Heart disease with pregnancy Incidence of heart disease
- Slides: 46
Heart disease with pregnancy
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 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 around – 30 weeks Intra partum period Just after delivery Second week of puerperium
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 Chest pain Hemoptysis
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 anomalies • X-ray chest – cardiomegaly, vascular prominence • Cardiac catheterization - rarely
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 ( 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 – 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 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 pregnancy Caffein , alcohol intake Pain Drugs – tocolytic
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 heart disease in baby – 5% Intrauterine fetal demise
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 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 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 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, 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 • 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 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 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 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 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 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 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 pulm edema • Sedation • Antibiotics
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 • 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 – good option- DMPA, Norplant IUCD-Less preferred COC - contraindicated Sterilization- vasectomy-best Tubal ligation-Interval, puerperial can be done
MCQs
1. Pregnancy is contraindicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy • Eisenmengers syndrome
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 by • Ergometrine • Oxytocin • Misoprostol • Carboprost
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 -12 weeks • 20 -22 weeks • 30 -32 weeks • 40 -42 weeks
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 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 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? • OCP • POP • Lng IUS • Diaphragm
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 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 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. 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. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4
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