Heart disease with pregnancy Incidence of heart disease

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Heart disease with pregnancy

Heart disease with pregnancy

Incidence of heart disease • Varies between 0. 1 – 4. 0 %, average

Incidence of heart disease • Varies between 0. 1 – 4. 0 %, average 1% • Mortality due to heart disease has decreased • Developed countries – maternal mortality due to heart disease has increased • Pregnancy with heart disease has increased • Developed countries – rheumatic is decreasing • Congenital heart disease with pregnancy is also increasing

Hemodynamic changes in normal pregnancy PARAMETER CHANGE (PERCENT) Plasma volume +40 Cardiac output +43

Hemodynamic changes in normal pregnancy PARAMETER CHANGE (PERCENT) Plasma volume +40 Cardiac output +43 Heart rate +17 Mean arterial pressure +4 Stroke volume +27 Systemic vascular resistance Pulmonary vascular resistance -21 -34

Critical periods • • • Changes start from as – 6 weeks Max changes

Critical periods • • • Changes start from as – 6 weeks Max changes around – 30 weeks Intra partum period Just after delivery Second week of puerperium

Pregnancy changes mimic cardiac disease • Symptoms – breathlessness, weakness, oedema, syncope • Tachycardia

Pregnancy changes mimic cardiac disease • Symptoms – breathlessness, weakness, oedema, syncope • Tachycardia • Splitting of 1 st hear sound • Murmur – systolic , breast bruit • Displacement of apex beat – upwards to left

Symptoms of heart disease • • • Progressive dyspnea or orthopnea Nocturnal cough Syncope

Symptoms of heart disease • • • Progressive dyspnea or orthopnea Nocturnal cough Syncope Chest pain Hemoptysis

Clinical findings of heart disease • • • Cyanosis Clubbing of fingers Persistent neck

Clinical findings of heart disease • • • Cyanosis Clubbing of fingers Persistent neck vein distention Systolic murmur grade 3/6 or greater Diastolic murmur Cardiomegaly Persistent arrythmia Persistent split second sound Pulmonary hypertension

Investigations • ECG – cardiac arrhythmias, hypertrophy • Echocardiography – cardiac status and structural

Investigations • ECG – cardiac arrhythmias, hypertrophy • Echocardiography – cardiac status and structural anomalies • X-ray chest – cardiomegaly, vascular prominence • Cardiac catheterization - rarely

NYHA (New York Heart Association) Functional grading of heart disease • Grade I: No

NYHA (New York Heart Association) Functional grading of heart disease • Grade I: No limitation of physical activityasymptomatic with normal activity • Grade II: Mild limitation of physical activity Symptoms with normal physical activity • Grade III: Marked limitation of physical activity Symptoms with less than normal activity, comfortable at rest • Grade IV: Severe limitation of physical activitysymptoms at rest

Classification of Heart Disease according to etiology • • • Congenital – non cyanotic

Classification of Heart Disease according to etiology • • • Congenital – non cyanotic ( ASD, VSD, Pulm stenosis, coarctation of aorta), cyanotic (Fallots tetralogy, Eisenmenger’s syndrome) Rheumatic heart disease – MS, MR, AS, AR Cardiomyopathy Ischaemic heart disease Others – conduction defects, syphilitic, thyrotoxic, hypertensive,

Classification of Heart Disease during pregnancy according to risk • Low risk ( 0

Classification of Heart Disease during pregnancy according to risk • Low risk ( 0 – 1%) – ASD, VSD, PDA, MS 1, 2, corrected FT • Medium risk ( 5 – 15 %) – MS-3, 4, MS with atrial fibrillation, AS, uncorrected FT • High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement

Poor prognostic indicators • • • h/o heart failure, ischaemic attack, stroke Arrhythmias, Base

Poor prognostic indicators • • • h/o heart failure, ischaemic attack, stroke Arrhythmias, Base line NYHA class 3 and 4 MV area below 2 cm sq, AV area below 1. 5 Ejection fraction less than 40%

Additional risk factors • • • Anaemia Infections Hypertension Physical labour Weight gain Multiple

Additional risk factors • • • Anaemia Infections Hypertension Physical labour Weight gain Multiple pregnancy Caffein , alcohol intake Pain Drugs – tocolytic

Effect of pregnancy on heart disease • Worsening of cardiac status • CCF, bacterial

