CardioCardio--vascular Diseases vascular Diseases

a n d a n d

pregnancypregnancypregnancypregnancy

Osama M. Osama M. Osama M. Osama M. Osama M. Osama M. Osama M. Osama M. WardaWardaWardaWardaWardaWardaWardaWarda; ; ; ; ; ; ; ; MDMDMDMDMDMDMDMD

Professor Professor of OB/GYNof OB/GYN

MansouraMansoura UniversityUniversity

Topics Topics INTRODUCTION INTRODUCTION � Hemodynamic changes during pregnancy *� Effects of pregnancy on maternal cardiac disease *� Effects of maternal cardiac disease on pregnancy * � Prognosis * � Preconceptional counseling *DIAGNOSIS OF HEART DISEASEDIAGNOSIS OF HEART DISEASE

**classification classification Clinical diagnosis/Clinical diagnosis/

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**classification classification Clinical diagnosis/Clinical diagnosis/

**Investigations Investigations

MANAGEMENTMANAGEMENT�� General management General management **

�� Management of specific problems;Management of specific problems;

Treatment of acute heart failureTreatment of acute heart failure**

Treatment of acute pulmonary edemaTreatment of acute pulmonary edema

Valve diseasesValve diseases

Surgically corrected heart disease Surgically corrected heart disease

Congenital heart diseaseCongenital heart disease

Other cardiovascular conditionsOther cardiovascular conditions

Introduction Introduction

Hemodynamic changes during pregnancy:Hemodynamic changes during pregnancy:

1.1. Increased cardiac outputIncreased cardiac output:: starts at starts at 10 10 weeks, reaches weeks, reaches maximum at maximum at 2424-- 28 28 weeks, remains elevated until delivery.weeks, remains elevated until delivery.

2.2. Increased intraIncreased intra--vascular volumevascular volume: It starts at : It starts at 8 8 weeks, weeks, reaches maximum at reaches maximum at 3232--36 36 weeks. weeks.

3.3. Increased pulse rateIncreased pulse rate:: due to hyperdynamic circulation & due to hyperdynamic circulation &

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3.3. Increased pulse rateIncreased pulse rate:: due to hyperdynamic circulation & due to hyperdynamic circulation & increased cardiac output.increased cardiac output.

4.4. Decreased peripheral vascular resistanceDecreased peripheral vascular resistance: manifested : manifested clinically by decreased both mean & diastolic BP mostly in the clinically by decreased both mean & diastolic BP mostly in the 22nd trimester. nd trimester.

5.5. Decreased pulmonary vascular resistanceDecreased pulmonary vascular resistance..

6.6. Decreased colloid oncotic pressureDecreased colloid oncotic pressure..

7.7. Increased in size & compliance of the aortic root.Increased in size & compliance of the aortic root.

IntroductionIntroduction

Effects of pregnancy on maternal cardiac disease:

1.1. Cardiac work is increasedCardiac work is increased due to hemodynamic changes; if exceeds the limits of functional capacity, congestive heart failure results.

2.2. Maternal mortalityMaternal mortality is 10% for all cardiac patients, however

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2.2. Maternal mortalityMaternal mortality is 10% for all cardiac patients, however varies widely with severity of cardiac problem.

3. There are 3 periods during which the danger of cardiac de-compensation is specially great:

32 -28the most critical period is ; ; weeks32 & 12 Between [A] weeks.

Introduction cont;Introduction cont;

[B]. During labor: [B]. During labor: [B]. During labor: [B]. During labor:

---- First stageFirst stageFirst stageFirst stage: : : : Every uterine contraction increase COP by 15-20% due to ejection of blood from the utero-placental circulation into maternal blood stream.

---- Second stageSecond stageSecond stageSecond stage: : : : Maternal pushing decreases venous

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---- Second stageSecond stageSecond stageSecond stage: : : : Maternal pushing decreases venous return to the heart; hence the COP is decreased that is critical for some cardiac lesions.

