2. Scenario:  Hx.:  A 30-year-old multigravida at the 20 weeks’ gestation.  Has a mild SOB with activity.  She has no symptoms at rest.  Had a childhood history of rheumatic fever.  P/E:  Diastolic murmur.  Investigations:  Echocardiography: Mitral stenosis.

4. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Signs & Symptoms of Cardiac Diseases. Special Types of Cardiac diseases Management and Counseling. Contraception in Cardiac Diseases.

5. Normal Hemodynamic Changes in Pregnancy:  Plasma volume  Cardiac Output  Heart rate  Left Ventricular Work index

6. Normal Hemodynamic Changes in Pregnancy:  Systemic Vascular Resistance SVR  Pulmonary Vascular Resistance PVR  BP

7. Normal Hemodynamic Changes in Pregnancy:  Murmur!!?? A systolic ejection murmur along the left sternal border is normal in pregnancy owing to increased COP. “Hyperdynamic Circulation” Diastolic murmurs are never normal in pregnancy and must be investigated.

8. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Special Types of Cardiac diseases Signs & Symptoms of Cardiac Diseases. Management and Counseling. Contraception in Cardiac Diseases.

9. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Special Types of Cardiac diseases Signs & Symptoms of Cardiac Diseases. Management and Counseling. Contraception in Cardiac Diseases.

10. Classification of Cardiac Diseases:

11. Structural Classification: Heart Diseases CongenitalAcquired

12. Structural Classification: Heart Diseases Congenital Non-Cyanotic ASD VSD Cyanotic Tetralogy of Fallot Eisenmenger’s Syndrome Marfan’s Syndrome Acquired

13. Structural Classification: Heart Diseases CongenitalAcquired Rheumatic Mitral Stenosis Coronary Heart Diseases Rare during child -bearing ages Cardiomyopathy Arrhythmia

14. Classification of Cardiac Diseases:

15. New York Heart Association Classification NYHA: ClassI No limitation with physical activities. Class II Mild limitation with physical activities. Class III Marked limitation with physical activities. Class IV Limitation at rest.

16. New York Heart Association Classification NYHA: Class I and Class II are low risk patients. They have a good prognosis and do not need invasive monitoring in labour. Class III and Class IV are High risk patients. They have a poor prognosis need invasive monitoring in labour.

17. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Signs & Symptoms of Heart Diseases Special Cardiac Diseases. Management and Counseling. Contraception in Cardiac Diseases.

18. Signs & Symptoms of Heart Diseases:  Symptoms:  Severe progressive dyspnea.  Orthopnea.  Paroxysmal Nocturnal Dyspnea PND.  Hemoptysis.  Chest pain.  Syncope.

19. Signs & Symptoms of Heart Diseases:  Signs:  Severe systolic murmur  3/6 “ with palpable thrill”.  Diastolic murmur.  Parasternal heave. “ cardiomegaly “.  Cyanosis & clubbing.  Signs of pulmonary HTN.  Persistent jugular venous distension.

20. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Signs & Symptoms of Heart Diseases Special Cardiac Diseases. Management and Counseling. Contraception in Cardiac Diseases.

22. Rules: Valvular Stenosis are NOT well-tolerated in pregnancy… Valvular insufficiency as well as ASD & VSD are well-tolerated in pregnancy…

23. Rheumatic Heart Diseases

24. Rheumatic Heart Diseases:  They are the most common etiology.  Mitral Stenosis:  The most common acquired heart disease in pregnancy.  Dx.: Echocardiography.  Complications: Slow diastolic follow. Diastolic Murmur. Left Atrial Enlargement: Atrial fibrillation  emboli. Subacute bacterial endocarditis SBE.

25. Rheumatic Heart Diseases:  Complications:  Pulmonary edema develops early.

26. Rheumatic Heart Diseases:  Mitral Insufficiency (Regurgitation):  Well tolerated in pregnancy…  In the past, rheumatic fever was the commonest etiology.  However, nowadays, the commonest cause is congenital mitral valve Prolapse.  Usually, not complicated by SBE. (No need for prophylaxis).

