1. Golnaz Houshmand.MD Cardiologist

2. Why we concern !

3.  Approximately 2% of pregnancies involve maternal cardiovascular disease, associated with increased risk to both mother and fetus.  Heart disease is the third most common cause of maternal death and the leading non-obstetric cause.

4.  In 2011, guidelines on the prevention of cardiovascular disease in women identified pregnancy complications as risk factors for cardiovascular disease.  Pulmonary embolism, arrhythmias, pre- eclampsia and peripartum cardiomyopathy, develop as a complication of pregnancy in previously healthy women.  women with pre-existing heart disease may be predisposed to some of these complications and less able to cope with them

5.  Advances in the practice of cardiology, The increasing success of neonatal surgery allows more infants with complex anomalies to reach adulthood, wanting normal lives with jobs and families.  Career women postponing pregnancy account for larger numbers of older patients with hypertension and coronary disease

6. hemodynamic

7.  during the first trimester steep increase in plasma volume, which causes dilution and anemia.  The stroke volume and, to a lesser extent, the heart rate increase and the cardiac output increases progressively. (around 40–50% above the pre-pregnancy.)  Accompanying decrease in vascular resistance, and diastolic and mean blood pressure.

8.  In cyanotic or potentially cyanotic congenital heart disease,  The drop in peripheral vascular resistance encourages right-to-left shunting, leading to increasing cyanosis  Rise in hematocrit with increased risk of thrombosis and paradoxical embolism.

9.  When trouble occurs it usually begins early, often by the end of the first trimester.  These considerations are of pivotal importance if the physician is to advise the woman correctly and not simply retreat with the easy option of advising against pregnancy or encouraging early termination

10. Significant heart conditions are usually known about before pregnancy but important exceptions are:  Pulmonary hypertension,  Mitral stenosis,  Cardiomyopathies  Fragile Aorta  ASD  Coronary Artery Disease

11. PMH & Examination

12.  Many disorders are apparent from the personal and family history, particularly cardiomyopathies, Marfan syndrome and congenital heart disease.  Ask specifically for possible sudden deaths in the family  There may be previous knowledge of a cardiac murmur, which may or may not be linked to a specific valve disease.  The outcome of any previous pregnancies ( hypertension, pre-eclampsia, pulmonary emboli or peripartum cardiomyopathy )

13.  An understanding of the normal findings on cardiac examination in a pregnant patient is important

14. Normal clinical findings that can mimic heart disease in pregnancy  Raised jugular venous pressure (prominent ‘a’ and ‘v’ waves, brisk ‘x’ and ‘y’ descents)  Volume-loaded left ventricle; full, sharp and collapsing pulse  Warm extremities  Peripheral edema  Palpitations  Tachycardia  Premature atrial/ventricular beats  Increased intensity of mitral closure sound  Third heart sound (rapid ventricular filling and is found in up to 90%)  Systolic murmur (90%)  Continuous murmur from venous hum, mammary soufflé

15.  A cervical venous hum, best heard over the supraclavicular fossa, is common in children, and is also found in pregnancy.  The mammary murmur, either systolic or continuous, is heard maximally at the second left or right intercostal space during late pregnancy in some women.  differentiated from a persistent arterial duct by applying gentle pressure, makes the mammary murmur disappear.

16.  An ejection systolic murmur never more than grade 3/6 in intensity  There should be no diastolic murmur.

17. Electrocardiography

18.  The heart rate may be increased by 10–15%.  Re-entrant supraventricular tachycardia is a relatively common benign arrhythmia.  persistent sinus tachycardia, atrial flutter, atrial fibrillation or ventricular tachycardia suggests underlying heart disease and should prompt further investigation.  The appearance of ventricular tachycardia in late pregnancy or in the puerperium should arouse suspicion of peripartum cardiomyopathy.

19. ECHOCARDIOGRAPHY

20.  Referral is often triggered by the detection of a systolic murmur by the obstetrician  Occasionally, the distinction between normality and abnormality may be subtle and an expert interpretation should be sought before the final report.  In most pregnancies echocardiography will reassure the mother-to-be who can then continue to enjoy her pregnancy.

21. A progressively increasing awareness in pregnant women during the third trimester is the presence of breathlessness.  A common symptom during pregnancy, this may be difficult to distinguish from breathlessness related to the onset of peripartum cardiomyopathy.  New onset of intraventricular conduction delay or left bundle-branch block on the ECG, together  with an ‘unusual’ breathlessness, should constitute an absolute indication for an early echocardiographic examination to assess left ventricular function.

22. RISK ASSESSMENT

23.  Worrisome predictors of maternal cardiac events include(from the CARPREG study)  (1) prior cardiac event (e.g., heart failure, transient ischemic attack, or stroke before pregnancy) or arrhythmia;  (2) baseline New York Heart Association (NYHA) class higher than class II or cyanosis;  (3) left-sided heart obstruction (mitral valve area smaller than 2 cm2, aortic valve area less than 1.5 cm2, or peak left ventricular outflow tract gradient greater than 30 mm Hg as assessed by echocardiography);  (4)ejection fraction less than 40%

24.  When none of the risk factors was present, the risk of a cardiovascular complication during pregnancy was less than 5%  The presence of one of the above risk factor, a risk of a cardiovascular complication during pregnancy of over 20%  more than one risk factor, the risk of a cardiovascular comaplication during pregnancy was over 70%.

