Cardiovascular Disease In Pregnancy It is a relatively common in women of child bearing age, complicate about 1% of pregnancies Maternal mortality related to heart disease has decreased remarkably over the past 50 years (from 5.6 to 0.3/ live birth) Heart disease are still the second most common non obstetrical cause of maternal mortality.

Cardiac Diseases Rheumatic heart disease Congenital heart disease Hypertensive heart disease Coronary Thyroid Syphilitic Kyphoscoliotic cardiac disease Idiopathic cardiomyopathy Corpulmonale Constrictive pericarditis Heart block Isolated myocarditis

Physiological Consideration with Heart Disease In Pregnancy The most important changes in cardiac function occurs in the first 8 weeks of pregnancy with maximum changes at 28 weeks ↓ Vascular resistance ↓ Blood pressure ↑ Heart rate ↑ Stroke volume ↑ COP ↑ Blood volume 30% - 50% Maternal weight and basal metabolic rate also affect COP

cont… Later in pregnancy COP is higher when women is in the lateral recumbent position than when she is in the supine During labor COP increase moderately in the first stage of labor and appreciably greater in the second stage COP also increase in the immediate post partum period

cont… Heart: The heart is displaced upward and to the left with lateral rotation on its long axis Resting pulse increase by about 10 bpm There is some changes in the cardiac sounds include: An exaggerated splitting of the first heart sound with increase loudness of both components, no definite changes in the aortic and pulmonary elements of the second sound, and aloud easily heard third sound

conti…. Systolic murmur is heard in 90 % of cases Soft diastolic murmur transiently in 20 % Continuous murmur arising from the breast vasculature in10 % of cases

Diagnosis of Heart Disease Some clinical indicators of heart disease during Pregnancy Symptoms: Progressive dyspnea or orthopnea Nocturnal cough Hemoptysis Syncope Chest pain

Clinical findings Cyanosis Clubbing of fingers persistent neck vein distension Systolic murmur grade 3/6 or greater Diastolic murmur Cardiomegaly Persistent arrhythmia Persistent split-second sound Criteria for pulmonary hypertension

Diagnostic studies Electrocardiography An average 15 – degree left – axis deviation in the ECG, and mild ST changes may be seen in the inferior leads, Atrial and ventricular premature contractions are relatively frequent Chest x – ray: Heart silhouette normally is larger in pregnancy, however gross cardiomegaly can be excluded

Echocardiography: Normal changes include : Tricuspid regurgitation, Significantly increase left atrial size and left ventricular outflow cross sectional area.

Clinical clssification The New York Heart Association’s Functional Classification [ NYHA] “ First published in 1928 “ Class 1 : Uncompromised, no limitation of physical activity Class 2 : Slightly compromised, slight limitation of physical activity Class 3 : Markedly compromised, marked limitation of physical activity Class 4 : Severely compromised, inability to perform any physical activity without discomfort

Preconceptional counseling Maternal mortality generally varies directly with functional classification at pregnancy onset; However this relationship may change as pregnancy progresses Patient with pulmonary hypertension, primary or secondary are in danger of undergoing decompensation during pregnancy

cont… Life threatening cardiac abnormalities can be reversed by corrective surgery and subsequent pregnancy is less dangerous In other cases fetal consideration predominate, for example the teratogenic effect of warfarin

Risks for Maternal Mortality Caused by Various Heart Disease Cardiac Disorder Mortality % Group 1 – Minimal Risk Atrial septal defect 0 -1 % Ventricular septal defect Patent ductus arteriosus Pulmonic or tricuspid disease Fallot tetralogy,corrected Bioprosthetic valve Mitral stenosis,NYHA classes 1&2

Group 2 – Moderate Risk % 2A : Mitral stenosis, NYHA classes 3 & 4 Aortic stenosis Aortic coarctation without valvar involvement Fallot tetralogy, uncorrected Previous myocardial infarction Marfan syndrome, normal aorta 2B : Mitral stenosis with atrial fibrillation Artificial valve

Group 3 – Major Risk % Pulmonary hypertension Aortic coarctation with valvar involvement Marfan syndrome with aortic involvement NYHA = New York Heart Association. From the American College of Obstetrics and Gynecologists (1992a ), with permission.

Management In assuring an optimal outcome, management should be a team approach involving ;obstetrician, cardiologist and anesthesiologist Risk to patient of : Heart failure, subacute bacterial endocarditis, and thromboembolic disease will be identified and minimized

Management Four concepts that affect management are emphasized by the American College of Obs /Gyn :- 1) the 50% increase in blood volume and COP by the early 3 rd trimester 2) further fluctuation in volume and COP in the peripartum period 3) a decline in systemic vascular resistance, reaching a nadir in the 2 nd trimester, and then rising to 20% below normal by late pregnancy 4) hyprcoagulability of special importance in women requiring anticoagulation in the non pregnant state

Management of Class 1 & 2 General measures: _ avoid contact with persons who have respiratory infection _ pneumococcal and influenza vaccines are recommended ( patient with valvar heart disease) _ cigarette smoking is prohibited _ diet, avoidance of strenuous activity and avoidance of anemia

management cont….. sign’s of heart failure: » persistent basilar rales » nocturnal cough » a sudden diminution in ability to carry out usual duties » increasing dyspnea on exertion » attacks of smothering with cough » hemoptysis, progressive edema and tachycardia

Management cont….. Labor and Delivery : * vaginal delivery is preferred unless there is obstetrical indication * relief of pain with intravenous analgesics, continuous epidural analgesia is recommended for most situation, but it’s contraindicated in patient with: [ Intracardiac shunt, pulmonary hypertension, Aortic stenosis ], to avoid the risk of maternal hypotension

* fluid balance and antibiotic prophylactic * semi recumbent position with lateral tilt * intensive medical management for any sign’s of impending ventricular failure [ pulse > 100, RR > 24, dyspnea ] * expedite vaginal delivery * close monitoring for the 3 rd stage of labor

puerperium * avoid complication of pph, anemia, infection and thromboembolism * delay the procedure of tubal sterilization until it is obvious that the mother is a febrile, not anemic and can ambulate without evidence of distress * option of contraceptive advise

Management of class 3&4 ؟ whether pregnancy should be undertaken ؟ consider pregnancy interruption ؟ prolonged hospitalization or bed rest ؟ vaginal delivery is preferred ؟ caesarian section delivery should be with the availability of experience anesthetic support in a facility with experience with complicated cardiac disease

Most common lesions: _Rheumatic heart disease Incidence of rheumatic fever is decreasing in developed countries, It still remain the chief cause of serious mitral valve disease in women,(3/4 th of cases of mitral stenosis) _Congenital Heart Disease: many congenital heart lesions appear to be inherited as polygenic characteristic, 10% of women with congenital heart disease would give birth to similarly affected infants, 50 % were concordant for the same anomaly

Peripartum cardiomyopathy : this is a diagnosis of exclusion, it describe women with peripartum heart failure with no apparent etiology, symptoms of cardiac decompensation appear during the last weeks of pregnancy or 1 to 6 months postpartum obstetrical complications such as : preeclampsia, anemia from blood loss, and infection either contribute or precipitate heart failure

Prognosis : favorable outcome for the mother with heart disease depends upon the : _ functional cardiac capacity _ other complications that further increase cardiac load _ quality of medical care provided _ psychological and socioeconomical factors