27. Rheumatic Heart Diseases:  Aortic Stenosis:  If severe: Mortality is high. The pregnancy should be terminated.  Correction: surgical Surgical correction is ideal to be done before pregnancy. If it is necessary to be done during pregnancy, it is done in the 2 nd trimester. 2 types: Closed surgery: can also be done in 1 st trimester. Open: is NEVER done during pregnancy.

28. Congenital Heart Diseases

29. Congenital Heart Diseases:  Acyanotic:  VSD and ASD are the most common congenital heart diseases.  They are well-tolerated in pregnancy.  Cyanotic:  Tetralogy of Fallot is the most common.  Should be repaired surgically.

30. Congenital Heart Diseases:

31.  Eisenmenger’s Syndrome:

32. Congenital Heart Diseases:  Eisenmenger’s Syndrome:  Characterized by pulmonary HTN and bidirectional shunt.  If the pulmonary pressure exceeds the systemic pressure, the shunt reverses  Mortality is high.  During pregnancy, decrease in systemic vascular resistance SVR places the patient at risk of mortality.  The mortality rate of Eisenmenger’s syndrome during pregnancy is about 50%

33. Congenital Heart Diseases:  Eisenmenger’s Syndrome:  Management:  Avoid Hypotension….

34. Marfan’s Syndrome

35. Congenital Heart Diseases:  Marfan’s Syndrome:  An autosomal dominant CT disease.  Defect on fibrillin gene on chromosome 15.  Fibrillin is an important components in the media layer of blood vessels wall.

36. Congenital Heart Diseases:  Marfan’s Syndrome:

37. Congenital Heart Diseases:  Marfan’s Syndrome:  If the aortic root is diameter is  40mm, the maternal mortality rate is high (about 50%).

38. Peripartum Cardiomyopathy

39. Peripartum Cardiomyopathy:

40.  Occurs in last few weeks of pregnancy and first few months post partum.  Enlargement and weakness of ventricles:  Biventricular Failure  Idiopathic.  Occurs more in multipara.  Maternal mortality is high 75%.  High risk for recurrence.

41. Maternal Mortality Risk:  Low Maternal Mortality:  1%  VSD, ASD, PDA  Minimal Mitral Stenosis.  Corrected Tetralogy of Fallot.  Porcine Heart Valve.

42. Maternal Mortality Risk:  Intermediate Maternal Mortality: 5-15%  Mitral stenosis with atrial fibrillation.  Uncorrected Tetralogy of Fallot.  Marfan’s syndrome (aortic root  40mm).  Artificial (Metalic) heart valve.

43. Maternal Mortality Risk:  High Maternal Mortality: 25-50%  Pulmonary HTN.  Eisenmenger’s syndrome.  Marfan’s syndrome (aortic root  40mm).  Aoric Coarctation.  Peripartum cardiomyopathy.

44. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Signs & Symptoms of Heart Diseases Special Cardiac Diseases. Management and Counseling. Contraception in Cardiac Diseases.

45. Management: Remember …. - Two major issues should be considered during management: Intravascular volume Intravascular volume Tachycardia -They are normal physiologic changes of pregnancy. -But, they increase stress on diseased heart.

46. Management: Remember …. so, management always seeks: Intravascular volume Intravascular volume Tachycardia -The aim of management is to: - Control the vascular volume -Control tachycardia. Control

47. Management:

48. Antepartum Management:  Low salt intake.  Diuretics if needed.  Avoid strenuous activities.  Control anemia.  Digitalis or  -blockers if indicated.  Done after the 20 th week of gestation if the mother has congenital heart diseases. Control intravascular volume: Control tachycardia: Feta echocardiogram:

49. Intrapartum Management:

50.  During labour, bleeding is going on  prevent hypotension.  Monitor intravenous fluid volume.  Use areterial line and pulmonary artery catheter, specially with classes NYHA III and IV.  Provide reassurance.  Use sedatives and epidural analgesia ( not anesthesia ) to control pain.  Avoid second stage pushing (bearing down).  Forceps to shorten the 2 nd stage. Control intravascular volume: Control tachycardia: ** ** Epidural anesthesia are not used because they cause peripheral pooling of blood.

