PREGNANCY AND HEART FAILURE

PROF.DR. MUHAMMAD AKBAR CHAUDHARY

M.R.C.P. (U.K.) F.R.C.P. (E)

F.R.C.P. (LONDON) F.A.C.C

Designed At A.V. Dept. F.J.M.C. By Rabia Kazmi

IF DISEASE DURING PREGNANCY IS TO BE WELL MANAGED, THE PHYSIOLOGICAL CHANGES OF PREGNANCY MUST BE KNOWN.

C. SIDNEEY BURWELL ,M.D.1958

POTENTIAL DANGERS OF PREGNANCY TO MOTHER

1. HEAMODYNAMIC BURDEN OF PREGNANCY MAY RESULT IN DISABILITY OR DEATH OF MOTHER

2. PREGNANCY MAY AGGREVATE, PRE-EXISTING MATERNAL HEART DISEASE.

3. DANGERS OF DEVELOPING BACTERIAL ENDOCARDITIS & RECURRENCE OF RHEUMATIC FEVER

4. PREGNANCY MAY CAUSE HEART DISEASES

POTENTIAL DANGERS TO FETUS

1. ABNORMAL ORGANOGENESIS OR DEATH DUE TO INADIQUATE BLOOD SUPPLY

2. 50% FETAL WASTAGE WITH SEVERE MATERNAL HEART DISEASE.

3. INCIDENCE OF CONG. HEART DISEASE IS INCREASED, WITH MOTHER HAVING CONG.H.D. (15% CHANCES) & SOMETIMES UP TO 50% (I.H.S.S. & MARFAN SYNDROME)

4. INCREASE CHANCES OF LOOSING MOTHER

CONGENITAL HEART DISEASE IN THE OFFSPRING OF A PARENT WITH CONGENITAL HEART DISEASE

Cardiacoutput(liters/min)

6

4

100

50

60

90

70

50

20-24 28-32 38-40 6-8 weeks PP

Heartrate(beats/min)

Stroke volume(cc)

Gestation

CHANGES IN C.V.S. DURING NORMAL PREGNANCY

IN NORMAL PREGNANCY Na+ AND WATER RETENSION OCCURES

PLASMA VOLUME BEGINS TO RISE AS EARLY AS 6th WEEK AFTER CONCEPTION.

PLASMA VOLUME APPROACHES MAXIMUM IN SECOND TRIMESTER AND IS 1 TIME NORMAL AT DELIVERY

TOTAL BODY WATER INCREASES TO 6-8. L.

TOTAL Na + RETENSION IS 500-900 meq.

12

IN PREGNANCYCARDIAC OUT PUT AND ITS DISTRIBUTION AT REST

CARDIOVASCULAR ASSESSMENT OF PREGNANT WOMANWHAT COULD BE NORMAL?

DYSPNOEA, CHEST PAIN, EASY FATIGABILITY, PALPITATIONS SYNCOPE MAY BE DUE TO PREGNANCY ONLY.

PERIPHERAL OEDEMA MAY OCCUR IN 80% NORMAL PREGNANT WOMAN.

VISIBLE NECK VEINS, PULMONARY RALES NOT UNCOMMON IN PREG.

CARDIOVASCULAR ASSESSMENT OF PREGNANT WOMAN

WHAT IS ABNORMAL? P.N.D, ORTHOPNOEA, SEVERE

DYSPNOEA LIMITING NORMAL ACTIVITY

HEMOPTYSIS SYNCOPE WITH EXERTION TYPICAL CHEST PAIN OF I.H.D. CYANOSIS CLUBBING SYSTOLIC MURMUR OF 3/6 AND

MORE. DIASTOLIC MURMUR.

