1. CVS Changes During Pregnancy PARAMETERDIRECTIONTIME COURSE Heart rate ↑ 1 st and 2 nd trimester (TM) Blood pressure ↓ Fall in TM 1 and 2, returns to baseline in 3 Cardiac output ↑ 45% above baseline by TM 3 Stroke Volume ↑ Peak at weeks 16 to 24 Systemic vascular resistance ↓ Nadir by mid pregnancy Pulmonary vascular resistance ↓ 20- 30% decrease

2. Outcome in Cardiac Disease CARPERG study multi-center prospective study across Canada (1994-1999) 599 pregnancies with established cardiac disease before pregnancy referred to cardiology followed at 2 nd, 3 rd trimester, 6 weeks & 6 months postpartum Incidence of cardiac complication  pulmonary edema, symptomatic arrhythmias,  stroke,cardiac arrest & cardiac death Circulation 2001

3. Outcome in Cardiac Disease Cardiac event occurred in 13 % (80/599) 55% occurred in the prepartum period. Pulmonary edema and cardiac arrhythmia accounted for most of the cardiac events Embolic strokes occurred during 4 pregnancies  dilated CM, mitral stenosis mechanical valve with suboptimal anticoagulation Circulation 2001

7. Vlavular Disease In Pregnancy Presents usually with arrhythmia or CHF Stenosis (mitral or aortic) is less tolerated than regurgitation Increased risk of cardio embolism Few case report of balloon valvuloplasty Elkayam JACC 2005

8. Anticoagulation For Mechanical Valve

9. Arrhythmia During Pregnancy Common gestational changes Increased HR  short PR & QT interval Lt axis with non specific ST changes Symptomatic arrhythmia is usually a manifestation of structural heart disease All anti-arrhythmic Rx are class C, may need dose adjustment

10. Peripartum Cardiomyopathy

11. Rare 1 in 13,000-15,000 High mortality 8% Half of the mortality occur in first 6 weeks postpartum& other half within a year  HF, arrhythmia or thromboembolism Cause unknown ? Viral Vs Autoimmune Abboud Int.Jr.Cardiology 2007

12. Peripartum Cardiomyopathy Risk factor : advanced age, multiparity multiple gestation, preeclampsia, HTN Rx : diuretic, after load reduction +/- inotropes Abboud Int.Jr.Cardiology 2007 Limited contractile function in asymptomatic patients with normal resting Echo upon dobutamine challenge Lampert Am Jr Obst & Gyne 1997