Effect of pregnancy on heart disease • Worsening of cardiac status • CCF, bacterial endocarditis, pulmonary edema, pulmonary embolism, rupture of aneurism • No long term effect on basic defect

Effect of heart disease on pregnancy • • • Abortion Preterm labour IUGR Congenital

Effect of heart disease on pregnancy • • • Abortion Preterm labour IUGR Congenital heart disease in baby – 5% Intrauterine fetal demise

Management Requires • High index of suspicion • Timely diagnosis • Effective management •

Management Requires • High index of suspicion • Timely diagnosis • Effective management • Team Approach • • • Obstetrician Cardiologist Anesthetist Neonatologist CTV surgeon Nursing Staff

Preconceptional Counseling • No pregnancy unless must esp in high risk types • Maternal

Preconceptional Counseling • No pregnancy unless must esp in high risk types • Maternal mortality varies directly with functional classification at pregnancy onset • Optimal Medical/Surgical treatment pre-pregnancy • Counselling– Maternal & Fetal risks – Prognosis – Social and cost considerations – Hospital delivery- Preferable at tertiary care centre

Medical termination of pregnancy • Termination advised in early pregnancy in high risk group

Medical termination of pregnancy • Termination advised in early pregnancy in high risk group only – ( Primary pulmonary Ht, Eisenmenger syndrome, Coarctation of aorta, Marfan syndrome with dilated aortic root) • Only in 1 st trim, better before 8 weeks • Suction evacuation preferred • MTP also carries risk for life

Antenatal care • Clear counseling of risk and prognosis • ANC every 2 weeks

Antenatal care • Clear counseling of risk and prognosis • ANC every 2 weeks upto 30 weeks then weekly • On each visit-note-pulse rate, BP, cough dyspnea, weight, anaemia, auscultate lung bases, reevaluate functional grade • Ensure treatment compliance • Exclude fetal congenital anomaly by level-III USG and fetal ECHO at 20 weeks in maternal congenital heart disease • Fetal monitoring

 • • Special Advice Rest, Avoid undue excitement/strain Diet/ Iron and vitamins Hygiene,

• • Special Advice Rest, Avoid undue excitement/strain Diet/ Iron and vitamins Hygiene, dental care to prevent any infection Dietary salt restriction (4 -6 g/d) Avoid smoking, drugs – betamimetics Early diag and tmt of PIH, infections Therapeutic/prophylactic cardiac interventions as applicable- – Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence of rheumatic fever – Diuretics, Beta Blockers, Digitalis, Anticoagulants – Surgical treatment as applicable - balloon mitral valvotomy

Indications for admission Elective admission • NYHA 1 – 2 weeks before EDD •

Indications for admission Elective admission • NYHA 1 – 2 weeks before EDD • NYHA 2 – 28 to 30 weeks • NYHA-III/IV- Irrespective of POG as soon as patient comes • To Change from oral anticoagulants to heparin-early pregnancy, 36 weeks in patients on anticoagulant Emergency admission • Deterioration of functional grade • Symptoms and signs of complications- Fever/ persistent cough/ basal crepts/ tachyarrhythias (P/R >100 min)/ JVP>2 cm/Anaemia/ Infections/ PET/Abnormal weight gain /other medical disorders

Labor and Management • Institutional delivery • Induction of Labor – Only for obstetric

Labor and Management • Institutional delivery • Induction of Labor – Only for obstetric indications – Oxytocin preferred- Higher concentration with restricted fluid – Intracervical foley instillation esp in congenital heart disease – PGE 2 Gel may be employed- Vasodilatation - use with caution

Management in first stage of labor • Confined to bed- propped up or semi

Management in first stage of labor • Confined to bed- propped up or semi recumbent • Intermittent oxygen inhalation 5 -6 l/min • Sedation and analgesia- (Epidural, pethidine, tramadol) • Cautious use of I. V. fluids (not >75 ml/hr except in aortic stenosis and VSD) • Stop anticoagulants • Digitalise if in CHF, P. R. >110/ min, R/R >24/min

Management in first stage of labor Diuretics in pulmonary congestion Deriphyllin if bronchospasm Prevention

Management in first stage of labor Diuretics in pulmonary congestion Deriphyllin if bronchospasm Prevention of infective endocarditis Cardiac monitoring and pulse oximetry ±pulmonary artery catheterisationcontinuous haemodynamic monitoring • Evaluation by Anaesthetist and cardiologist • •

