Heart Failure in Pregnancy Council on Women’s Health Philippine Heart Association

Introduction About 2% of pregnancies involve maternal cardiovascular disease Increased risk to both mother and fetus Cardiac disease may sometimes be manifested for the 1st time in pregnancy because of the hemodynamic changes Signs and symptoms of a normal pregnancy may mimic the presence of cardiac disease

Case Presentation AB a 22 year old married, bank teller Visited for the first time an obstetrician 5 months PTC she had a positive pregnancy test Felt perfectly well prior to consult Few days ago started to have shortness of breath on climbing 2 flights of stairs, easy fatigability on walking 2 blocks and had palpitations

Pertinent PE BP- 100/60 CR- 89/min RR- 21 cycles/min Heart-AB at 5th ICS LMCL, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex Referred by the obstetrician to a cardiologist

Questions Does AB have heart disease? Is she experiencing heart failure symptoms? What are the hemodynamic changes occurring in her? What are the differential diagnoses? How should you go about managing her? Medical? Surgical? Timing? Can she tolerate the pregnancy? What is the safest mode of delivery?

Question: Does AB have heart disease?

Question: Is she experiencing heart failure symptoms?

Pregnancy Clinical features mimicking heart disease: Dyspnea- due to hyperventilation, elevated diaphragm Pedal edema Cardiac impulse diffuse and shifted laterally from elevated diaphragm Jugular veins may be distended and JVP raised Systolic ejection murmurs in LPSB in 96% of pregnant women

Question: Evaluation of Heart Failure in Pregnancy How should we go about evaluating AB? Evaluation of Heart Failure in Pregnancy 1. Detailed Hx and PE to determine FC 2. 12 lead ECG 3. Chest Xray - Optional 4. 2D Echo Doppler 5. Plasma B Type natriuretic peptide 6. Blood works-CBC,electrolytes, renal and thyroid function 7. TEE (seldom) 8. Fetal echocardiography

Differential Diagnoses of Heart Failure in Pregnancy Pneumonia Pulmonary embolism Amniotic fluid embolism Renal failure with volume overload Acute lung injury

High risk pregnancies Pulmonary hypertension Dilated cardiomyopathy, EF≤40% Symptomatic obstructive lesions -AS,MS,PS,CoA Marfan syndrome with aortic root ≥40mm Cyanotic lesions Mechanical prosthetic valves

Question: Cardiac Diseases in Pregnancy Risk Score Risk Scores 1. A prior cardiac event ( arrhythmia,stroke,TIA,HF) 2.Baseline NYHA FC≥II or cyanosis(saturation≤ 90% 3. Systemic ventricular systolic dysfunction 4. Left heart obstruction - MVA ≤ 2 cm - aortic valve area≤ 1.5 cm - peak flow gradient ≥ 30mm Hg What is the risk of AB? Can she tolerate her pregnancy? Risk Scores 0 - 5% risk (low) 1 - 27% risk (interm) >1 - 75% (high)

Management Medical NYHA Class I or II -Limit strenuous exercise -Provide adequate rest -Supplemental iron and vitamins -Low salt diet -Regular cardiac and obstetric evaluation NYHA III and IV -May need hospitalization for close monitoring

Management Percutaneous valvotomy? Timing?

Management Surgical Cardiac surgery seldom necessary and should be avoided if possible Higher risk of fetal malformations and loss May induce premature labor Optimal time- 20-28 wk gestation Extracorporeal circulation- normothermic Higher pump flow rate, higher pressure with a mean of 60 mmHg Advise short bypass time

Management Anticoagulation? Warfarin Unfractionated Heparin Low Molecular Weight Heparin

What is Warfarin Embryopathy? Used in 1st trimester- teratogenic in 15-25% of cases 1. nasal cartilage hypoplasia 2. stippling of bones 3. IUGR 4. brachydactyl

SBE Prophylaxis? Antibiotic – a) 2 gm ampicillin IV plus 1.5 mg/Kg gentamicin IV prior to procedure, followed by one more dose of ampicillin 8 hours later If with allergy from ampicillin, 1 gm vancomycin may be used.

What is the Safest Mode of Delivery? Vaginal delivery is feasible and preferable CS is for an obstetric indication Exception are anticoagulated patients CS may be indicated in 1. Marfan syndrome, 2. severe pulmonary HPN 3. severe obstructive lesions eg AS

Physiologic Changes during Labor and Puerperium First stage- Cardiac output increased by 15%. Each uterine contraction releases 500 ml of blood leading to increases in CO and BP, later reflex bradycardia. Second stage- Increase in intra-abdominal pressure(valsalva) causes decrease in venous return and CO Third stage- Blood loss during delivery. Vaginal- 400 ml CS- 800 ml - these lead to reduced blood volume and CO

Hemodynamic Changes after Delivery Abrupt increase in venous return because of autotransfusion from the uterus. Baby no longer compress the uterus. Autotransfusion of blood continues 24-72 hrs after delivery. Pulmonary edema may occur.

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