---- Third stageThird stageThird stageThird stage:::: Immediately following delivery of the fetus & placenta, the obstructive effect of the pregnant uterus disappears leading to sudden transfusion of blood from the lower limbs and the utero-placental vascular tree to systemic circulation leading to CHF.

Introduction cont;Introduction cont;

[C]. Post-partum 4th & 5th days: This period is This period is

most dangerous for certain cardiac patients such as most dangerous for certain cardiac patients such as

those with those with primary pulmonary hypertension, primary pulmonary hypertension, Eisenmenger syndrome, Eisenmenger syndrome,

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Eisenmenger syndrome, Eisenmenger syndrome,

aortic stenosis, aortic stenosis, oror cyanotic heart diseasecyanotic heart diseasedue to decreased peripheral resistance with rightdue to decreased peripheral resistance with right--toto--

left shunt, and pulmonary emboli from silent ilioleft shunt, and pulmonary emboli from silent ilio--

femoral thrombus. femoral thrombus.

Introduction cont;Introduction cont;

Effects of maternal cardiac disease on Effects of maternal cardiac disease on pregnancy:pregnancy:

1.1. Perinatal mortalityPerinatal mortality is increased (is increased (2020%) mostly with %) mostly with cyanotic heart disease. It is drastically improved by cyanotic heart disease. It is drastically improved by adequate preadequate pre--natal care.natal care.

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adequate preadequate pre--natal care.natal care.

2.2. PerinatalPerinatal morbiditymorbidity is increased due to is increased due to preterm laborpreterm laborpreterm laborpreterm laborpreterm laborpreterm laborpreterm laborpreterm labor& intra& intra--uterine fetal growth restriction (uterine fetal growth restriction (IUGRIUGRIUGRIUGRIUGRIUGRIUGRIUGR) as a ) as a result of chronic tissue hypoxia.result of chronic tissue hypoxia.

3.3. Fetal congenital cardioFetal congenital cardio--vascular anomalies:vascular anomalies: In In mothers with congenital heart disease, the incidence mothers with congenital heart disease, the incidence is increased (is increased (44..55% versus % versus 00..6 6 % in overall population).% in overall population).

Introduction cont;Introduction cont;

Prognosis:Prognosis:

�� The overall maternal mortality is The overall maternal mortality is 1010%.%.

�� The overall perinatal mortality is The overall perinatal mortality is 2020%.%.

Prognostic factors are:Prognostic factors are:

�� The functional cardiac capacity.The functional cardiac capacity.

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�� The functional cardiac capacity.The functional cardiac capacity.

�� Other complication that further increase the cardiac load.Other complication that further increase the cardiac load.

�� Quality of medical care provided.Quality of medical care provided.

�� Psychological & socioPsychological & socio--economic factors may be of great economic factors may be of great

importance, because for some women bed rest may be required importance, because for some women bed rest may be required

throughout pregnancy.throughout pregnancy.

Preconceptional counseling:Preconceptional counseling:Preconceptional counseling:Preconceptional counseling:Preconceptional counseling:Preconceptional counseling:Preconceptional counseling:Preconceptional counseling:

during counseling the couple and family; consider this classification of during counseling the couple and family; consider this classification of the ACOGthe ACOG

Risk for maternal mortality caused by various heart disease: MORTALITYCARDIAC DISORDER

0-1% Group 1

1. Atrial septal defect (ASD) 2. Ventricular septal defect (VSD) 3. Patent ductus areriosus (PDA) 4. Pulmonic or tricuspid disease. 5. Fallot's tetralogy; corrected 6. Bioprosthetic valve 7. Mitral stenosis NYHA class I& II

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5-15%

Group 2:2A 1. Mitral stenosis NYHA III & IV 2. Aortic stenosis. 3. Aortic co-arctation without valvar involvement 4. Fallot's tetralogy; uncorrected 5. Previous myocardial infarction 6. Marfan syndrome; normal aorta 2B : 1. Mitral stenosis with atrial fibrillation 2. Artificial valve

25-50%

Group 3:1. Pulmonary hypertension 2. Aortic coarctation with valvar involvement 3. Marfan syndrome with aortic involvement

Diagnosis of heart disease:Diagnosis of heart disease:

[A] Clinical Diagnosis:[A] Clinical Diagnosis::SYMPTOMS

1. Severe or progressive dyspnea (breathlessness).

2 Progressive orthopnea3 Paroxysmal nocturnal

dyspnea.

