1. PREGNANCY AND HEART FAILURE PROF.DR. MUHAMMAD AKBAR CHAUDHARY M.R.C.P. (U.K.) F.R.C.P. (E) F.R.C.P. (LONDON) F.A.C.C Designed At A.V. Dept. F.J.M.C. By Rabia Kazmi

2.  IF DISEASE DURING PREGNANCY IS TO BE WELL MANAGED, THE PHYSIOLOGICAL CHANGES OF PREGNANCY MUST BE KNOWN.  C. SIDNEEY BURWELL,M.D.1958

3. POTENTIAL DANGERS OF PREGNANCY TO MOTHER 1. HEAMODYNAMIC BURDEN OF PREGNANCY MAY RESULT IN DISABILITY OR DEATH OF MOTHER 2. PREGNANCY MAY AGGREVATE, PRE- EXISTING MATERNAL HEART DISEASE. 3. DANGERS OF DEVELOPING BACTERIAL ENDOCARDITIS & RECURRENCE OF RHEUMATIC FEVER 4. PREGNANCY MAY CAUSE HEART DISEASES

4. POTENTIAL DANGERS TO FETUS 1. ABNORMAL ORGANOGENESIS OR DEATH DUE TO INADIQUATE BLOOD SUPPLY 2. 50% FETAL WASTAGE WITH SEVERE MATERNAL HEART DISEASE. 3. INCIDENCE OF CONG. HEART DISEASE IS INCREASED, WITH MOTHER HAVING CONG.H.D. (15% CHANCES) & SOMETIMES UP TO 50% (I.H.S.S. & MARFAN SYNDROME) 4. INCREASE CHANCES OF LOOSING MOTHER

5. CONGENITAL HEART DISEASE IN THE OFFSPRING OF A PARENT WITH CONGENITAL HEART DISEASE

8. CHANGES IN C.V.S. DURING NORMAL PREGNANCY

10. IN NORMAL PREGNANCY Na+ AND WATER RETENSION OCCURES Na+ AND WATER RETENSION OCCURES PLASMA VOLUME BEGINS TO RISE AS EARLY AS 6 th WEEK AFTER CONCEPTION. PLASMA VOLUME BEGINS TO RISE AS EARLY AS 6 th WEEK AFTER CONCEPTION. PLASMA VOLUME APPROACHES MAXIMUM IN SECOND TRIMESTER AND IS 1 TIME NORMAL AT DELIVERY PLASMA VOLUME APPROACHES MAXIMUM IN SECOND TRIMESTER AND IS 1 TIME NORMAL AT DELIVERY TOTAL BODY WATER INCREASES TO 6-8. L. TOTAL BODY WATER INCREASES TO 6-8. L. TOTAL Na + RETENSION IS 500-900 meq. TOTAL Na + RETENSION IS 500-900 meq. 1 2

11. IN PREGNANCY CARDIAC OUT PUT AND ITS DISTRIBUTION AT REST

12. CARDIOVASCULAR ASSESSMENT OF PREGNANT WOMAN WHAT COULD BE NORMAL ? DYSPNOEA, CHEST PAIN, EASY FATIGABILITY, PALPITATIONS SYNCOPE MAY BE DUE TO PREGNANCY ONLY. DYSPNOEA, CHEST PAIN, EASY FATIGABILITY, PALPITATIONS SYNCOPE MAY BE DUE TO PREGNANCY ONLY. PERIPHERAL OEDEMA MAY OCCUR IN 80% NORMAL PREGNANT WOMAN. PERIPHERAL OEDEMA MAY OCCUR IN 80% NORMAL PREGNANT WOMAN. VISIBLE NECK VEINS, PULMONARY RALES NOT UNCOMMON IN PREG. VISIBLE NECK VEINS, PULMONARY RALES NOT UNCOMMON IN PREG.