CARDIAC LESION RELEVANT HEMODYNAMIC CHANGE IN PREGNANCY

RESULT TIME OF GREATEST RISK

DEMONSTRATED RISK

MANAGEMENT

CARDIOMYOPATHY, RHEUMATIC FEVER

MYOCARDITIS;

BLOOD VOLUME CARDIAC OUT PUT

PULMONARY CAPILLARY PRESSURECARDIAC OUT PUT

>12 WEEKS UNCOMMON;MATERNAL MORBIDITY

TREAT PULMONARY CONGESTIONAVOID PREGNANCY IF LEFT VENTRICULAR FAILURE IS PRESENT

A. MYOCARDIAL DISEASES

EFFECT OF PREGNANCY ON VARIOUS HEART DISEASES

EFFECTS OF PREGNANCY ON VARIOUS HEART DISEASESB. VALVE ABNORMALITIES

MITRAL STENOSIS

MITRAL REGURGITATION (INCLUDE MITRAL PROLAPSE WHEN COMPLICATED BY IMPORTANT MITRAL REGURGITATION )

AORTIC STENOSIS

AORTIC REGURGITATION

PULMONARY STENOSIS

CARDIAC OUT PUT HEART RATE BLOOD VOLUME PULMONARY VASCULAR RESISTANCE

OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY BLOOD VOLUME

OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY

BLOOD VOLUME

OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY

PULMONARY CAPILLARY PRESSURE

VENOUS RETURN LA FILLING LA FILLING PULMONARY CAPILLARY PRESSURE

VENOUS RETURN LV FILLING CARDIAC OUT PUT

PULMONARY CAPILLARY PRESSURE

VENOUS RETURN LV FILLING CARDIAC OUT PUT

12 WEEKS (WHEN HEMODYNAMIC CHANGES BECOME SIGNIFICANT)

LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY) & POSTPARTUM >12 WEEKS

LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY)& POST PARTUM PREGNANCY

>12 WEEKS

LATE IN PREGNANCYWHEN SUPINE (LABOR, DELIVERY, SURGERY) & POSTPARTUM

MATERNAL MORBIDITY & MORTALITY FROM PULMONARY CONGESTION & PULMONARY EDEMA FETAL GROWTH & FETAL LOSS POSSIBLE EXPLANATION OF SOME MATERNAL DEATHS

UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL

MATERNAL MORTALITY UNCOMMON BECAUSE AORTIC STENOSIS IS RARE

UNCOMMON:PREGNANCY IS USUALLY UNEVENTFUL

UNCOMMON:PREGNANCY IS USUALLY UNEVENTFUL

LIMIT DEMANDS FOR CARDIAC OUTPUT, BASED ON SYMPTOMS AVOID TACHYCARDIA TREAT TRACHYARRYTHMIA

MAINTAIN VENOUS RETURN, ESPECIALLY IF SYMPTOMS OF CARDIAC OUTPUT OCCURRX OF PULMONARY CONGESTION IF OCCURS (RESTRICT SODIUM, DIURETICS)

MAINTAIN VENOUS RETURN STRICT LIMITATION OF ACTIVITY, AND IF SYMPTOMS PRESIST,PROCEED TO VALVE SURGERY OR INTERRUPTION OF PREGNANCY RX OF PULMONARY CONGESTION IF IT OCCURS (RESTRICT SODIUM INTAKE ,DIURETICS )MAINTAIN VENOUS RETURN

EFFECTS OF PREGNANCY IN VARIOUS HEART DISEASE

C. CONGENITAL HEART DISEASES-GARDLAC LESION RELEVENT

HEMODYNAMIC CHANGE IN PREGNANCY

RESULT TIME OF GREATEST RISK

DEMONSTRATED RISK

MANAGEMENT

SHUNTS;LEFT TO RIGHT (ESTALDEFECT,PATENT DUCTUS)

RIGHT TO LEFT (EISENMENGR’S SYNDROME, TETRALOGY OF FALLOT)

CARDIAC OUT

PUT BLOOD VOLUME PULMONARY VASCULAR RESISTANCE PERIPHERAL VASCULAR RESISTANCE OBSTRUCTION OF INFERIOR VENA CAVA

PULMONARY CAPILLARY PRESSURE

SHUNTING AND VENOUS RETURN PULMONARY BLOOD FLOW

>12 WEEKS

LATE IN PREGNANCY WHEN SUPINE (LABOUR, DELIVERY, SURGERY) AND POST PARTUM

UNCOMMON:PREGNANCY IS USUALLY UNEVENTFUL

MATERNAL MORTALITY DUE TO SUDDEN DEATH FETAL GROWTH & FETAL LOSS

RX OF PULMONARY CONGESION IF IT OCCURES (RESTRICT SODIUM INTAKE , DIURETICS )

