography• TREATMENT:

• Medical treatment of heart failure • Hydralazine, Nitrates, Dopamine, β blockers

are safe• ACE inhibitors, ARBs, Renin Inhibitors avoided

PERIPARTUM CARDIOMYOPATHY

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MYOCARDIAL INFARCTION• MATERNAL RISK:

– Rare in pregnancy– 19 % immediate mortality

• MANAGEMENT:– INITIAL:

• Opiates, anticoagulants• Coronary angiography after delivery• MOD: Vaginal with epidural analgesia• Instrumental delivery• Oxytocin infusion in 3rd stage • Ergometrine avoided

– PUERPERIUM:• MB-CPK raised• Pregnancy discouraged in futureDr. Taila Amber

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PREGNANCY AND DRUGS

STENOTIC LESIONS REGURGITATION LESIONS

• Bblocker: metoprolol ,propranolol (class C ),atenolol (class D ).

• C channel antagonist: verapamil , diltiazem (class C)

• Digoxin : (class C).

• Diuretic: for patient with pulmonary congestion.

• Vasodilators: only If BP is high :• Hydralazine:(class C ).• Nitrate :(class C ).

• Diuretic:• Thiazide: ( class B).• Loop diuretic: (class C ).• Avoid hypotension & placental

hypoperfusion

ACE inhibitor ,ARBS (class X ).

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CONTRACEPTION

• Barrier methods – unreliable.• COC contraindicated.• Progesterone only pill have better side effect profile

& long acting slow releasing as Mirena intrauterine system have improved efficacy.

• Sterilization where family completed. (Laparoscopic clip sterilization carries risk).

Dr. Taila Amber

CONCLUSIONPregnancy causes significant haemodynamic changes

and imposes an additional burden on the cardiac patient, especially around the time of labour and in the immediate puerperium.

To achieve a successful pregnancy outcome, a clear understanding of these haemodynamic adaptations as well as meticulous maternal and foetal surveillance for risk factors and complications throughout the pregnancy is essential.

Dr. Taila Amber

CONCLUSION

Appropriate contraceptive and family planning advice as well as pre-conceptional counseling are also important.

The concerted efforts of a team consisting of theobstetrician, cardiologist, anesthetist, cardiothoracic surgeon, neonatologist, and pediatric cardiologist are mandatory to ensure optimal results.

Dr. Taila Amber

THANK YOU

Dr. Taila Amber