13. CARDIOVASCULAR ASSESSMENT OF PREGNANT WOMAN WHAT IS ABNORMAL? P.N.D, ORTHOPNOEA, SEVERE DYSPNOEA LIMITING NORMAL ACTIVITY P.N.D, ORTHOPNOEA, SEVERE DYSPNOEA LIMITING NORMAL ACTIVITY HEMOPTYSIS HEMOPTYSIS SYNCOPE WITH EXERTION SYNCOPE WITH EXERTION TYPICAL CHEST PAIN OF I.H.D. TYPICAL CHEST PAIN OF I.H.D. CYANOSIS CYANOSIS CLUBBING CLUBBING SYSTOLIC MURMUR OF 3/6 AND MORE. SYSTOLIC MURMUR OF 3/6 AND MORE. DIASTOLIC MURMUR. DIASTOLIC MURMUR.

14. CARDIAC LESION CARDIAC LESION RELEVANT HEMODYNAMI C CHANGE IN PREGNANCY RELEVANT HEMODYNAMI C CHANGE IN PREGNANCY RESULT RESULT TIME OF GREATEST TIME OF GREATEST RISK RISK DEMONSTRATED RISK DEMONSTRATED RISK MANAGEMENT MANAGEMENT CARDIOMYOPA THY, CARDIOMYOPA THY, RHEUMATIC FEVER RHEUMATIC FEVER MYOCARDITIS ; MYOCARDITIS ; BLOOD VOLUME BLOOD VOLUME CARDIAC OUT PUT CARDIAC OUT PUT PULMONARY CAPILLARY PRESSURE PULMONARY CAPILLARY PRESSURE CARDIAC OUT PUT CARDIAC OUT PUT >12 WEEKS >12 WEEKS UNCOMMON; MATERNAL MORBIDITY UNCOMMON; MATERNAL MORBIDITY TREAT PULMONARY CONGESTION TREAT PULMONARY CONGESTION AVOID PREGNANCY IF LEFT VENTRICULAR FAILURE IS PRESENT AVOID PREGNANCY IF LEFT VENTRICULAR FAILURE IS PRESENT A.MYOCARDIAL DISEASES EFFECT OF PREGNANCY ON VARIOUS HEART DISEASES

15. EFFECTS OF PREGNANCY ON VARIOUS HEART DISEASES B. VALVE ABNORMALITIES MITRAL STENOSIS MITRAL REGURGITATION (INCLUDE MITRAL PROLAPSE WHEN COMPLICATED BY IMPORTANT MITRAL REGURGITATION ) AORTIC STENOSIS AORTIC REGURGITATION PULMONARY STENOSIS CARDIAC OUT PUT CARDIAC OUT PUT HEART RATE HEART RATE BLOOD VOLUME BLOOD VOLUME PULMONARY VASCULAR RESISTANCE PULMONARY VASCULAR RESISTANCE OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY BLOOD VOLUME BLOOD VOLUME OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY BLOOD VOLUME OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY PULMONARY CAPILLARY PRESSURE PULMONARY CAPILLARY PRESSURE VENOUS RETURN VENOUS RETURN LA FILLING LA FILLING PULMONARY CAPILLARY PRESSURE PULMONARY CAPILLARY PRESSURE VENOUS RETURN VENOUS RETURN LV FILLING LV FILLING CARDIAC OUT PUT CARDIAC OUT PUT PULMONARY CAPILLARY PRESSURE VENOUS RETURN VENOUS RETURN LV FILLING LV FILLING CARDIAC OUT PUT CARDIAC OUT PUT  12 WEEKS (WHEN HEMODYNAMIC CHANGES BECOME SIGNIFICANT)  LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY) & POSTPARTUM >12 WEEKS  LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY)& POST PARTUM PREGNANCY  >12 WEEKS LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY) & POSTPARTUM MATERNAL MORBIDITY & MORTALITY FROM PULMONARY CONGESTION & PULMONARY EDEMA MATERNAL MORBIDITY & MORTALITY FROM PULMONARY CONGESTION & PULMONARY EDEMA FETAL GROWTH & FETAL LOSS POSSIBLE EXPLANATION OF SOME MATERNAL DEATHS FETAL GROWTH & FETAL LOSS POSSIBLE EXPLANATION OF SOME MATERNAL DEATHSUNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL MATERNAL MORTALITY UNCOMMON BECAUSE AORTIC STENOSIS IS RARE MATERNAL MORTALITY UNCOMMON BECAUSE AORTIC STENOSIS IS RAREUNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL UNCOMMON: UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL LIMIT DEMANDS FOR CARDIAC OUTPUT, BASED ON SYMPTOMS AVOID TACHYCARDIA TREAT TRACHYARRYTHMI A MAINTAIN VENOUS RETURN, ESPECIALLY IF SYMPTOMS OF CARDIAC OUTPUT OCCUR RX OF PULMONARY CONGESTION IF OCCURS (RESTRICT SODIUM, DIURETICS) MAINTAIN VENOUS RETURN STRICT LIMITATION OF ACTIVITY, AND IF SYMPTOMS PRESIST,PROCEED TO VALVE SURGERY OR INTERRUPTION OF PREGNANCY RX OF PULMONARY CONGESTION IF IT OCCURS (RESTRICT SODIUM INTAKE,DIURETICS ) MAINTAIN VENOUS RETURN

