1. Cardiac Disease in Pregnancy

2. Physiological Changes in the Cardiovascular System During Pregnancy A thorough knowledge –essential In order to understand –the additional impact of cardiac disease

3. Physiological Changes 1 The first cardiovascular change associated with pregnancy Peripheral vasodilation (induced by progesterone) leading to A decrease in systemic vascular resistance

4. Physiological Changes 2 Cardiac output increases 8 weeks : 20% 20-28 weeks :40-50% Stroke volume increase 80ml/t –ventricular end-diastolic volume –wall muscle mass –contractility Heart rate increase –10 to 15 beats per minute

5. Physiological Changes 3 Labour leads to further increases in cardiac output In the first stage: 15% In the second stage: 50% –abdominal pressure plummeted –pain and anxiety : sympathetic stimulation –pulmonary artery pressure increased –blood back into the circulation with each uterine contraction: 300-500 ml

6. Physiological Changes 4 After delivery, cardiac output increases again immediately : 60-80% –sudden interruption of placental circulation –uterine contraction –relief of caval compression –within 1 h: rapid decline to pre-labour values Puerperium: –uterine contractions –retented Interstitial fluid returned to circulation –return to normal after 2 weeks

7. Physiological Changes 5 The greatest change period in systemic blood circulation and heart burden –32 to 34 weeks –Intrapartum –3 days postpartum Easily induced heart failure

8. Table 1 -- Normal Hemodynamic Changes During Pregnancy Hemodynamic Parameter Change During Normal Pregnancy Change during labor and delivery Change during postpartum Blood volume↑ 40-50%↑↓ (autodiuresis) Heart rate↑ 10-15 beats/min↑↓ Cardiac output↑ 30-50 %↑ additional 50%↓ Blood pressure↓ 10 mm Hg↑↓ Stroke volume↑ 1st and 2nd trimester; ↓ 3rd trimester ↑ (300-500 mL per contraction) ↓ Systemic vascular resistance ↓↑↓

9. Types of CD during pregnancy Congenital heart disease Rheumatic heart disease Hypertensive disorders in pregnancy heart disease Peripartum cardiomyopathy Other

10. Congenital heart disease Left → right shunt ① atrial septal defect ② ventricular septal defect ③ patent ductus arteriosus No shunt ① pulmonary artery stenosis ② coarctation of the aorta ③ Marfan syndrome right → Left shunt: Tetralogy of Fallot 、 Eisenmenger's syndrome

11. Rheumatic heart disease Mitral incompetence: isolated can tolerance pregnancy, delivery and puerperium. Mitral stenosis: 1Blood volume (during pregnancy) 2Blood volume back to the heart (intrapartum and early puerperium) Pulmonary venous hypertension Acute pulmonary edema Pulmonary circulation volume Left atrial pressure

12. Rheumatic heart disease Aortic stenosis: severe Pulmonary edema Low discharge capacity heart failure Aortic incompetence : severe Left ventricular failure Bacterial endocarditis

13. HDIP heart disease No history of heart disease and signs Sudden onset of systemic failure left ventricular failure Peripheral small artery resistance increased Myocardial ischemia, interstitial edema, hemorrhage and necrosis spots Blood viscosity increased to promote myocardial ischemia water, sodium retention

14. HDIP heart disease Misdiagnosed as the flu and bronchitis Early diagnosis is important After eliminate the cause, most can be restored

15. Peripartum Cardiomyopathy (PPCM) Define: dilated cardiomyopathy Interval: between the last 3 month of pregnancy up to the first 6 months postpartum Women : without preexisting cardiac dysfunction Fetal death:10~30% Maternal mortality is approximately 9% –heart failure, pulmonary infarction, arrhythmia These women should be counseled against subsequent pregnancies

16. PPCM The exact etiology : unknown Possible causes –infection, immunity, multiple pregnancy, hypertension, malnutrition –viral myocarditis –automimmune phenomena –specific genetic mutations

17. PPCM Symptoms Fatigue Dyspnea on exertion, orthopnea Nonspecific chest pain Abdominal discomfort and distension palpitations, cough, hemoptysis, hepatomegaly, edema other heart failure symptoms

18. PPCM Typical signs Heart enlarged Myocardial contractility reduce Ejection function reduced ECG: Arrhythmias left ventricular hypertrophy ST segment and T wave abnormalities

19. CD main threat to pregnant women Heart failure Subacute infective endocarditis Hypoxia and cyanosis Venous thrombosis and pulmonary embolism

20. The impact of CD in pregnant women A validated cardiac risk score Predict a maternal chance of having adverse cardiac complications Risk factor01>1 Maternal cardiac event rates 5%27%75% Table 2 Risk factor and maternal cardiac event rates

21. Table3 Predictors of Maternal Risk for Cardiac Complications CriteriaExamplePoin ts* Prior cardiac events heart failure, transient ischemic attack, stroke before present pregnancy 1 Prior arrhythmia symptomatic sustained tachyarrhythmia or bradyarrhythmia requiring treatment 1 NYHA III/IV or cyanosis 1 Valvular and outflow tract obstruction aortic valve area 30 mm Hg 1 Myocardial dysfunction LVEF <40% or restrictive cardiomyopathy or hypertrophic cardiomyopathy 1

22. Maternal Cardiac Lesions and Risk of Cardiac Complications Low Risk Atrial septal defect Ventricular septal defect Patent ductus arteriosus Asymptomatic aortic stenosis with low mean gradient ( 50%) Aortic regurgitation with normal LV function and NYHA functional class I or II little

