pregnancy in Heart disease د.ايناس الخياط

Physiological effects of pregnancy on CVS :   - By 6 – 8 peripheral vasodilitation occur → » ↓ systemic vascular resistance ↑ Cardiac output(CO.) by 20 % . - ↑ CO. to about maximum of 40 % by 24 – 28 wks of gestation . so ↑ risk of H. F. in this period . - ↑ HR – 10 – 15 % . - ↑ CO up to 80%above pre-labour values in first few hrs after delivery . - CO. return to normal at 2 wks post delivery .

Issues in pre-pregnancy counselling of women with heart disease 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 for frequent hospital attendance and possible admission . Intensive maternal and fetal monitoring during labour . Other options – contraception , adoption , surrogacy . Timing of pregnancy .

Antenatal Management a joint obstetric / cardiac History Examination Investigations Follow up maternal &fetal well-being

The stages of heart failure-New work heart Association ( NYHA ) classification 1. Mild No limitation of physical activity . Ordinary physical activity does not precipitate fatigue , palpitations , dyspnoea , angina . 2. Mild Slight limitation of physical activity . Comfortable at rest , but ordinary physical activity results in fatigue, palpitation or dyspnoea. 3. Moderate Marked limitation of Physical activity . Comfortable at rest , but less than ordinary activity causes fatigue , palpitation or dyspnoea . 4. Severe Unable to carry out any physical activity without discomfort . Symptoms of cardiac insufficiency at rest . If any physical activity is undertaken , discomfort is increased .

Toronta risk markers for maternal cardiac events 1 Prior episode of heart failure , arrhythmia or stroke . 2 NYHA class > II or cyanosis . 3 Left heart obstruction . 4. Reduced left ventricular function ( EE < 40 per cent ) 0 predictors : risk of cardiac event is 5per cent ; I predictor : risk of cardiac event is 37 per cent ; > 1 predicators : risk of cardiac event is 75 per cent .

High-risk cardiac conditions Systemic ventricular dysfunction ( ejection fraction < 30 per cent , NYHA class III – IV ) . Pulmonary hypertension Cyanotic congenital heart disease . Aortic pathology ( dilated aortic root > 4 cm , Marfan syndrome ) . Ischaemic heart disease . Left heart obstructive lesions ( aortic , mitral stenosis ) Prosthetic heart valves ( metal ) . Previous peripartum cardiomyopathy .

Fetal risks of maternal cardiac disease Recurrence ( congenital heart disease ) . Maternal cyanosis ( fetal hypoxia ) . Iatrogenic prematurity . FGR . Effects of maternal drugs ( teratogenesis , growth restriction , fetal loss ) .

Maternal risks: -Endocarditis. -Arrythmias. - Paraxysmal embolic events. -Heart failure &pulmonary hypertention. - Death .

Risk factors for the development of heart failure Respiratory or urinary infections . Anaemia . Obesity . Corticosteroids . Tocolytics . Multiple gestation . Hypertension . Arrhymais . Pain-related stress . Fluid overload TREAT HEART FAILUR AS IN NON PREGNANT ONE

Management of labour and delivery Management of labour in women with heart disease Avoid induction of labour of possiblr . Use prophylactic antibiotic . Ensure fluid balance . Avoid the supine position . Discuss regional / epidural anaesthesia / analgesia with senior anaesthetist . Keep the second stage short . Use syntocinon judiciously .

Specific conditions Ischaemic heart disease Mitral and aortic stenosis Marfan syndrome Pulmonary hypertension : Peripartum cardiomyopathy ( CMP Coarctation of Aorta Prosthetic heart valves

Strategies of anticoagulant regimen in pregnancy:   (1.) Continue warfairn during pregnancy. ( or ) (2.) Replace warfarin with high dose heparin from 6th – 12th wks of gestation & 10 days before the delivery (3.) use high dose unfractionated or low molecular weight heparin throughout pregnancy.

Which option is chosen will depend on several factors: 1. Type of mechanical valve : the risk of thrombosis is less with the newer bi-leaflet valves than first & 2nd generation ball and cage valves . 2. The position of the value replacement : Mitral position > risk Aortic position 3. number of mechanical valves : Two valves give a high risk of thrombosis . 4. The dose of warfarin required to maintain a therapeutic INR . 5. Any previous history of embolic events .

Stratification of cardiac conditions according to risk of bacterial endocarditis :  - High-risk : Prosthetic valves , previous bacterial endocarditis , complex cyanotic congenital heart disease ( fallot's , transposition of great arteries ,surgical systemic / pulmonary shunt ) . acquired valvular disease .   Moderate risk : Hypertrophic cardiomyopathy . Mitral value prolapse with mitral regurge .  

Stratification of cardiac conditions according to risk of bacterial endocarditis : Negligible risk : Secundum ASD . Repaired ASD , VSD , PDA . mitral prolapse with or without regurgitation . Physiological Heart murmurs . Pacemakers .   For high & moderate risk : Endocarditis prophylaxis is recommended .