25. WHO CLASSIFICATION

27. WHO I Uncomplicated, small or mild - PS - PDA - MVP Successfully repaired simple lesions (ASD or VSD, PDA, PAPVC). Atrial or ventricular ectopic beats, isolated

28. WHO II or III WHO II (if otherwise well and uncomplicated) Unoperated ASD,VSD Repaired tetralogy of Fallot Most arrhythmias WHO II–III (depending on individual) Mild left ventricular impairment HCM Native or tissue valvular heart disease not considered WHO I or IV Marfan syndrome without aortic dilatation Aorta <45 mm in aortic disease associated with bicuspid aortic valve Repaired coarctation

29. WHO III Mechanical valve Systemic right ventricle Fontan circulation Cyanotic heart disease (unrepaired) Other complex congenital heart disease Aortic dilatation 40–45 mm in Marfan syndrome Aortic dilatation 45–50 mm in aortic disease associated with bicuspid aortic valve

30. WHO IV(pregnancy contraindicated) Severe PAH of any cause Severe systemic ventricular dysfunction (LVEF <30%, NYHA III–IV) Previous peripartum cardiomyopathy with any residual impairment of left ventricular function Severe MS, severe AS Marfan syndrome with aorta dilated >45 mm Aortic dilatation >50 mm in aortic disease associated with bicuspid aortic valve Native severe coarctation

31.  The highest maternal mortality from heart disease is in patients with pulmonary hypertension, whether idiopathic, or associated with other disease or with reversed central shunt in Eisenmenger syndrome. The maternal mortality rate may be as high as 50%

32.  Most women with heart disease who are in New York Heart Association class I or II before pregnancy accomplish pregnancy safely.  Valve regurgitation is generally well tolerated during pregnancy, primarily because of the afterload reduction and increased heart rate.  Patients with simple congenital cardiac defects do well  Most patients with heart disease do well.

33. Congenital Heart Disease

34.  The category of patients with congenital heart disease who have had previous surgery.  If the operation were ‘corrective’, pregnancy would usually proceed normally but would sometimes be complicated by arrhythmia, (usually benign), and endocarditis.  Patients who have undergone palliative surgery may be at risk of heart failure or thromboembolism as well as infection and arrhythmia.

35.  Echocardiography and transesophageal imaging helps both in initial assessment of risk and in serial documentation of progress.  Cardiac magnetic resonance imaging (MRI) may be complementary

36.  A comprehensive pre-pregnancy assessment is recommended for all patients with a history of operated or unoperated congenital heart disease  Optimal management of the pregnant patient with congenital heart disease includes accurate diagnosis, and the correct prediction of the hemodynamic consequences of both the pregnancy on the cardiac disorder and the cardiac disorder on the baby’s development.

37. FETAL ECHO  the woman with congenital heart disease, a fetal cardiac echocardiogram can start at week 14 and is offered at approximately 18 to 22 weeks of pregnancy to determine whether a congenital cardiac anomaly is present.

38. Cardiomyopathies

39. HCM  Parents should be informed about the autosomal dominant inheritance pattern, which has variable penetrance. genetic counseling and family screening are appropriate before pregnancy  The left ventricle seems to fill better during pregnancy and without undue rise in filling pressure in most cases.  Pressure gradients may be high but usually do not affect outcome  Generally, hypertrophic cardiomyopathy is well tolerated during pregnancy.

40.  Patients with significant symptoms before pregnancy may not do well and become hemodynamically unstable.  Common symptoms include palpitation, angina, and breathlessness. In a study of 127 women with 271 pregnancies, 36 women (28.3%) reported cardiac symptoms but 90% were symptomatic before pregnancy

41. DCM  When discovered late in pregnancy, dilated cardiomyopathy may be regarded as peripartum because of its temporal relationship with pregnancy  when detected earlier in pregnancy the condition is likely to have been pre-existing.  Echocardiography shows a hypokinetic left ventricle that may or may not be dilated.  Patients with idiopathic dilated cardiomyopathy usually are counseled not to have a pregnancy if the ejection fraction is lower than 40%.  Exercise testing also may be helpful, because women with ejection fractions of 40% to 50% may not tolerate pregnancy well if they have a poor functional aerobic capacity

42. PPCM  Occurring during the last months of pregnancy or within 5 months of delivery in previously healthy women.  Cardiac imaging (usually with echocardiography) is essential to establish the diagnosis.  The higher incidence in some countries suggests the influence of environmental risk factors or a common genetic mutation.  Known risk factors include multiparity, black race, older maternal age, and particularly preeclampsia

43.  Normalization of ventricular function occurs in approximately 23% to 54% of patients with PPCM  more likely if the ejection fraction is greater than 30% at the time of diagnosis.  Most physicians counsel against a second pregnancy, even if the ventricular function does return to normal, PPCM will recur in approximately 30% of cases.  recurrence may result in significant clinical deterioration and even death.

44. Fragile Aorta

45.  Women with Marfan syndrome are always a worry in pregnancy.  The family history is important and serial measurement of aortic root diameter are important. ( family history of aortic rupture or evidence of aortic root widening)  Dissection occurs most often in the last trimester of pregnancy (50%) or the early postpartum period (33%).  The diagnosis of aortic dissection should be considered in all patients with chest pain during pregnancy.

46. THANKS FOR YOUR ATTENTION