This document discusses heart disease in pregnancy. It notes that congenital heart diseases now constitute at least half of cardiac cases seen in pregnancy. It describes the normal physiological changes in pregnancy that increase cardiac output and decrease vascular resistance. It then discusses diagnosing and classifying heart disease in pregnancy, risks for maternal mortality, management during labor and delivery, and specific management for conditions like mitral stenosis, aortic stenosis, congenital heart diseases, and infective endocarditis.
This document discusses heart disease in pregnancy. It notes that congenital heart diseases now constitute at least half of cardiac cases seen in pregnancy. It describes the normal physiological changes in pregnancy that increase cardiac output and decrease vascular resistance. It then discusses diagnosing and classifying heart disease in pregnancy, risks for maternal mortality, management during labor and delivery, and specific management for conditions like mitral stenosis, aortic stenosis, congenital heart diseases, and infective endocarditis.
This document discusses heart disease in pregnancy. It notes that congenital heart diseases now constitute at least half of cardiac cases seen in pregnancy. It describes the normal physiological changes in pregnancy that increase cardiac output and decrease vascular resistance. It then discusses diagnosing and classifying heart disease in pregnancy, risks for maternal mortality, management during labor and delivery, and specific management for conditions like mitral stenosis, aortic stenosis, congenital heart diseases, and infective endocarditis.
This document discusses heart disease in pregnancy. It notes that congenital heart diseases now constitute at least half of cardiac cases seen in pregnancy. It describes the normal physiological changes in pregnancy that increase cardiac output and decrease vascular resistance. It then discusses diagnosing and classifying heart disease in pregnancy, risks for maternal mortality, management during labor and delivery, and specific management for conditions like mitral stenosis, aortic stenosis, congenital heart diseases, and infective endocarditis.
Assoc.Prof.Pawin Puapornpong. Faculty of Medicine Srinakharinwirot University Epidermiology
In the past , rheumatic heart disease accounted
for the majority of cases.
Now ,congenital heart diseases constitute at
least half of all cases.
Hypertensive heart disease has becomes
relatively common cause of peripartum heart failure. Physiology Increase cardiac output 30%-50%, of total at 8 wk and then maximize at midpregnancy.
Decrease vascular resistance
Increase PR,stroke volume,diastolic filling
time.
Normal left ventricular filling pressure by
dilated ventricle. Hemodynamic change in normal pregnancy Parameter change (%)
Cardiac output +43
HR +17 Left ventricular stroke work index +17 Vuscular resistance Systemic -21 Pulmonary -34 Mean arterial pressure +4 Colloid osmotic pressure -14 Diagnosis
Difficult to diagnose,because murmur
,edema ,dyspnea are common in pregnancy. Symptoms Progressve dyspnea or orthopnea Nocturnal cough Hemoptysis Syncope Chest pain Clinical Findings Cyanosis Clubbing of fingers Persistent neck vein dilatation Systolic murmur grade 3/6 Diastolic murmur Cardiomegaly Persistent arrhythmia Persistent split-second sound Criteria for pulmonary hypertention Diagnostic study EKG diaphragm is elevate,15-degree left axis deviation,mild ST change Atrial and ventricular premature contraction are common in normal pregnancy.
Chest X-rayslight heart enlargement
cannot be detected.
Echocardiographynoninvasive,some normal pregnancy inducdes TR and increase left atrial size. Clinical classification Class 1 no limitation of physical activity Class 2 slight limitation of physical activity Class 3 marked limitation of physical activity Class 4 inability to perform any physical activity without discomfort. Risks for maternal mortaliity Group 1 minimal risk 0-1%
ASD,VSD PDA Pulmonic or tricuspid disease TOF,corrected Bioprosthetic valve MS,NYHA classes 1 and 2 Group 2 Moderate Risk 5-15% 2A:MS,NYHA class 3 and 4 AS TOF ,uncorrected Marfan syndrome , normal aorta Previous MI Aortic coarctation without valve involvement 2B:MS with AF Artificial valve Group 3 Major risk 25-50%
Pulmonary hypertension
Aortic coarctation with valvar involvement
Marfan syndrome with aortic involvement
Management of classes 1 and 2 Mortalities rate is low.
