1. Cardiac diseases in pregnancy

4. 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.

5. 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

6. 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

7. 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

8. 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).

9. 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

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

11. 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

12. 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

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

14. Specific conditions ischaemic 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

15. 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.

16. 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

17. 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.

18. 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.

19. 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.