SIGNS:1. Cyanosis2 Clubbing of fingers3 Congested neck veins4 Cardiomegaly5 Diastolic murmur

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dyspnea.4 Hemoptysis5 Syncope with exertion6 Chest pain related to effort or

emotion

5 Diastolic murmur6 Systolic murmur greater than

grade 3/67 sustained arrhythmia8 persistent split 2nd sound9 pulmonary hypertension criteria

(left parasternal lift & loud P2)

CLINICAL CLASSIFICATION ( NYHA: 1979) The New York Heart Association (NYHA) classified heart disease into 4 classes depending on the degree of functional impairment:

Description Class Asymptomatic ( uncompromised)I

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Asymptomatic ( uncompromised)ISymptomatic with heavy exertion (slightly compromised)IISymptomatic with light exertion (markedly compromised)IIISymptomatic at rest ( severely compromised)IV

[B] Investigations:[B] Investigations:

1- Electrocardiography (ECG)

2- Chest X- ray to evaluate the heart silhouette.

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silhouette.

3- Echocardiography

General management:Management of class I and II:

[A]. Prevention of heart failure:1- Prevention of infection.2- Prohibition of cigarette smoking.3- Bed rest (most important measure).4- Dietary salt restriction.

[A]Prevention of HF

[B]EARLY recognition of HF

[C]Measures during labor

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4- Dietary salt restriction.5- Correction of anemia.6- Diuretics when salt restriction is not enough to limit

the intravascular expansion.7- Prophylactic digitalization.

General management:Management of class I and II:

[B]. Early recognition of heart failure:1- Persistent basilar rales, frequently with cough

2 Sudden diminution in ability to carry up usual duties

3 Increasing dyspnea with exertion

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3 Increasing dyspnea with exertion

4 Attacks of smothering with cough

5 Hemoptysis

6 Tachycardia

7 Progressive edema

General management:Management of class I and II:

[C]. General measures for labor :1- position: semi-sitting with left lateral tilt2- pulse oximetry 3- adequate pain relief4- restriction of i.v. fluids to 75 ml/hr

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5- oxygen by mask or nasal cannula6- avoid bolus oxytocin & ergot compounds( eg methergin)7- antibiotic prophylaxis 8-thrombosis prophylaxis (sp. cases)9-prevention of postpartum pulmonary edema (by immediate

postpartum diuretics)10- Delivery should be accomplished vaginally unless there is

an obstetrical indication for cesarean section.

%]%]44[ maternal mortality [ maternal mortality Management of classes III and IV:Management of classes III and IV:

� When the patient is seen early in pregnancy (in 1st

trimester), the option of pregnancy termination should be discussed with the family

� If pregnancy to be continued ( patient refused termination or seen late in pregnancy):

1- prolonged hospitalization is necessary

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1- prolonged hospitalization is necessary 2- the measures described in management of classes

I&II are done.

3- surgery is hazardous in these patients, so CS is only done when there is strong obstetrical indication.

