Cardiac diseases in pregnancy

Cardiac diseases in pregnancy

Heart Diseases in Pregnancy







These women should be fully assessed before pregnancy and the maternal and fetal risks carefully explained.
Cardiologist should be involved in assessment.
Concurrent medical problems should be aggressively treated
If pt require surgical correction should be undertaken before a pregnancy.

Issues in prepregnancy counselling

Risk of maternal death
Possible reduction of maternal life expectancy
Effects of pregnancy on cardiac disease
Mortality associated with high risk conditions
Risk of fetus developing congenital heart disease
Risk of preterm labour and FGR
Need of frequent hospital admission
Other options –contraception,adoption,surrogacy
Timing of pregnancy


Antenatal management
Experienced physicians and obstetricians should manage this pt
Routine physical examination
Echocardiography to serially assess the pt
Any signs of deterioating cardiac stutus should be carefully assess and treated
Bed rest
Anticoagulation is a complicated issue

Stages of heart failure new york heart association classification

1 mild no limitation of physical activity
2 mild slight limitation.comfortable at rest
3 moderate marked limitation
4 severe unable to carry out any activity and symptoms of insufficiency at rest

Risk markers for maternal cardiac events

Prior episode of heart failure ,arrhythmia or stroke
2 class>2 or cyanosis
3 left heart obstruction
4 reduced left ventricular function (EF<40 per cent).

High risk conditions

Systemic ventricular dysfunction ef <30 % class3-4
Pulmonary hypertention
Cyanotic congenital heart disease
Aortic pathology (marfan syndrom)
Ischaemic heart disease
Left heart obstructive lesions (aortic, mitral stenosis)
Prosthetic heart valves
Previous peripartum cardiomyopathy


Fetal risks of maternal cardiac disease
Recurrence (congenital heart disease)
Fetal hypoxia
Iatrogenic prematurity
FGR
Effects of drugs

Management of labour

Avoid induction of labour
Use prophylactic antibiotics
Ensure fluid balance
Avoid supine position
Discuss anaesthesia with senior anasesthetist
Keep second stage short
Use syntocinon judiciously

Treatment of heart failure in pregnancy

Heart failure in pregnancy is dangerous
Treatment are the same as non pregnant
Diagnosis by clinical signs and echocardiography
Treat:should admitted and give diuretics ,vasodilators and digoxin ,oxygen and morphine
If arrhythmias require selective beta blockade


Risk factors for heart failure
Respiratory or urinary infections
Anaemia
obesity
corticosteroids
Tocolytics
Multiple gestation hypertension
arrhythmias
Pain related stress
Fluid overload

Specific conditionsischaemic heart disease

The risk of MI during pregnancy is estimated as 1 in 10 000 and the peak incidence is the third trimester , in parous women older than 35
The underlying pathology is not atherosclerotic, and coronary artery dissection is the primary cause in postpartum period
The diagnosis of MI is often missed and prompt diagnosis and treatment are necessary to reduce the high associated maternal and perinatal mortality

Mitral and aortic stenosis

Obstructive lesions of the left heart are well recognized risk factors for maternal morbidity and mortality
Aortic stenosis is usually congenital and mitral stenosis usually rheumatic in origin.
For those with known mitral stenosis, 40% experience worsening symptoms in the pregnancy with the average time of onset of pulmonary oedema at 30 weeks.


The aim of treatment is to reduce the heart rate, achieved through bed rest, oxygen,beta blockade and diuretic.
Maternal mortality is reported at 2 per cent and the risk of an adverse fetal outcome is directly related to the severity of mitral stenosis
The risk of maternal death in those with severe aortic stenosis is reported as 17per cent , with fetal mortality of 30per cent
If the woman`s condition deteriorates before delivery is feasible , surgical intervention such as balloon or surgical aortic valvotomy can be considered , although there is less experience and success than with mitral stenosis

Marfan syndrome

Is an autosomal dominant connective tissue abnormality that may lead to mitral valve prolapse and aortic regurgitation , aortic root dilatation and aortic rupture or dissection .
Pregnancy increases the risk of aortic rupture or dissection and has been associated with maternal mortality of up to 50per cent
Echocardiography is the principal investigation
Women with an aortic root <4 cm should be reassured that their risks are lower , and the risk of an adverse cardiac event is around 1 per cent
A number of obstetric complications have also been described : early pregnancy loss , preterm labour , cervical weakness , uterine inversion and postpartum haemorrhage .

Pulmonary hypertension

Is characterized by an increase in the pulmonary vascular resistance resulting in an increased workload placed on the right side of the heart
The main symptoms are fatigue , breathlessness and syncope , and clinical signs are those of right heart failure .
Pregnancy is associated with a high risk of maternal death
Close monitoring by a multidisciplinary team is crucial .
The mortality of the condition remains high at 30-50 per cent .
Pt should be strongly advised against pregnancy and given clear contraceptive advice , with early termination advased in the event of pregnancy .

Classification of PH

Idiopathic – sporadic or familial
Persistent PH of the newborn


Associated with :
Collagen vascular disease
Congenital pulmonary to systemic shunts
Drugs or toxins
Portal hypertension
PH with left heart disease
PH with lung disease
PH due to thrombosis and / or embolic disease .