1. pregnancy in Heart disease
د.ايناس الخياط

2. Physiological effects of pregnancy on CVS :
- By 6 – 8 peripheral vasodilitation occur → » ↓ systemic vascular resistance
↑ Cardiac output(CO.) by 20 % .
- ↑ CO. to about maximum of 40 % by 24 – 28 wks of gestation .
so ↑ risk of H. F. in this period .
- ↑ HR – 10 – 15 % .
- ↑ CO up to 80%above pre-labour values in first few hrs after delivery .
- CO. return to normal at 2 wks post delivery .

3. Issues in pre-pregnancy counselling of women with heart disease
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 for frequent hospital attendance and possible admission .
Intensive maternal and fetal monitoring during labour .
Other options – contraception , adoption , surrogacy .
Timing of pregnancy .

4. Antenatal Management a joint obstetric / cardiac History Examination
Investigations
Follow up maternal &fetal well-being

5. The stages of heart failure-New work heart Association ( NYHA ) classification
1. Mild
No limitation of physical activity . Ordinary physical activity does not precipitate fatigue , palpitations , dyspnoea , angina .
2. Mild
Slight limitation of physical activity . Comfortable at rest , but ordinary physical activity results in fatigue, palpitation or dyspnoea.
3. Moderate
Marked limitation of Physical activity . Comfortable at rest , but less than ordinary activity causes fatigue , palpitation or dyspnoea .
4. Severe
Unable to carry out any physical activity without discomfort . Symptoms of cardiac insufficiency at rest . If any physical activity is undertaken , discomfort is increased .

6. Toronta risk markers for maternal cardiac events1
Prior episode of heart failure , arrhythmia or stroke . 2
NYHA class > II or cyanosis . 3
Left heart obstruction . 4.
Reduced left ventricular function ( EE < 40 per cent )
0 predictors : risk of cardiac event is 5per cent ; I predictor : risk of cardiac event is 37 per cent ; > 1 predicators : risk of cardiac event is 75 per cent .

7. High-risk cardiac conditions
Systemic ventricular dysfunction ( ejection fraction < 30 per cent , NYHA class III – IV ) .
Pulmonary hypertension
Cyanotic congenital heart disease .
Aortic pathology ( dilated aortic root > 4 cm , Marfan syndrome ) .
Ischaemic heart disease .
Left heart obstructive lesions ( aortic , mitral stenosis )
Prosthetic heart valves ( metal ) .
Previous peripartum cardiomyopathy .

8. Fetal risks of maternal cardiac disease
Recurrence ( congenital heart disease ) .
Maternal cyanosis ( fetal hypoxia ) .
Iatrogenic prematurity .
FGR .
Effects of maternal drugs ( teratogenesis , growth restriction , fetal loss ) .

9. Maternal risks: -Endocarditis. -Arrythmias.
- Paraxysmal embolic events.
-Heart failure &pulmonary hypertention.
- Death .

10. Risk factors for the development of heart failure
Respiratory or urinary infections .
Anaemia .
Obesity .
Corticosteroids .
Tocolytics .
Multiple gestation .
Hypertension .
Arrhymais .
Pain-related stress .
Fluid overload
TREAT HEART FAILUR AS IN NON PREGNANT ONE

11. Management of labour and delivery
Management of labour in women with heart disease
Avoid induction of labour of possiblr .
Use prophylactic antibiotic .
Ensure fluid balance .
Avoid the supine position .
Discuss regional / epidural anaesthesia / analgesia with senior anaesthetist .
Keep the second stage short .
Use syntocinon judiciously .

12. Specific conditions Ischaemic heart disease Mitral and aortic stenosis
Marfan syndrome
Pulmonary hypertension :
Peripartum cardiomyopathy ( CMP
Coarctation of Aorta
Prosthetic heart valves

13. Strategies of anticoagulant regimen in pregnancy:
(1.) Continue warfairn during pregnancy. ( or )
(2.) Replace warfarin with high dose heparin from 6th – 12th wks of gestation & 10 days before the delivery
(3.) use high dose unfractionated or low molecular weight heparin throughout pregnancy.

14. Which option is chosen will depend on several factors:
1. Type of mechanical valve : the risk of thrombosis is less with the newer bi-leaflet valves than first & 2nd generation ball and cage valves .
2. The position of the value replacement : Mitral position > risk Aortic position
3. number of mechanical valves : Two valves give a high risk of thrombosis .
4. The dose of warfarin required to maintain a therapeutic INR .
5. Any previous history of embolic events .

15. Stratification of cardiac conditions according to risk of bacterial endocarditis :
 - High-risk : Prosthetic valves , previous bacterial endocarditis , complex cyanotic congenital heart disease ( fallot's , transposition of great arteries ,surgical systemic / pulmonary shunt ) . acquired valvular disease .  
Moderate risk :
Hypertrophic cardiomyopathy . Mitral value prolapse with mitral regurge .

16. Stratification of cardiac conditions according to risk of bacterial endocarditis :
Negligible risk :
Secundum ASD .
Repaired ASD , VSD , PDA .
mitral prolapse with or without regurgitation .
Physiological Heart murmurs .
Pacemakers .
For high & moderate risk :
Endocarditis prophylaxis is recommended .