SABE Prophylaxis Not recommended for all • At risk for infection • Severe lesions

SABE Prophylaxis Not recommended for all • At risk for infection • Severe lesions Prophylaxis Ampicillin-2 G IV/IM + Gentamicin 1. 5 mg/kg (max 120) 6 hours later- Ampicillin-1 G I. V. /IM or 1 G P. O. If Allergic to Penicillin Vancomycin-1 G I. V. or Clindamycin – 600 mg IV + Gentamicin-1. 5 mg/kg -

Management of second stage of labor • Delivery in propped up position • Avoid

Management of second stage of labor • Delivery in propped up position • Avoid forceful bearing down • Adequate pain relief-epidural/pudendal block avoid spinal/Saddle block • Cut short second stage of labor- episiotomy, vacuum, forceps – not always must • Strict Cardiovascular monitoring

Third stage of labor • • AMTSL-10 U oxytocin IMI Avoid bolus syntocinon/Ergometrine Propped

Third stage of labor • • AMTSL-10 U oxytocin IMI Avoid bolus syntocinon/Ergometrine Propped Up, oxygen inhalation Furosemide I. V. 40 mg Pethidine/morphine (15 mg) Watch for signs of CHF & Pul. Edema Treat PPH energetically

First Hour After Delivery • Propped up/sitting position, oxygen • Watch for signs of

First Hour After Delivery • Propped up/sitting position, oxygen • Watch for signs of pulm edema • Sedation • Antibiotics

Indications for C/S • Mainly obstetrical • Coarctation of aorta • Marfan syndrome with

Indications for C/S • Mainly obstetrical • Coarctation of aorta • Marfan syndrome with dilated root of aorta – Prefer epidural anaesthesia – Narcotic conduction analgesia/GA in Pulmonary hypertension and pts having intracardiac shunts

 • Advice at time of discharge: • Continue medical treatment • Avoid infection

• Advice at time of discharge: • Continue medical treatment • Avoid infection • Reassesment after 6 weeks or earlier if some complication occurs • Iron supplementation • Cardiological consultation for definitive management of heart disease

 • Contraceptive advice at time of discharge: • • • Contraception- Barrier, Progesterone

• Contraceptive advice at time of discharge: • • • Contraception- Barrier, Progesterone – good option- DMPA, Norplant IUCD-Less preferred COC - contraindicated Sterilization- vasectomy-best Tubal ligation-Interval, puerperial can be done

MCQs

MCQs

1. Pregnancy is contraindicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy

1. Pregnancy is contraindicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy • Eisenmengers syndrome

2. Pregnancy is contraindicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy

2. Pregnancy is contraindicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy • Eisenmengers syndrome

2. Third stage of labour in a case of heart disease should be managed

2. Third stage of labour in a case of heart disease should be managed by • Ergometrine • Oxytocin • Misoprostol • Carboprost

Third stage of labour in a case of heart disease should be managed by

Third stage of labour in a case of heart disease should be managed by • Ergometrine • Oxytocin • Misoprostol • Carboprost

3. In pregnancy with heart disease risk of cardiac failure increases at • 10

3. In pregnancy with heart disease risk of cardiac failure increases at • 10 -12 weeks • 20 -22 weeks • 30 -32 weeks • 40 -42 weeks

3. In pregnancy with heart disease risk of cardiac failure increases at • 10

3. In pregnancy with heart disease risk of cardiac failure increases at • 10 -12 weeks • 20 -22 weeks • 30 -32 weeks • 40 -42 weeks

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is • NYHA Class 1 • NYHA Class 2 • NYHA Class 3 • NYHA Class 4

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is • NYHA Class 1 • NYHA Class 2 • NYHA Class 3 • NYHA Class 4

5. Which of the following contraceptive is contraindicated in a woman with heart disease?

5. Which of the following contraceptive is contraindicated in a woman with heart disease? • OCP • POP • Lng IUS • Diaphragm

5. Which of the following contraceptive is contraindicated in a woman with heart disease?

5. Which of the following contraceptive is contraindicated in a woman with heart disease? • OCP • POP • Lng IUS • Diaphragm

6. A 24 year old pregnant Gr 2 P 1 woman, having prosthetic valve

6. A 24 year old pregnant Gr 2 P 1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

6. A 24 year old pregnant Gr 2 P 1 woman, having prosthetic valve

6. A 24 year old pregnant Gr 2 P 1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down.

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down.

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4