1. Management of Heart Disease in Pregnancy

2.  It is estimated that 1% to 3% of women either have cardiac disease entering pregnancy or are diagnosed with cardiac disease while they are pregnant.  Approximately 10% of all maternal deaths in the United States can be attributed to cardiac disease  75% of the women with various types of cardiac disease had no complications during pregnancy.  complication in 25% include :

3.  Congestive heart failure, including pulmonary edema (12.3%)  Cardiac arrhythmias (6%)  Thromboembolism (1.9%)  Angina (1.4%)  Hypoxemia (0.7%)  Infective endocarditis (0.5%)  The overall maternal mortality rate in this group was 2.7%, and the stillbirth and spontaneous abortion rate was 7.7%.

4. -- High-Risk Pregnancies (not pregnant) Pulmonary hypertension Dilated cardiomyopathy, ejection fraction <40% Symptomatic obstructive lesions Aortic stenosis Mitral stenosis Pulmonary stenosis Coarctation of the aorta Marfan syndrome with aortic root >40 mm Cyanotic lesions Mechanical prosthetic valves

5. M Maternal cardiac risk: (1) (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 (4) reduced systemic ventricular systolic function (ejection fraction less than 40%). -The estimated risk of a cardiac event in pregnancies with 0, 1, and more than 1 point was 5%, 27%, and 75%, respectively. - -It was concluded that those with a low cardiac risk of 0 could safely be delivered in a community hospital, -but those at intermediate or high cardiac risk (risk score of 1 or more) should be delivered at a regional center.

6. Mode of Delivery   For most patients with cardiac disease, a vaginal delivery is feasible and preferable   a cesarean section is indicated only for obstetric reasons.   Exceptions to this include the patient who is anticoagulated with warfarin because the baby is also anticoagulated, and vaginal delivery carries an increased risk to the fetus of intracranial hemorrhage

7.   Cesarean section may also be considered in patients who have a dilated unstable aorta (e.g., Marfan syndrome),   severe pulmonary hypertension   a severe obstructive lesion such as aortic stenosis.   High-risk patients should be delivered in a center where expertise is available to monitor the hemodynamic changes of labor and delivery and to intervene when necessary

8.   If vaginal delivery is elected, fetal and maternal electrocardiographic monitoring should be performed.  -  -Delivery can be accomplished with the mother in the left lateral position so that the fetus does not compress the inferior vena cava, thereby maintaining venous return.   The second stage should be assisted, if necessary (e.g., forceps or vacuum extraction), to avoid a long labor. Blood and volume loss should be replaced promptly

9. Thank you