AVOID PREGNANCY MAINTAIN VENOUS RETURN

COARCTATION OF THE AORTA

OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS

BLOOD VOLUME PULSE PRESSURE STEROID HARMONES? TENDANCY TO HYPERTENSION

VENOUS RETURN LV FILLING CARDIAC OUT PUT

DISTENSION OF AORTIC ROOT

LATE IN PREGNANCYWHEN SUPINE(LABOUR, DELIVERY, SURGERY) & POSTPARTUM >12 WEEKS

UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL

AORTIC RUPTURE DISSECTION OF AORTARUPTURE OF INTRACRANIAL ANEURYSM

MAINTAIN VENOUS RETURN

DELAY PREGNANCY UNTILL RX, OPTIMAL TREAT HYPERTENSION & MINIMIZE PULSE PRESSURE

EFFECTS OF PEGNANCY IN VARIOUS HEART DISEASE

D. OTHER PROBLEMS

ANY CAUSE OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY

VENOUS RETURN LV FILLING CARDIAC OUTPUT

LATE IN PREGNANCY WHEN SUPINE (LABOUR DILIVERY, SURGERY) AND POSTPARTUM

MATERNAL MORTALITY DUE TO SUDDEN DEATH

AVOID PREGNANCYMAINTAIN VENOUS RETURN TRY TO LOWER PULMONARY VASCULAR RESISTANCE

IDIOPATHIC HYPERTROPHIC CARDIOMYOPATHY

SUBAORTIC STENOSIS

MARFAN’S SYNDROME

OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS HEART RATE BLOOD LOSS AT DELIVERY BLOOD VOLUME

BLOOD VOLUME PULSE PRESSURE STEROID HORMONES

VENOUS RETURN LV FILLING LV OBSTRUCTION CARDIAC OUTPUT

PULMONARY CAPILLARY PRESSURE

DISTENSION OF AORTIC ROOT

>12 WEEKS

>12 WEEKS

MATERNAL MORTALITY DURING PREGNANCY

MATERNAL MORBIDITY DURING PREGNANCY MATERNAL MORTALITY FROM AORTIC DISSECTION OR RUPTURE

MAINTAIN VENOUS RETURN ADRENERGIC BLOCKAGE WILL LV OUT FLOW OBSTRUCTION

RX OF PULMONARY CONGESTION, ESPECIALLY DIURETICSAVOID PREGNANCY, MINIMIZE PULSE PRESSURE

•PULMONARY HYPERTENSION

•DEVELOPMENT ABNORMALITIES

EFFECTS OF PREGNANCY ON VARIOUS C.V.S. DISEASESE.

HYPERTENSION CORONARY ARTERY DISEASE CARDIAC ARRHTHMIAS D.V.T & PUL. THROMBO EMBOLISM

MANAGEMENT OF HEART FAILURE IN PREGNANCYA. GENERAL CONSIDERATION1. HIGHEST PRIORITY TO MATERNAL HEALTH2. FETAL WELLBEING SHOULD BE

CONSIDERED AS PART OF EACH DIAGNOSTIC MANAGEMENT CONSIDRATION

3. GENERAL MEASURES SHOULD BE TAKEN BEFORE DRUG INTERVENTION

4. DRUGS, DIAGNOSTIC STUDIES, SURGERY SHOULD BE CONSIDERED FOR MAXIMUM SECURITY OF MOTHER

MANAGEMENT

B.1. PRE-CONCEPTUAL COUNSELLING2. MINIMISE STRESS ON HEART3. AVOID ANXIETY4. AVOID SYSTEMIC INFECTIONS5. AVOID ANAEMIA6. DISCOURAGE SMOKING7. IMMUNIZE BEFORE PREGNANCY8. ANTIBIOTIC PROPHYLAXIS- AGAINST

BACTERIAL ENDOCARDITIS OR RECURRENCE OF RHEUMATIC FEVER

9. PROPER MANAGEMENT OF THROMBO- EMBOLIC EVENTS

MANAGEMENT

C. DRUGS AVOID DRUGS IF POSSIBLE. IF SITUATION, WHERE CARDIAC FAILURE CAN NOT BE

CONTROLLED WITHOUT DRUGS – THEY SHOULD NOT BE WITHHELD

DIURETICS INOTROPIC AGENTS BETA BLOCKERS ANTIARRHYTHMIC AGENTS. CALCIUM CHANNEL BLOCKERS VASODILATORS ANTICOAGULANTS