Treatment of acute CHF during pregnancy:Treatment of acute CHF during pregnancy:

[A]. Exclusion of precipitating causes as:

1- Anemia2- Infection3- Arrhythmia4-Non-compliance to

[B]. Active management:

1- Reducing cardiac work by bed rest

2- Decreasing the preload by diuretics

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4-Non-compliance to medication or salt restriction

5- Excessive physical activity6- Administration of salt

retaining medications (eg steroids)

diuretics

3- Improving the cardiac contractility by digitalis & other agents (dopamine, dobutamine)

4- Reducing the after-load with vasodilators

Management of Acute Pulmonary Edema (APE)Management of Acute Pulmonary Edema (APE)

[A] [A] ProphylaxisProphylaxis: :

by preventing precipitating causes which are:

1-Administration of βadrenergic agents (eg. Tocolysis)

[B] Active management:1- APE due to β adrenergicagent by

discontinuation of the drug, extensive diuresis, and oxygen by mask.

2- APE due to preclampsia-eclampsia;the treatment is difficult due to endothelial injury, capillary permeability, and

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Tocolysis)2- Pre-eclampsia and

eclampsia3- Congestive heart failure

capillary permeability, and decreased plasma colloid pressure. However, supportive measures and expectant therapy is favoured, although prognosis is poor.

3- APE due to CHF; treatment is essentially for CHF (seebefore).

CARDIAC VALVE DISEASESCARDIAC VALVE DISEASES

The causes of valve lesions in childbearing age are:

1- Rheumatic fever

2- Congenital heart disease

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2- Congenital heart disease

3- Other rare causes (e.g connective tissue diseases)

CARDIAC VALVE DISEASESCARDIAC VALVE DISEASES

Mitral stenosis (MS):

Diagnosis:1- middiastolic rumbling murmur at apex2- AF by ECG

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2- AF by ECG3- Echocardiography (most important)

Management: 1- general measures (see before) plus2- β- blockers (to slow heart rate)3- vaginal delivery is preferable than CS

CARDIAC VALVE DISEASESCARDIAC VALVE DISEASES

Mitral insufficiency (MI):

Diagnosis:1- pansystolic harsh murmur (grade > 3/6) at the apex propagated to axilla2- echocardiography (most important)

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2- echocardiography (most important)

Management:1- general measures (see before) plus2- prevention against infective endocarditis (most important measure)

Note: heart failure is rare and pregnancy is well tolerated with MI and also AI.

CARDIAC VALVE DISEASESCARDIAC VALVE DISEASESAortic Stenosis (AS):

Diagnosis:1- Ejection systolic murmur over the aortic area2- Echocardiogram ( most important)

Management:

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Management:It is a serious condition with pregnancy

[A] During pregnancy:1- Asymptomatic patients; general measures and close observation2- Symptomatic patients;� Strict limitation of activity� Prompt treatment of infection� Surgical correction (valvotomy; or valve replacement) must be

considered if symptoms persist despite bed rest.

CARDIAC VALVE DISEASESCARDIAC VALVE DISEASESAortic Stenosis (AS): continued;

[B] During labor: (HYPOTENSION IS THE MAJOR RISK)1- Intensive monitoring using:� Pulmonary artery catheterization� Narcotic epidural analgesia to avoid hypotension� Maintain a margin of safety in the intravascular volume in

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� Maintain a margin of safety in the intravascular volume in anticipation of unexpected hemorrhage.

� Prophylaxis against bacterial endocarditis

2- Delivery : in vaginal delivery the 2nd stage of labor should be shortened by forcepsor vacuumextraction. Cesareandelivery is indicated for obstetrical reasons and for patients who are hemodynamically unstable.

SURGICALLY CORRECTED HEARTSURGICALLY CORRECTED HEARTValve Replacement:

Usually mitral, and to a lesser extent aortic.Usually mitral, and to a lesser extent aortic.Two types of valves; prosthetic (metallic), or natural (porcine) valveTwo types of valves; prosthetic (metallic), or natural (porcine) valve..

Management:

[A] Porcine tissue valves: following the general measures. No anticoagulation required.

[B]. Prosthetic valve:� Full anticoagulation (INR=2 : 2.5 ): heparins (SC) or oral warfarins,

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� Full anticoagulation (INR=2 : 2.5 ): heparins (SC) or oral warfarins, or alternating to avoid fetal morbidity from warfarins in the first trimester, and at term.

