1. Heart Failure in Pregnancy
Council on Women’s Health
Philippine Heart Association

2. Introduction
About 2% of pregnancies involve maternal cardiovascular disease
Increased risk to both mother and fetus
Cardiac disease may sometimes be manifested for the 1st time in pregnancy because of the hemodynamic changes
Signs and symptoms of a normal pregnancy may mimic the presence of cardiac disease

3. Case Presentation AB a 22 year old married, bank teller
Visited for the first time an obstetrician
5 months PTC she had a positive 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

4. Pertinent PE BP- 100/60 CR- 89/min RR- 21 cycles/min
Heart-AB at 5th ICS LMCL, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex
Referred by the obstetrician to a cardiologist

5. Questions Does AB have heart disease?
Is she experiencing heart failure symptoms?
What are the hemodynamic changes occurring in her?
What are the differential diagnoses?
How should you go about managing her? Medical? Surgical? Timing?
Can she tolerate the pregnancy?
What is the safest mode of delivery?

6. Question:
Does AB have heart disease?

10. Question:
Is she experiencing heart failure symptoms?

12. Pregnancy Clinical features mimicking heart disease:
Dyspnea- due to hyperventilation, elevated diaphragm
Pedal edema
Cardiac impulse diffuse and shifted laterally from elevated diaphragm
Jugular veins may be distended and JVP raised
Systolic ejection murmurs in LPSB in 96% of pregnant women

13. Question: Evaluation of Heart Failure in Pregnancy
How should we go about evaluating AB?
Evaluation of Heart Failure in Pregnancy
1. Detailed Hx and PE to determine FC
2. 12 lead ECG
3. Chest Xray - Optional
4. 2D Echo Doppler
5. Plasma B Type natriuretic peptide
6. Blood works-CBC,electrolytes, renal
and thyroid function
7. TEE (seldom)
8. Fetal echocardiography

14. Differential Diagnoses of Heart Failure in Pregnancy
Pneumonia
Pulmonary embolism
Amniotic fluid embolism
Renal failure with volume overload
Acute lung injury

15. High risk pregnancies Pulmonary hypertension
Dilated cardiomyopathy, EF≤40%
Symptomatic obstructive lesions AS,MS,PS,CoA
Marfan syndrome with aortic root ≥40mm
Cyanotic lesions
Mechanical prosthetic valves

17. Question: Cardiac Diseases in Pregnancy Risk Score Risk Scores
1. A prior cardiac event ( arrhythmia,stroke,TIA,HF)
2.Baseline NYHA FC≥II or cyanosis(saturation≤ 90%
3. Systemic ventricular systolic dysfunction
4. Left heart obstruction
- MVA ≤ 2 cm
- aortic valve area≤ 1.5 cm
- peak flow gradient ≥ 30mm Hg
What is the risk of AB? Can she tolerate her pregnancy?
Risk Scores
0 - 5% risk (low)
1 - 27% risk (interm)
>1 - 75% (high)

18. Management Medical NYHA Class I or II -Limit strenuous exercise
-Provide adequate rest
-Supplemental iron and vitamins
-Low salt diet
-Regular cardiac and obstetric evaluation
NYHA III and IV
-May need hospitalization for close monitoring

20. Management
Percutaneous valvotomy?
Timing?

21. Management
Surgical
Cardiac surgery seldom necessary and should be avoided if possible
Higher risk of fetal malformations and loss
May induce premature labor
Optimal time wk gestation
Extracorporeal circulation- normothermic
Higher pump flow rate, higher pressure with a mean of 60 mmHg
Advise short bypass time

22. Management Anticoagulation? Warfarin Unfractionated Heparin
Low Molecular Weight Heparin

23. What is Warfarin Embryopathy?
Used in 1st trimester- teratogenic in 15-25% of cases
1. nasal cartilage hypoplasia
2. stippling of bones
3. IUGR
4. brachydactyl

24. SBE Prophylaxis?
Antibiotic – a) 2 gm ampicillin IV plus 1.5 mg/Kg gentamicin IV prior to procedure, followed by one more dose of ampicillin 8 hours later
If with allergy from ampicillin, 1 gm vancomycin may be used.

25. What is the Safest Mode of Delivery?
Vaginal delivery is feasible and preferable
CS is for an obstetric indication
Exception are anticoagulated patients
CS may be indicated in
1. Marfan syndrome,
2. severe pulmonary HPN
3. severe obstructive lesions eg AS

26. Physiologic Changes during Labor and Puerperium
First stage- Cardiac output increased by 15%. Each uterine contraction releases 500 ml of blood leading to increases in CO and BP, later reflex bradycardia.
Second stage- Increase in intra-abdominal pressure(valsalva) causes decrease in venous return and CO
Third stage- Blood loss during delivery. Vaginal- 400 ml CS- 800 ml
- these lead to reduced blood volume and CO

27. Hemodynamic Changes after Delivery
Abrupt increase in venous return because of autotransfusion from the uterus. Baby no longer compress the uterus.
Autotransfusion of blood continues hrs after delivery. Pulmonary edema may occur.

28. Thank You
Thank you