16. EFFECTS OF PREGNANCY IN VARIOUS HEART DISEASE C. CONGENITAL HEART DISEASES- GARDLAC LESION RELEVENT HEMODYNAMIC CHANGE IN PREGNANCY RESULT TIME OF GREATEST RISK DEMONSTRATED RISK MANAGEMENT SHUNTS; LEFT TO RIGHT (ESTALDEFECT,PAT ENT DUCTUS) RIGHT TO LEFT (EISENMENGR’S SYNDROME, TETRALOGY OF FALLOT) CARDIAC OUT PUT CARDIAC OUT PUT BLOOD VOLUME BLOOD VOLUME PULMONARY VASCULAR RESISTANCE PULMONARY VASCULAR RESISTANCE PERIPHERAL VASCULAR RESISTANCE OBSTRUCTION OF INFERIOR VENA CAVA PERIPHERAL VASCULAR RESISTANCE OBSTRUCTION OF INFERIOR VENA CAVA PULMONARY CAPILLARY PRESSURE PULMONARY CAPILLARY PRESSURE SHUNTING AND VENOUS RETURN SHUNTING AND VENOUS RETURN PULMONARY BLOOD FLOW PULMONARY BLOOD FLOW >12 WEEKS LATE IN PREGNANCY WHEN SUPINE (LABOUR, DELIVERY, SURGERY) AND POST PARTUM UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL MATERNAL MORTALITY DUE TO SUDDEN DEATH MATERNAL MORTALITY DUE TO SUDDEN DEATH FETAL GROWTH & FETAL GROWTH & FETAL LOSS FETAL LOSS RX OF PULMONARY CONGESION IF IT OCCURES (RESTRICT SODIUM INTAKE, DIURETICS ) AVOID PREGNANCY MAINTAIN VENOUS RETURN COARCTATION OF THE AORTA OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD VOLUME BLOOD VOLUME PULSE PRESSURE PULSE PRESSURE STEROID HARMONES STEROID HARMONES ? TENDANCY TO HYPERTENSION VENOUS RETURN VENOUS RETURN LV FILLING LV FILLING CARDIAC OUT PUT CARDIAC OUT PUT DISTENSION OF AORTIC ROOT LATE IN PREGNANCY WHEN SUPINE (LABOUR, DELIVERY, SURGERY) & POSTPARTUM >12 WEEKS UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL AORTIC RUPTURE DISSECTION OF AORTA RUPTURE OF INTRACRANIAL ANEURYSM MAINTAIN VENOUS RETURN DELAY PREGNANCY UNTILL RX, OPTIMAL TREAT HYPERTENSION & MINIMIZE PULSE PRESSURE

