heart disease in pregnancy-a journal report

8/4/2019 Heart Disease in Pregnancy-A Journal Report

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4/21/12

Assessment anManagement of CaDisease in Pregna

CEBU INSTITUTE OFMEDICINE



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Outline• Introduction

•

Cardiorespiratory changesa. Intrapartum hemodynamics

b. Postpartum hemodynamics

• Physical Examination in pregnant patient

•

Non invasive cardiac investigations• Bacterial endocarditis prophylaxis

• Risk of congenital heart disease in offspring



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• General Cardiac Management Issues

a. Preconceptional counselling

b. Prenatal care

c. Predictors of poor maternal and neonatal outd. Labor and delivery

e. Post partum care

• Contraception

•

Conclusion



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Cardiorespiratory Changes


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• Heart rate, stroke volume, cardiaoutput, and blood pressure are

significantly dependent on mateposition esp. after 28th week of gestation

•

A rise in cardiac output is associwith an increased blood flow to torgans crucial in pregnancy



•

Pregnancy is associated with asignificant increase in respiratotidal volume, leading to an increin minute ventilation, but therespiratory rate remains unchan



Intrapartum Hemodynamics

•

Each uterine contraction is associatean expulsion of 300 to 500 ml of blofrom the uterus into general circulatadding to preload

•

The cardiac output in active labor isincreased by 2.5L/minute into the ra7-8L/min

• Cardiac output and stroke volume a

highest



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•

BP and CVP are elevated inassociation with uterine contrac



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Postpartum Hemodynamics

• Immediately after delivery there issignificant increase in cardiacoutput



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In a group of parturient women whoepidural anaesthesia, cardiac output wreported to be approximately 40% abobaseline values at 15 minutes after vadelivery and 25% at 30 minutes postp

James CF, Banner T, Caton D. Cardiac Output in Women UndergoingSection

with Epidural or General anesthesia. AmJ Obstet Gynecol 1989;160:



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A comparison group who received ganaesthetic also had elevations in caroutput of approximately 30% and 15%above baseline at 15 and 30 minutespostpartum

James CF, Banner T, Caton D. Cardiac Output in Women UndergoingSection

with Epidural or General anesthesia. AmJ Obstet Gynecol 1989;160:



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• Maternal heart rate actually fall

10 beats per minute during thisdespite a mean blood loss of approximately 500 mL associatwith vaginal delivery and 1000

associated with Caesarean sect



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•

By two weeks postpartum, cardoutput has reduced by 33%. Apostpartum diuresis peaks by thsecond to fifth postpartum day

lasts for several weeks.



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Physical Examination in tPregnant Patient

•

More diffuse apical impulse• Palpable systolic pulsation along

left sternal border



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• First heart sound increased in

intensity and widely split.• In the third trimester the splittin

the second heart sound widens

than normal with inspiration.



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• In a study, 92% developed an e

systolic murmur usually heard athe left sternal border. These arusually I to II out of VI in intensit

Cutforth R, MacDonald CB. Heart sounds and murmurs in pregnancy

1966;71:741–7.



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• Tricuspid valve inflow

murmur/Graham Steell PulmonaRegurgitation murmur

– Most common diastolic murmur in

pregnancy – Associated with physiologic dilata

the Pulmonary Artery – Resolves after delivery

h i l i i i



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• Mitral and Aortic regurgitation

decrease during pregnancysecondary to the decrease insystemic vascular resistance

•

Prominent neck veins or inspirawheeze may normally be identi

• Pedal edema is very common

N i i C di



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Non-invasive CardiacInvestigations

• ECG may show left-axis deviatio

and ST-T wave changes in the thtrimester.

• On Echocardiogram, the heart

appears mildly volume overloadand hyperkinetic.

B t i l E d diti



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Bacterial EndocarditisProphylaxis

• Prophylaxis against bacterial

endocarditis in the pregnant pawith structural cardiac disease, congenital or acquired, is not

currently recommended.• The risk of bacteremia at the tim

vaginal delivery or Caesarean s

is low

Ri k f C it l H t Di



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Risk of Congenital Heart Disin Offspring

• A discussion of the increased ris

congenital heart disease in theioffspring is an important compoof prenatal counselling.

•

The risk is generally higher if thmother, rather than the father, affected.

Ri k f C it l H t Di



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Risk of Congenital Heart Disin Offspring

• Fetal echocardiography at 18 to

weeks’ gestation is recommenda pregnant patient with a congeheart defect.

G l C di M



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General Cardiac ManagemIssues

• Preconceptual Counselling – Genetic counselling, either before

early in pregnancy, is recommendidentify the risk for their offspring

G l C di M



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• Prenatal Care – Patient with cardiac disease shoul

seen early in the first trimester – Assessment by a cardiologist early

pregnancy is also indicated – Patients are seen for prenatal visit

every two weeks, or more frequennecessary.

General Cardiac Managem



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• Prenatal Care – A fetal echocardiogram is recomm

at 18 to 21 weeks’ gestation for pwith congenital heart disease.




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• Prenatal Care – A fetal echocardiogram is recomm

at 18 to 21 weeks’ gestation for pwith congenital heart disease.

–

Use of iron, prenatal vitamins, anddietary counselling to avoid anemwhich is a common problem inpregnancy



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Greatest risk for Cardiac event dupregnancy:

1. Prior cardiac event or arrythmia

2. NYHA functional class II or cyanosis

3. Left Heart obstruction or systemic

ventricular dysfunction

0= 5 % risk

1= 27 % risk

>1= 75 % risk




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• Labor and Delivery – Patients may await spontaneous l

and can be counselled that the raCaesarean section is not increasebecause of heart disease alone

– Careful monitoring of the mother fetus once in labor especially fluidmanagement and ECG monitoring




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• Post-Partum Care – Most crucial time for some patient

cardiac disease – Close monitoring should be maint

for at least 48 hours when cardiacoutput remains elevated




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• Post-Partum Care – Most patients are reassessed at fo

six weeks postpartum, by which tthe woman’s hemodynamic statusreturned to the nonpregnant state




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• Contraception – Sterilization of the male partner

obviously carries the least risk forwoman with cardiac disease

–

Barrier methods, when used consand properly, are usually effective




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• Contraception – Oral contraceptives can be used i

patients with cardiac disease withseveral exceptions

•

Patients with right to left shunts• Patients with cardiac disease th

associated with hypertension




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• Contraception – Progestin-only oral contraceptives

depotmedroxyprogesterone acetabe used, as the thromboembolic roral contraceptives is thought to bto the estrogen component.

– Progestin-releasing intrauterine de(IUD) can be an excellent choice



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Conclusion

• The difficult issues in a pregnan

complicated by cardiac disease best managed through a teamapproach.

•

Patients with severe symptoms close attention and may requiremedical and occasionally surgic

treatment during pregnancy



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Conclusion

• Labor, delivery, and the immed

postpartum period are associatwith significant hemodynamicchallenges and patients should

monitored throughout.• Pregnancy with cardiac disease

usually has a successful outcom



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THANK YOU

heart disease in pregnancy-a journal report

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