1. Max Brinsmead MB BS PhD May 2015

2.  In the UK this has increased over time  Deaths in 1982 – 85 7.3 per million births  in 2003 – 05 22.7 per million births  Due mainly to increasing maternal age and ↑ incidence of coronary artery disease  In PNG there were 4 admissions to the antenatal ward for heart disease in 2010 amongst 12,109 deliveries

3.  Myocardial ischaemia/Infarction 33%  Cardiomyopathy 33%  Rheumatic heart disease 10%  Congenital heart disease 10%  In developing countries there is more rheumatic heart disease and less coronary artery disease

4.  Pregnancy increases the risk 3 – 4 fold  But age >40 increases the risk 30 fold  When infarction occurs 33% women will die  Associated risk factors... ▪ Hypertension ▪ Pre eclampsia ▪ Diabetes ▪ Smoking ▪ Obesity ▪ Hyperlipidaema

5.  A high index of suspicion in patients at risk  If they develop chest pain then early recourse to... ▪ ECG ▪ Serum tropinins ▪ CT or MRI ▪ Angiography if required

6.  Unknown aetiology and no known risk factors  25% will be associated with hypertension  Sometimes due to viral myocarditis  Can occur any time in the antenatal period and up to 6 months postpartum

7.  A patient who complains of increasing dyspnoea  Especially nocturnal orthopnoea  Investigate by... ▪ ECG ▪ CXR ▪ Echocardiography

8.  Mitral stenosis is the most common  And most serious  But it is difficult to detect  So early referral and echocardiography is recommended when...  Any diastolic murmur is detected  There is any history suggestive of rheumatic fever

9.  Usually associated with systolic hypertension  So keep this controlled  Also a complication of Marfan’s Sydrome  The spider people  With dislocated lens  May be a family history  But 30% are spontaneous mutations  Risk of aortic dissection is low if the aortic root diam is <40 mm

10.  Survival after corrective or palliative surgery now more common  Cyanotic CHD carries the poorest prognosis  And any degree of pulmonary hypertension is worrying  In terms of frequency the problems are:  Left ventricular outflow obstruction ± Bicuspid aortic valve  Coarctation of the aorta  Tetralogy of Fallot  Right ventricular outflow obstruction  Ebstein’s anomaly (<1%)

11.  Start Preconception ▪ Complete diagnostic work up ▪ Multidisciplinary care ▪ Patient education ▪ Family Planning  Contraception ▪ COC’s are only relatively contraindicated for most ▪ But Progestin-only contraception may be better ▪ IUCD insertion may require resuscitation backup ▪ Mirena may be better than copper IUDs

12.  Antenatal Care ▪ Multidisciplinary care ▪ Preferably seen by same person for each visit  Cardiac evaluation at each visit ▪ Know what to ask for (based on knowledge of the patient) ▪ Know what to look for (based on what was found before) ▪ Rising pulse rate at rest may be first sign of trouble  Low threshold for admission ▪ Fetal echocardiography for those with CHD  Delivery Planning ▪ Multidisciplinary meeting at 32 – 34 w ▪ Decide on timing, place and type of delivery ▪ Labour & Delivery in ICU may be the best option

13.  Intrapartum Care ▪ Multidisciplinary team ▪ Minimise cardiovascular stress ▪ Analgesia – best by epidural ▪ Caesarean only for the usual obstetric indications ▪ But this may include high risk of failed induction ▪ Assisted delivery ▪ 2 units Syntocinon IV or low dose Syntocinon infusion the safest option for the 3 rd stage ▪ The greatest risk of CCF is immediately postpartum  Postpartum Care ▪ Consider thromboprophylaxis  Family Planning

14.  The New York Heart Association (NYHA) Classification  Class I ▪ No symptoms and no limitation to ordinary physical activity  Class II ▪ Mild symptoms (dyspnoea or angina) with slight limitation to physical activity  Class III ▪ Marked limitation of activity due to symptoms  Class IV ▪ Symptoms at rest

15. Please leave a note on the Welcome Page of this website