Heart Failure in Pregnancy Ramon M. Gonzalez, MD Professor UST Medicine and Surgery

AB a 22y/o married, bank teller Visited for the 1st time an obstetrician 5 months PTC she had a (+) 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

Bp-100/60mmHg CR-89/min RR=21cycles/min Heart- AB at 5th ICS LMCL, no thrills, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex Referred by the obstetrician to a cardiologist

Cardiovascular changes in pregnancy Parameter Percentage of change _______________________________________________ Cardiac output 40-50% Increase Intravascular volume 45% Increase Heart rate 15-25% Increase Systemic vascular resistance 20% Decrease Stroke volume 30% Increase Systolic BP Minimal Diastolic BP 20% Decrease at mid-pregnancy O2 consumption 30-40% Increase

Periods of increase cardiac output 28-32 weeks gestation Labor and Delivery Immediately postpartum

Hemodynamics during labor Parameter Stage of Labor Percentage of change ____________________________________________________ Cardiac output Latent phase 10% Increase Active phase 25% Increase Expulsive phase 40% Increase Immediate postpartum 70-80% Increase Heart rate All stages Increase CVP All stages Increase

Hemodynamics during puerperium Parameter Postpartum Percentage of change _______________________________________________________________ Cardiac output W/in 1hr 30% above pre-labor values 24-48 hr Just below pre-labor values 2 weeks 10% above pre-pregnant values 12-24 weeks Baseline pre-pregnancy values Heart rate Immediate Decrease 2 weeks Pre-pregnant values Stroke volume 48 hr Remains above pre-labor values 24 weeks 10% above pre-pregnant values

What is the effect of pregnancy on heart disease?

Change in New York Heart Association (NYHA) functional class between first visit and follow-up during pregnancy in patients with predominant mitral valve disease.

Maternal outcome in patients with mitral stenosis Congestive heart failure 43% vs 0% p<0.0001 Arrhythmias 20% vs 0% p<0.0001 Hospitalization 43% vs 2 p 0.001 Mortality 0% vs 0% p 1.0

Conclusion Women with VHD had a high rate of clinical deterioration Marked increase in morbid events during pregnancy, including CHF, arrhythmias and need to either initiate or increase cardiovascular drug therapy or to hospitalize patients during pregnancy.

What is the effect of heart disease on fetal outcome?

Fetal outcome in patients with mitral stenosis Preterm delivery 35±7 vs 39±2wks p <0.0002 IUGR 24% vs 0% p <0.001 Stillbirth 4% vs 0% p 0.5 Birth weight 2845g vs 3372g p 0.02

Offspring risk for congenital heart defects Defect Mother affected Father affected (%) (%) Aortic stenosis 13–18 3 Atrial septal defect 4–4.5 1.5 Atrioventricular canal 14 1 Coarctation of the aorta 4 2 Patent ductus arteriosus 3.5–4 2.5 Pulmonic stenosis 4–6.5 2 Tetralogy of Fallot 2.5 1.5 Ventricular septal defect 6–10 2

Main Aims of Management To optimize the mother’s condition during pregnancy To monitor for deteriorations Minimize any additional load on the cardiovascular system

Management of Cardiac Disease in Pregnancy: General Principles of Management Women in NYHA class I and II proceed to pregnancy without morbidity. All women with heart disease should be managed by a multidisciplinary team. Antenatal management is directed towards avoiding cardiac decompensation. Special attention should be directed toward both prevention and early recognition of heart failure.

Warning signs of heart failure Persistent basilar rales, frequently accompanied by a nocturnal cough A sudden diminution in ability to carry out usual duties Increasing dyspnea on exertion Clinical findings may include hemoptysis, progressive edema and tachycardia

Management of Cardiac Disease in Pregnancy: General Principles of Management Even when pregnancy is well tolerated, infection, anemia, pain and anxiety, often result in clinical deterioration and require aggressive management. A clear plan for the management of labor and delivery should be established in advance

Management during Pregnancy In symptomatic patients, medical treatment should be the first line of management. Cardiac drugs commonly used during pregnancy includes β blockers, hydralazine, diuretics and digoxin. Advice bed rest and oxygen.

Management during Pregnancy Fetal assessment to monitor the potential problems arising from heart disease and pharmacologic treatment of the mother.

Management: Labor and Delivery Vaginal delivery is the preferred mode of delivery A short and pain free labor and delivery - minimize hemodynamic fluctuation Hemodynamic monitoring including O2 saturation, ECG, arterial pressure, pulmonary artery and wedge pressures and cardiac output especially in class III and IV patients

Management: Labor and Delivery Epidural analgesia produces good analgesia without major hemodynamic changes It is administered in incremental doses Slower onset of anesthesia, allows maternal CVS to compensate for occurrence of sympathetic blockade, resulting in lower risk of hypotension and decreased uteroplacental blood flow.

Management: Labor and Delivery Epidural analgesia spares the lower extremity “muscle pump,” aiding in venous return and also decreases the incidence of thromboembolic events. During the 2nd stage – prevent maternal effort in “pushing” Shorten the 2nd stage – vacuum or forceps delivery

Management: Labor and Delivery Fetal heart rate monitoring during labor Induction of labor to optimize the timing of delivery in relation to anticoagulation and availability of medical staff Cesarean section obstetrics indication, specific cardiac lesions and deterioration of cardiac performance

Management: Postpartum Oxytocin administered by infusion and not by bolus Methyergonovine and Carboprost Produces severe hypertension, tachycardia and increased pulmonary vascular resistance

Management: Postpartum High level maternal surveillance is required until the main hemodynamic changes after delivery have resolved. Postpartum hemorrhage, infection, anemia and thromboembolism are much more serious complications in those with heart disease.

Management: Postpartum Recent review of parturients with heart disease found that the worst cardiac compromise did not always occur at the time of delivery.

Thank You