1. Heart Disease with Pregnancy
د. ياسمين حمزة

2. Heart disease is rare but potentially serious medical condition that complicates 1% of all pregnancies.
The prevalence & incidence of all heart disease in pregnancy may vary from one community to another, as 50y. Ago rheumatic heart disease accounted for 90% of all heart disease in pregnancy , but since the wide spread use of AB in strep. Infection ,so the fig. has fallen to less than 50%.
Congenital HD now accounts for 50% of women with HD in pregnancy because with advances in pediatrics cardiac surgery ,so more women with congenital HD are surviving & reaching child bearing age group.

3. Irrespective of the underlying condition ,pregnancy had a significant burden on the heart due to the normal physiological changes that occur as both bl. Volume &C.O.P increase by 40% ,& the increase in C.O.P is achieved by an increase in both stroke volume & arise H.R of about B.P.M.

4. Maternal risk:
MMR in heart disease is mostly due to risk of H.F & thromboembolism.
Pulmonary HT ,MS&Eisenmmenger’s syndrome:25-50%
Fallot’s tetralogy :5%
Rheumatic HD:1%
Infective endocarditis: very rare

5. Fetal risks:
Fetal problems are mainly due to restriction of maternal C.O.P & hence placental perfusion resulting in :
1-IuGR
2-PTL
3-abortion
4-The etiological cause of CHD is multifactorial &is present in 8 per live born babies & if a parent is affected the risk is increased to 5%.

6. Pre-pregnancy Mx:
Most women with HD will be aware of their condition prior to falling in pregnancy & a cardiologist should be involved in this assessment with ECHO done freq. & medical therapy should be optimized & if the pt. required $ it is recommended to be done prior to preg. .
Inform the couple about the MMR & fetal risks.
Inform the couple about the need of freq. hospitalization & admission.

7. Antenatal MX:
- All pregnant pt. with HD should be managed in a joint between obst. & card.
- Assessment of PR , RR , BP ,JVP , basal crepitation , ankle edema sacral edema , fundal height
- invs. & admission for bed rest to reduce cardiac work load.
- RX any risk for development of HF: (Resp. infection ,UTI ,anemia ,obesity ,HT,arrhythmia,pain related stress ,multiple gestation).
- Anticoagulation: it is essential in pt. with congenital HD who have pulmonary HT,artificial valve replacement & those with Atrial F.
(*In the 1st trim. Warfarin is usually stopped & heparin used IV not S.C ,if use the low molecular wt. heparin (enoxaparin) can be used S.C because it had a longer ½ life in the blood stream.
(*in the 2nd trim. Warfarin may be restarted until 37wk. , then heparin should be introduced until delivery).
- if labor occur while the pt. on warfarin, vit k is given to reduce the bleeding tendency.

8. - Rx of HF during preg. is the same as in non- preg
- Rx of HF during preg.is the same as in non- preg.: admission , bed rest ,O2 ,morphine
- confirm the DX by Ex & inve. (ECHO)
- Drugs : digoxin used in HF, or AF.
- Diuretics; in acute state of HF & pulmonary edema
- Antiarrhythmic drugs
- Assessment of the fetal well being & IUGR

9. MX of labor & delivery:
- In nearly all cases the aim of mx is to await the onset of spontaneous natural labor.
- Avoid induction of labor if possible unless for obstetrical indication.
- Epidural anesthesia :by senior anesthetist to avoid hypotension.
- Prophylactic AB.
- Avoid supine position : better in semi setting position or lateral.
- Shortened the 2nd stage of labor : by forceps or ventose.
- Mx of 3rd stage by using oxytocin : because ergometrin associated with strong vasoconstriction &HT &HF.
-AB cover post-delivery.

10. Prosthetic Heart Valves:
Heterograft are easiest to manage in pregnancy because no special precautions are necessary ,but they only last about 8- 12y. And thus these days most women will have artificial valves which give a better life expediency without further operation.
They require the women to be fully anticoagulated to avoid clot formation on the valve with resulting embolism.
This resulting a problem in pregnancy, since the best anticoagulant warfarin is embriopathic, thus it is usual to transfer the mother to i.v. heparin as soon as pregnancy is diagnosed.

11. Thyroid Disorders with Pregnancy
Pregnancy has significant impact on the normal maternal thyroid physiology.
During pregnancy the production of TBG by the live doubles as a result of estrogenic stimulation →↑T3 &T4 but no significant change in FT3 & FT4 , but the renal clearance of iodine increases in pregnancy.

12. Maternal Hyperthyroidism:
It occur in 1/500 pregnancy & in the majority of cases it is DX prior to pregnancy.
Causes:
1- Grave’s Disease: in 90% of cases.
2-Toxic nodular goiter.
3-Hashimoto’s thyroiditis
4-multiple nodular goiter.
5-Trophoblastic
C/F: the DX may be difficult to make during pregnancy because mild maternal tachycardia , wt. loss ,heart murmurs &heat intolerance are all symptoms in early pregnancy.
Inve.:↑FT3,FT4,↓TSH

13. Maternal complications:
1-Maternal cardiac arrhythmias & AF.
2-diarrhea & vomiting.
3-If the cause is autoimmune these Abs may cross the placenta & cause fetal goiter.
Fetal complications:
1-IUGR
2-Still birth
3-PTL
4-fetal goiter.

14. Treatment:
The aim of therapy is to maintain FT3 & FT4 in normal range. Usually the RX is with carbimazole & it’s lowest dose must be used as high dose may cross the placenta & cause fetal hypothyroidism.
- Beta-blocker s.t. used to RX arrhythmias & tachycardia.
- occasionally $ may be undertaken.
- Radioactive iodine is CI.

15. Maternal Hypothyroidism:
The commonest world wide cause for this is iodine deficiency , but rarely seen now a days. Maternal iodine deficiency is associated with cretinism in the newborn as a result of congenital hypothyroidism.
The commonest reason for maternal hypothyroidism is over treated hyperthyroidism.
If the pt. diagnosed with hypoth. They should receive full thyroid replacement (thyroxin) during pregnancy & TFT should be done serially.
In the postnatal period there is relation ship between thyroid funx. & postnatal depression .