infection - heart failure
No smoking respiratory tract infection
illegal drug bacterial endocarditis
CHF persistence basilar rales ,
nocturnal dyspnea,Tachytcardia , hemoptysis , progressive edema Labor and delivery Normal labor , C/S indication Pulmonary artery catheterization Continuous epidural block hypotension Semirecumbent position Record vital sign keep PR <100,RR<24 F/E , V/E Intrapartum heart failure heart failure pathophysiology
Surgically corrected heart disease Sx in childhood , 15-20% not Sx because asymptommatic complication : thromboembolism or hemorrhage from anticoagulant Warfarin prevent embolism but teratogenic ,heparin 6-12wk and then continuous warfarin stop anticoagulant before delivery start 6 hr if NL and 24 hr if C/S Valvar heart disease
Type Cause Pathophysiology Pregnancy
Mitral stonosis Rheumatic LA dilate, PH , AF HF from fluid
congenital and dilate connective tissue Mitral stenosis Rheumatic endocarditis causes in MS. LV dilate and PH from increase preload Clinical dyspnea , fatique , palpitation , cough , hemoptysis , tachycardia diastolic filling time b- block AF aortic embolization , CVA cardioversion Management Limit activities ,Sodium restrict , diuretic New onset AF verapamil or electrical cardioversion Chronic AF b- block , digoxin , heparin Vaginal delivery and epidural analgesia Prophylaxis endocarditis Mitral insufficiency No symptom Improve in pregnancy because decrease peripheral resistance is reduced regurgitation HF develop from tachyarrthmia Rx by b- block Prophylaxis endocarditis Aortic stenosis Disease of aging. LV hypertrophy , decrease preload decrease CO Chest pain , syncope , heart failure , suddend death from arrythmia Severe AS extremely dangerous Management Asymptomatic no Rx but observation only Limitation activities and Rx infection Balloon valvulotomy is high complication hypotension , maintain CO Epidural analgesia V/E and F/E Prophylaxis endocarditis Aortic insufficiency LV hypertrophy and dilatation Fatigue , dyspnea , edema Improve in pregnancy If HF Rx sodium restrict , rest , diuretic Epidural analgesia Prophylaxis endocarditis Congenital heart disease ASD Risk of ASD in fetus 5-10 % Congenital asymptomatic until third or forth decade PH is rare If CHF develop Rx Prophylaxis endocarditis VSD Spontaneously close in 90% during childhood Adult with unrepaired large defect develop HF and PH If turn to Eisenmenger syndrome , mortalities rate is 30-50%. Prophylaxis endocarditis PDA Some woman with an unrepaired persistent ductus develop PH. hypotension reverse blood flow from pulmonary a. to aorta cyanosis Prophylaxis endocarditis TOF Cyanotic heart Large VSD , RV hypertrophy ,overiding aorta Peripheral resistance decrease shunt and cyanosis worsens Hypoxia , polycythemiapreterm , fetal death , LBW Eisenmenger syndrome Secondary pulmonary hypertension Rt to Lt shunt Most common : ASD , VSD Prognosis depend on severity Pulmonary hypertension Primary and secondary Limited activities , avoid of supine position , diuretic , oxygen supplement and vasodilate therapy venous return and Rt ventricular filling maternal death Epidural analgesia Mitral valve prolapse Connective tissue disease 15% in normal young women asymptomatic , rare symptom : palpitation , dyspnea clinical improve in pregnancy antibiotic prophylaxis Peripartum cardiomyopathy Dx by exclude peripartum heart failure but no underlying heart disease Bx : myocarditis precipitate:anemia , infection , preelampsia Idiopathic cardiomyopathy in preg Prolong b -mimetic tocolytic provoking cardiomyopathy symptom : CHF , dyspnea , orthopnea , palpitation , chest pain Echocardiogram : EF < 45% , increase end- diastolic dimension Rx : heart failure idiopathic prognosis better than identifies cause Infective endocarditis Subacute endocarditis viridan gr. Streptococci. And Enterococcus species
Acute endocarditis coaglase positive
staphylococci , S. aureus in native valve or iv drug abuse , S. epidermis in prosthetic valve , Strep pneumoniae and N. gonorrheae in acute and fulminant Sign and symptom Flu like , anorexia , fatique , embolic lesion ,+blood colture Negative echocardiographic not exclude Rx most viridan :penicillin G iv and gentamicin 2 wk Allergy for penicillin :cef 3 or vancomycin 4 wk Other organism C/S 4-6 wk Prosthetic valve 6-8 wk Antimicrobial prophylaxis Moderate-high risk Normal labor not indication for antibiotic prophylaxis Preterm , PROM , manual placenta removal , 4 degree tear and high moderat risk must take antibiotic High risk Prosthetic heart valve previous endocarditis complex congenital cyanotic heart disease surgically constructed systemic pulmonary shunts Moderate risk Most other congenital malformation not in high or low risk categories acquire valve dysfunction hypertrophic cardiomyopathy mitral valve prolapse with valve regurgitation Not recommended ASD surgically corrected without prosthetic valve coronary a. with previous bypass Sx mitral valve prolapse without valve regurgitation physiologic murmur pacemaker previous rheumatic without valve dysfunction Antibiotic High risk : ampicillin +gentamicin Penicillin-allergic patients : vancomycin +gentamicin Moderat risk : amoxycillin or ampicillin Arrhythmia Bradyarrhythmia : permanent artificial pacemaker SVT: Rx like non pregnancy , digoxin , adenosine , calcium channel blocker VT : cause ? , b- block AF : underlying? , digitalis to control rate Coarctation of aorta Hypertension in upper extremities and normal or reduced in lower extremities Hypertension aortic rupture B- block to prevent hypertension C/S is recommended Prophylaxis endocarditis Marfan syndrome Autosomal dominant Systemic connective tissue disease AR , MR , aortic dissection C/S if valve dissection 50% offspring Aortic dissection Severe chest pain , loss in peripheral pulse , murmur Abnormal CXR and angiogram is definite Noninvasive iv CT or MRI Rx reduce BP MI
Rx like non pregnancy
Nitroglycerine , morphine , lidocain calcium channel blocker , b- block C/S if indication Epidural analgesia Thank you