� General measures are followed.� Prolonged hospitalization � Prophylaxis against infection� Postpartum contraception; oral contraceptives containing estrogens &

progestins are contraindicated due to possible thrombogenic action. Tubal sterilization should be considered.

SURGICALLY CORRECTED HEARTSURGICALLY CORRECTED HEART

Mitral Valvotomy:

� Good clinical results following valvotomy do not guarantee an uncomplicated labor & delivery. Heart failure develops in about 40% of patients during their 1st post-operative pregnancy.

� Coexisting AF is specially ominous & commonly

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� Coexisting AF is specially ominous & commonly associated with heart failure, thrombo-embolism, and maternal death.

� Management as in cases with porcine tissue valve.� Fetal complications are not increased.� Closed mitral valvotomy performed during

pregnancy is usually well-tolerated & downgrades the functional class from grade III, or IV to class I.

CONGENITAL HEART DISEASE WITH CONGENITAL HEART DISEASE WITH

PREGNANCYPREGNANCY

Atrial Septal Defect ( ASD): � Pregnancy is well-tolerated unless pulmonary hypertension

developed.� Bacterial endocarditis prophylaxis is indicated.� Management following the general measures.

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Ventricular Septal Defect (VSD):� Pregnancy is well-tolerated with small-to-moderate left-to-

right shunts. When pulmonary arterial pressure reaches the systemic pressure (Eisenmenger's syndrome); maternal mortality is 50%, pregnancy is contra-indicated & therapeutic abortion is advised.

� Bacterial endocarditis prophylaxis is recommended.

CONGENITAL HEART DISEASE WITH CONGENITAL HEART DISEASE WITH

PREGNANCY cont.;PREGNANCY cont.;

Cyanotic Heart Disease:� The classical most encountered lesion in

pregnancy is Fallot's tetralogy.

Poorly tolerate pregnancy with maternal

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� Poorly tolerate pregnancy with maternal mortality 10%, and also increased fetal morbidity (abortion, preterm labor) and IUFD.

� Management follows the general measures with care taken to avoid sudden hypotension.

Maternal tolerance to heart diseaseMaternal tolerance to heart disease

tolerated: -Well

Pulmonary stenosis ----1111

2- Aortic insufficiency

3- Mitral insufficiency

4- Congenital heart block

tolerated in absence of tolerated in absence of --WellWell

pulmonary hypertension:pulmonary hypertension:

11-- Atrial septal defect Atrial septal defect

22-- Ventricular septal defectVentricular septal defect

33-- Patent ductus arteriosusPatent ductus arteriosus

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4- Congenital heart block33-- Patent ductus arteriosusPatent ductus arteriosus

Variable tolerance depending on

functional capacity of the heart:

1- Uncomplicated aortic

coarctation

2- Aortic stenosis

3- Mitral regurgitation

4- Aortic regurgitation

tolerated & source of significant problems -Poorly

during pregnancy:

11-- Mitral stenosis Mitral stenosis 22-- Peripartum cardiomyopathyPeripartum cardiomyopathy

33-- Primary pulm. hypertension Primary pulm. hypertension 44-- EisenmengerEisenmenger

55-- Marfan's syndrome with dilated aortic rootMarfan's syndrome with dilated aortic root

66-- Metallic valve prosthesis Metallic valve prosthesis

77-- Congenital cyanotic HDCongenital cyanotic HD

88-- Any class III or IV lesionAny class III or IV lesion

Indications of therapeutic abortion Indications of therapeutic abortion

in cardiac patients:in cardiac patients:

1- Eisenmenger's syndrome

2- Marfan's syndrome with dilated aortic root

3- Primary pulmonary hypertension

4- Tight mitral stenosis

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4- Tight mitral stenosis

5- Aortic stenosis symptomatic despite absolute bed rest

6- Constrictive or dilated cardiomyopathy

7- Congestive heart failure in prior pregnancy (occurrence in subsequent pregnancy is inevitable).

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