1. بنام خدا

2. Pregnancy & Heart Disease

3. Introduction Among heart diseases,
-Western world Congenital heart disease, most frequent CVD (75–82%), with shunt lesions predominating (20–65%).
RHD dominates in non-western countries [56–89% ]; Congenital heart disease [just 9–19%].

4. Valvular Heart Disease
Risk Stenotic lesions > Regurgitant lesion
[ increased C.O. increased transvalvular gradient vs. [ reduced SVR reduces Regurgitant volume]
Left sided diseases> Right sided disease

11. Pharmacological management of symptoms
MS with symptoms or PAH, restricted activities and β1-selective blockers are recommended. Diuretics are recommended when congestive symptoms persist despite β-blockers.
BMV
NYHA class III/IV or sys PAP > 50mm Hg, preferably after 20 weeks .
Anticoagulation
Paroxysmal or Permanent AF, LA thrombus, prior embolism
Considered in mod/sev MS with spontaneous echo contrast, LA > 40ml/m2, low CO
Delivery
Vaginal delivery in mild MS, NYHA I/II, no PAH
CS in Mod/Sev MS, NYHA III/IV, PAH

14. Pharmacological management of symptoms
HF- treat with diuretics
AF- b-blockers, CCB to control HR, Digoxin also may be used
During Pregnancy
Severe symptomatic AS + refractory to medical therapy/ life threatening symptoms Non calcified valve may be subjected to BAV. emergency AVR
Delivery
Vaginal delivery + regional anesthesia in non-sev AS
CS in Sev AS

16. PS & PR PS is generally well tolerated
Complication of sever PSRV failure & Arrhythmias.
Prepregnancy balloon valvuloplasty in severe stenosis (peak Doppler gradient > 64 mmHg)
CS is considered in patients with severe PS and in NYHA class III/IV despite medical therapy and bed rest, in whom percutaneous pulmonary valvotomy cannot be performed or has failed.
Severe PR with impaired RV function
pre-pregnancy pulmonary valve replacement (preferably bioprosthesis) should be considered.

17. Prosthetic valves Mechanical valves Bioprosthetic valves
Excellent H.D. Performances
Long term durability
Thrombogenic
Bioprosthetic valves
Good H.D Performances
Much less thrombogenic
High risk of valve degeneration [~50% women <30yrs at 10 yr post implant]

21. Shunt lesions
Hemodynamically significant shunt best repaired pre pregnancy
Insignificant lesions, good LV function no indication for closure during pregnancy
Severe PAH/ eisenmenger syndrome – high risk
Pre-pregnancy evaluation of the severity of a shunt, residual defect in case of repair, estimation of pulmonary pressures, cardiac dimensions & function

22. Coarctation of Aorta
Unrepaired native CoA and those repaired with residual HTN, residual CoA, or aortic aneurysms have an increased risk of aortic rupture and rupture of a cerebral aneurysm during pregnancy and delivery
Risk Factors to be screened for- aortic dilatation and bicuspid aortic valve
HTN should be treated[ aggressive treatment avoided to prevent placental hypoperfusion]

23. Cyanotic congenital heart disease
Maternal complications (HF, pulmonary or systemic thrombosis, SVT, IE) occur in 30% of cyanotic pregnant patients.
If resting O2 sat. <85%- substantial maternal and fetal mortality risk expected and pregnancy is contraindicated. If 85–90%, measure it during exercise Significant and early decrease  pregnancy has poor prognosis.
With resting maternal blood saturation >90%, fetal outcome is good (<10% fetal loss).

24. Cyanotic congenital heart disease
Tetralogy of Fallot
In unrepaired patients, surgical repair is indicated before pregnancy [ Repaired TOF usually tolerate pregnancy well]
Cardiac complications during pregnancy upto 12% of patients. [Arrhythmias & HF- Thr. Emb., progressive aortic root dilatation, & IE].
Risk Factors  RV Dysfunction &/or mod to sev. PR [Pregnancy associated with persisting increase in RV size]
In repaired symptomatic TOF, RV dilatation due to severe PR, pre-pregnancy PVR (homograft)
Ebstein’s anomaly
Ebstein’s anomaly without cyanosis & HF, pregnancy is often tolerated well.
Symptomatic + Cyanosis and/or HF should be treated before pregnancy or counselled against pregnancy. In severe symptomatic TR  pre-pregnancy repair . [haemodynamic status depends on TR severity & RV function]
Other complications- shunt reversal and cyanosis; paradoxical emboli

25. Pulmonary Hypertension& Eisenmenger
Maternal death occurs in “the last trimester of pregnancy & in the first months after delivery”
pulmonary hypertensive crises
pulmonary thrombosis
refractory right heart failure.
This occurs even in patients with little or no disability before or during pregnancy.
Risk factors for maternal death are: late hospitalization, severity of PAH, and GA.

26. Management Avoid Pregnancy
Maintain circulating Volume, and to avoid systemic Hypotension, Hypoxia, and Acidosis which may precipitate refractory HF
Supplemental O2 therapy if hypoxaemia; Haemodynamic monitoring by Swan–Ganz catheter not indicated now [PA rupture]
Diuretics must be used judiciously and at the lowest E.D. to avoid haemoconcentration and intravascular volume depletion. Microcytosis and iron deficiency should be treated with supplemental oral or i.v. iron
Anticoagulation- Continued in patients were there is indication for use outside pregnancy. Used with caution in Eisenmenger syndrome [prone to haemoptysis and thrombocytopenia]- used in PE or HF
I.V. Prostacyclin or aerosolized Iloprost [to improve haemodynamics during delivery]
Continue drugs for PAH [Bosentan-teratogenic, Sildenafil-category B]
Planned CS