51. Intrapartum Management:  For subacute bacterial endocarditis SBE.  Indications: Vaginal delivery (specially with previous SBE). Prosthetic heart valve. Complex congenital heat diseases.  They are NOT recommended for any C/S delivery.  Recommended agents: Antibiotics prophylaxis: Ampicillin (2g) IV + Gentamicin (250)mg IV or vancomycin (1g) IV.

52. Management:

53. Intrapartum Management:  Monitor closely for postpartum intravascular volume overload.  After placental delivery, sudden  intravascular volume. Control intravascular volume:    Uterine contraction Sudden emptying of uterine venous sinuses postpartum intravascular overload

54. Counseling….

55. NYHA I & NYHA II classes can get pregnant and continue without any major complications. NYHA III, NYHA IV and high risk groups are advised not to get pregnant.

56. Counseling…. Left lateral rest is helpful to prevent hemodynamic fluctuation during pregnancy as well as during labour. Left lateral rest is helpful to prevent hemodynamic fluctuation during pregnancy as well as during labour.

57. Counseling…. -Avoid supine position. -Gravid uterus compresses inferior vena cava  syncope. -This condition is called: Supine Hypotension Syndrome..

58. Counseling…. Reduce unnecessary cardiac work by ensuring regular rest and avoid excess exertion. Provide prophylaxis against SBE Minimize the use of diagnostic studies with radiation

59. Counseling…. A patient receiving anticoagulants containing warfarin should shift to heparin -N.B: -Metalic Valve: -A patient with metallic valve, subcutaneous heparin is NOT effective. -Warfarin is better. -If the patient is pregnant, she should receive IV heparin in therapeutic range frequently through the pregnancy. -In the last trimester, shift heparin to warfarin.

60. Outlines: Review Hemodynamic Changes During Pregnancy Classification of Cardiac Diseases. Signs & Symptoms of Heart Diseases Special Cardiac Diseases. Management and Counseling. Contraception in Cardiac Diseases.

61. Contraception:  OCP are not ideal as they increase thromboembolic activity.  IUCD can cause infection-  endocarditis. It can be used but with SBE prophylaxis.  Barrier contraceptives – Have high failure rates.  Progestin only is better:  pills or Long acting injectable progesterone.  Irreversible methods of contraception:  Are the best specially those with high risk, but usually is not acceptable by patients.

62. DISCUSSION….

63. Problem: Patient Snapshot I: She has unrepaired VSD. Her perinatal course is uncomplicated. She had worked throughout the pregnancy without any limitation. What is the appropriate intervention? a.No need for invasive monitoring. b.She should have IV fluid infusion with close monitoring of hydration status. c.Consider emergency C/S with invasive monitor. d.Give her tocolytic agents and ask her to come after 1 week.

64. Problem: Patient Snapshot II: She has unrepaired Tetralogy of Fallot. Prenatally she had severe dyspnea with activity and has to be hospitalized at ICU. She now has bilateral basal crackle. What is the appropriate intervention? a.She is NYHA class III, needs induction of labour with invasive monitoring at cardiac ICU. b.Give her bronchodilator and O2 and discharge her and ask her to take rest at left lateral position. c.She can continues labour without any complication so no intervention is needed. d.Order serum BNP to confirm cardiac limitation.

65. Problem: Patient Snapshot III: She has Eisenmenger’s syndrome. She is having bright red vaginal bleeding and locaalized uterine tenderness. Her heart rate is 145pbm with BP of 90/60mmHg. What is the appropriate intervention? a.Let her continue labour with careful monitoring of volume status. b.Give her diuretics and digitalis. c.Give her analgesia, epidural anesthesia and use forceps for delivery. d.Consider emergency C/S since there is a maternal distress, monitor her invasively.

66. Thanks…