17. EFFECTS OF PEGNANCY IN VARIOUS HEART DISEASE D. OTHER PROBLEMS ANY CAUSE OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY VENOUS RETURN VENOUS RETURN LV FILLING LV FILLING CARDIAC OUTPUT CARDIAC OUTPUT LATE IN PREGNANCY WHEN SUPINE (LABOUR DILIVERY, SURGERY) AND POSTPARTUM MATERNAL MORTALITY DUE TO SUDDEN DEATH MATERNAL MORTALITY DUE TO SUDDEN DEATH AVOID PREGNANCY MAINTAIN VENOUS RETURN TRY TO LOWER PULMONARY VASCULAR RESISTANCE IDIOPATHIC HYPERTROPHIC CARDIOMYOPATHY SUBAORTIC STENOSIS SUBAORTIC STENOSIS MARFAN’S SYNDROME OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS HEART RATE BLOOD LOSS AT DELIVERY HEART RATE BLOOD LOSS AT DELIVERY BLOOD VOLUME BLOOD VOLUME PULSE PRESSURE PULSE PRESSURE STEROID HORMONES STEROID HORMONES VENOUS RETURN VENOUS RETURN LV FILLING LV FILLING LV OBSTRUCTION LV OBSTRUCTION CARDIAC OUTPUT CARDIAC OUTPUT PULMONARY CAPILLARY PRESSURE PULMONARY CAPILLARY PRESSURE DISTENSION OF AORTIC ROOT >12 WEEKS MATERNAL MORTALITY DURING PREGNANCY MATERNAL MORTALITY DURING PREGNANCY MATERNAL MORBIDITY DURING PREGNANCY MATERNAL MORBIDITY DURING PREGNANCY MATERNAL MORTALITY FROM AORTIC DISSECTION OR RUPTURE MATERNAL MORTALITY FROM AORTIC DISSECTION OR RUPTURE MAINTAIN VENOUS RETURN ADRENERGIC BLOCKAGE WILL LV OUT FLOW OBSTRUCTION ADRENERGIC BLOCKAGE WILL LV OUT FLOW OBSTRUCTION RX OF PULMONARY CONGESTION, ESPECIALLY DIURETICS AVOID PREGNANCY, MINIMIZE PULSE PRESSURE PULMONARY HYPERTENSION DEVELOPMENT ABNORMALITIES

18. EFFECTS OF PREGNANCY ON VARIOUS C.V.S. DISEASES E. HYPERTENSION HYPERTENSION CORONARY ARTERY DISEASE CORONARY ARTERY DISEASE CARDIAC ARRHTHMIAS CARDIAC ARRHTHMIAS D.V.T & PUL. THROMBO EMBOLISM D.V.T & PUL. THROMBO EMBOLISM

19. MANAGEMENT OF HEART FAILURE IN PREGNANCY A. GENERAL CONSIDERATION 1. HIGHEST PRIORITY TO MATERNAL HEALTH 2. FETAL WELLBEING SHOULD BE CONSIDERED AS PART OF EACH DIAGNOSTIC MANAGEMENT CONSIDRATION 3. GENERAL MEASURES SHOULD BE TAKEN BEFORE DRUG INTERVENTION 4. DRUGS, DIAGNOSTIC STUDIES, SURGERY SHOULD BE CONSIDERED FOR MAXIMUM SECURITY OF MOTHER

20. MANAGEMENT B. 1. PRE-CONCEPTUAL COUNSELLING 2. MINIMISE STRESS ON HEART 3. AVOID ANXIETY 4. AVOID SYSTEMIC INFECTIONS 5. AVOID ANAEMIA 6. DISCOURAGE SMOKING 7. IMMUNIZE BEFORE PREGNANCY 8. ANTIBIOTIC PROPHYLAXIS- AGAINST BACTERIAL ENDOCARDITIS OR RECURRENCE OF RHEUMATIC FEVER 9. PROPER MANAGEMENT OF THROMBO- EMBOLIC EVENTS

21. MANAGEMENT C. DRUGS AVOID DRUGS IF POSSIBLE. AVOID DRUGS IF POSSIBLE. IF SITUATION, WHERE CARDIAC FAILURE CAN NOT BE CONTROLLED WITHOUT DRUGS – THEY SHOULD NOT BE WITHHELD IF SITUATION, WHERE CARDIAC FAILURE CAN NOT BE CONTROLLED WITHOUT DRUGS – THEY SHOULD NOT BE WITHHELD DIURETICS DIURETICS INOTROPIC AGENTS INOTROPIC AGENTS BETA BLOCKERS BETA BLOCKERS ANTIARRHYTHMIC AGENTS. ANTIARRHYTHMIC AGENTS. CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS VASODILATORS VASODILATORS ANTICOAGULANTS ANTICOAGULANTS