23. Maternal Cardiac Lesions and Risk of Cardiac Complications Low Risk Mitral valve prolapse –(isolated or with mild to moderate mitral regurgitation and normal LV function) Mitral regurgitation with normal LV function and NYHA class I or II Mild to moderate mitral stenosis –(mitral valve area >1.5 cm 2, mean gradient <5 mm Hg) without severe pulmonary hypertension) Mild/moderate pulmonary stenosis Repaired acyanotic congenital heart disease without residual cardiac dysfunction

24. Maternal Cardiac Lesions and Risk of Cardiac Complications Intermediate Risk Large left-to-right shunt Coarctation of the aorta Marfan syndrome with a normal aortic root Moderate to severe mitral stenosis Mild to moderate aortic stenosis Severe pulmonary stenosis

25. Maternal Cardiac Lesions and Risk of Cardiac Complications High Risk Eisenmenger's syndrome Severe pulmonary hypertension Complex cyanotic heart disease –(tetralogy of Fallot, Ebstein's anomaly, truncus arteriosis, transposition of the great arteries, tricuspid atresia) Marfan syndrome with aortic root or valve involvement

26. Maternal Cardiac Lesions and Risk of Cardiac Complications High Risk Uncorrected severe aortic stenosis with or without symptoms Uncorrected severe mitral stenosis with NYHA functional class II-IV symptoms Aortic and/or mitral valve disease (stenosis or regurgitation) with moderate to severe LV dysfunction (EF <40%) NYHA class III-IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology History of prior peripartum cardiomyopathy

27. The impact of CD in Fetal Premature birth Low birth weight Respiratory distress Fetal death Neonatal death Genetic heart disease

28. Diagnosis History: Palpitations, difficulty breathing or heart failure Organic heart disease Rheumatic fever

29. Diagnosis Signs and symptoms abnormal: Exertional dyspnea, Paroxysmal nocturnal dyspnea, orthopnea, hemoptysis, recurrent exertional chest pain Cyanosis, clubbing, jugular vein engorgement continuing Cardiac auscultation –a diastolic murmur and/or grade Ⅲ or rough systolic murmur over the whole –a pericardial friction rub, diastolic gallop, alternating pulse

30. Early signs of heart failure Chest tightness, palpitations, shortness of breath after mild activity Resting heart rate> 110 beats / min Respiration> 20 times / min Paroxysmal nocturnal dyspnea The end of the lung wet rales persisted

31. Diagnosis: Diagnosis: auxiliary examination Noninvasive testing of the heart may include: ECG: severe arrhythmias –atrial fibrillation, atrial flutter, Ⅲ degree atrioventricular block, ST segment and T wave abnormalities and changes Chest radiograph –the heart was significantly expanded Echocardiogram –expansion of the heart chamber –myocardial hypertrophy –valvular motion abnormalities –cardiac structural abnormalities

32. Management Before pregnancy: –detailed examination to determine whether she is suitable to pregnant access to counselling –specialized –multidisciplinary –preconception In order to empower them to make choices about pregnancy

33. Not suitable for pregnancy ！ Cardiac function grade Ⅲ ~ Ⅳ Those who previously had heart failure A pulmonary hypertension, severe stenosis the main A Ⅲ atrioventricular block, atrial fibrillation, atrial flutter,diastolic gallop; Cyanotic heart disease Active rheumatic or bacterial endocarditis

34. The main aims of management To optimize the mother's condition during the pregnancy –considering ß -blockers –Thromboprophylaxis –pulmonary arterial vasodilators To monitor for deterioration Minimize any additional load on the cardiovascular system

35. Pregnant women with CD Should be assessed clinically as soon as possible A multidisciplinary team and appropriate investigations undertaken The core members of the team should include: Suitably experienced obstetricians Cardiologists Anaesthetists Midwives Neonatologists Intensivists

36. Management Management of gestation period Regular prenatal care Early prevention of heart failure –adequate rest –appropriate weight limit –treatment the motivation of heart failure : infection, anemia,PIH The treatment of heart failure –as same as those who are not pregnant

37. Mode of Delivery Vaginal delivery: –cardiac function Ⅰ ~ Ⅱ grade –not a fetal macrosomia –cervical conditions are good 

38. Managementintrapratum Management in intrapratum First stage of labor Semi-recumbent position, oxygen masks, attention Bp, R, P, heart rate, –cedilanid : 0.4mg +5% GS20ml iv slow (when necessary) –antibiotics : during labor to 1 week after postpartum

39. Managementintrapratum Management in intrapratum Low-dose regional analgesia:usually recommended providing effective pain relief reduce the further increases in –cardiac output –myocardial oxygen demand Be careful not to inhibit the neonatal breathing

40. Managementintrapratum Management in intrapratum Second stage of labor: –episiotomy, facilitate instrumental delivery to shorten the stage Third stage of labor: –Ergot disabled to prevent venous pressure increased –injection of morphine or pethidine immediately postpartum –abdominal pressure sandbags –control the liquid velocity

41. Mode of Delivery Cesarean section: –Marfan syndrome : expansion of the aortic root> 45 mm –use warfarin during delivery –sudden hemodynamic deterioration –severe pulmonary hypertension and severe aortic stenosis

42. Management Management in puerperium Monitoring heart rate, blood oxygen, blood pressure during delivery 24 hours She could not breast-feeding –more than grade Ⅲ cardiac function Prophylactic antibiotics High-level maternal surveillance

43. Thanks four your listening