CARDIAC DISEASE IN PREGNANCY – Dr. Kudoyi

PLAN Epidemiology Pathology Clinical Presentation Investigations Management – New York Heart Association

Classificationo Antepartum o Intrapartum o Post Natal

EPIDEMIOLOGY Cardiac disease complicates 1% (0.3 – 3.0%) of

pregnancies worldwide It is the most important non-obstetric cause of

maternal mortality Worldwide MMR = 5/100,000 deliveries; K.N.H MMR

= 3,200/100,000 deliveries 95% of cardiac disease in pregnancy are due to

Rheumatic heart diseases (RHD) in developing countries. This is due to high prevalence of untreated beta haemolytic streptoccocal throat infections.

About 90% of cardiac diseases in pregnancy are due to congenital heart disease in some developed countries

PATHOLOGY In normal pregnancy hemodynamic changes occur

from the first trimester and peak in the 3rd trimester into a high output cardiac status

HR increases by 10% (10-15 beats/min) Plasma volume increases by 40%.

This increase in cardiac output may cause a systolic murmur in women who are healthy. However diastolic murmurs are always indicative of heart disease.

With cardiac disease in pregnancy increased cardiac output predisposes to CCF

CCF is further predisposed to byo Sepsiso Anemiao Exercises (physical activity)

To prevent CCF prevent sepsis and anaemia and reduce exercises.

AETIOLOGY1. Rheumatic Heart Disease (RHD)

90% involve mitral valve Mitral stenosis has highest risk for CCF When tricuspid valve is affected all

other valves are usually involved

2. Congenital Heart Disease (CHD) VSD, ASD, PDA are commonest

3. Hypertensive Heart Disease (HHD) Age above 35yrs Below 35yrs common causes are

i. renal artery stenosisii. phaechromocytomaiii. thyrotoxicosis

4. Peripartum Cardiomyopathy Rare

Patient without a heart lesion develops CCF in pregnancy or post-partum

Treat with digoxin and lasix5. Ischaemic Heart Disease

6. Syphylitic Heart Disease

7. Cor pulmonale Increased pulmonary vascular

resistance Chronic obstructive airway diseases e.g

asthma or chronic bronchitis.

COMPLICATIONS OF CARDIAC DISEASE1. Maternal –

CCF Pulmonary embolism Anaemia

2. Fetal IUGR Abortions Preterm deliveries IUFD

CLINICAL PRESENTATION1. Failure to thrive – poor growth, finger clubbing2. C.C.F

symptoms – shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, wheezing.

signs – tachycardia,Increased JVP, Murmurs, basal creps, alae nasi flaring, tachypnoea, oedema, ascites, tender hepatomegaly

3. Tissue hypoxia – pallor, cyanosis, oliguria, anuria , confusion , coma , cold periphery .

4. Myocardial strain – angina pain , palpitations, fibrillation

5. Murmurs6. Infective endocarditis

INVESTIGATIONS1. ECG2. Echo – cardiogram3. Urinalysis4. Haemogram5. U/E

NEW YORK HEART ASSOCIATION CLASSIFICATIONBased on functional state of the heart.

1. Grade 1 -Uncompromised.-No Limitation of physical activity.

2. Grade 2 -Slight limitation of physical activity-Dyspnoea on moderate exertion

3. Grade 3 -Marked limitation of physical activity-Dyspnoea on mild exertion.

4. Grade 4 -Inability to perform any physical activity

-Dyspnoea at rest , current or past CCF

MANAGEMENT

ANTENATAL CARE1. Combined team of cardiologist & obstetricians.2. Grades 1&2 as out-patients until 36 weeks of

gestation.

3. Prevent excess weight gain (diet) Fluid retention (frusemide) Anemia (haematinics) Sepsis (screen for UTI & isolate from URTI

patients)4. Adequate rest – 10hrs at night , 2 hrs daytime.5. Prop up in bed 6. Treat pre-eclampsia aggressively7. Grades 3&4 – give digoxin 0.25mg & Frusemide 40

mg daily8. RHD – monthly benzathine penicillin 2.4 MU.9. Prosthetic valves – anticoagulate.10. Dental Procedures be done under antibiotic cover11. Minor Heart surgery .e.g valvotomy is allowed. 12. Avoid open heart surgery

INTRAPATUMPrepare resuscitation tray containing ; -

1. Digoxin2. Frusemide3. Adrenaline4. Naloxone.5. Hydrocortisone6. Calcium gluconate7. Sodium bicarbonate8. Aminophylline9. Oxytocin10. Pethidine or morphine

1ST STAGE 1. Keep propped up2. I.M morphine 15mg or I.M pethidine 100mg to allay

anxiety & minimize pain.3. Oxygen by mask.4. Avoid I.V. fluids and if given , add I.V. frusemide5. If oxytocin is necessary use pump to minimize

fluid infusion.6. Delay ARM.7. I.V. Broad-spectrum antibiotics8. Minimize number of pelvic exams.9. Caesarean sections for obstetric indications only.

2nd STAGE1. No valsava maneuver2. Vacuum extraction.

3rd STAGE1. I.V. frusemide 40mg stat2. Massage uterus3. Avoid ergometrine4. I.M. oxytocin 10 units

PEUPERIUM1. Keep admitted for 10 days.2. Limit exercises3. Continue with antibiotics.4. Continue anticoagulation

POST-NATAL VISIT1. Advice on limited family size , 1-2 children.2. BTL or vasectomy3. Progesterone only drugs – microlut , jadelle ,

noristerat 4. Barrier – condoms5. Avoid oestrogens – may cause fluid retention.6. Avoid IUCD – increases sepsis rate.

NOTES