pregnancy in Heart disease Physiological effects of pregnancy

pregnancy in Heart disease ﺍﻳﻨﺎﺱ ﺍﻟﺨﻴﺎﻁ. ﺩ

Physiological effects of pregnancy on CVS : �- By 6 – 8 peripheral vasodilitation occur → » ↓ systemic vascular resistance �↑ Cardiac output(CO. ) by 20 %. �- ↑ CO. to about maximum of 40 % by 24 – 28 wks of gestation. � so ↑ risk of H. F. in this period. �- ↑ HR – 10 – 15 %. �- ↑ CO up to 80%above pre-labour values in first few hrs after delivery. �- CO. return to normal at 2 wks post delivery.

counselling of women with heart disease �Risk of maternal death. �Possible reduction of maternal life expectancy. �Effects of pregnancy on cardiac disease. �Mortality associated with high risk conditions. �Risk of fetus developing congenital heart disease. �Risk of preterm labour and FGR. �Need for frequent hospital attendance and possible admission. �Intensive maternal and fetal monitoring during labour. �Other options – contraception , adoption , surrogacy. �Timing of pregnancy.

Antenatal Management a joint obstetric / cardiac � History � Examination � Investigations � Follow up maternal &fetal well-being �

work heart Association ( NYHA ) classification � 1. Mild � No limitation of physical activity. Ordinary physical activity does not precipitate fatigue , palpitations , dyspnoea , angina. � 2. Mild � Slight limitation of physical activity. Comfortable at rest , but ordinary physical activity results in fatigue, palpitation or dyspnoea. � 3. Moderate � Marked limitation of Physical activity. Comfortable at rest , but less than ordinary activity causes fatigue , palpitation or dyspnoea. � 4. Severe � Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken , discomfort is increased.

Toronta risk markers for maternal cardiac events Markers � 1 Prior episode of heart failure , arrhythmia or stroke. � 2 NYHA class > II or cyanosis. � 3 Left heart obstruction. � 4. Reduced left ventricular function ( EE < 40 per cent ) � 0 predictors : risk of cardiac event is 5 per cent ; I predictor : risk of cardiac event is 37 per cent ; > 1 predicators : risk of cardiac event is 75 per cent.

High-risk cardiac conditions �Systemic ventricular dysfunction ( ejection fraction < 30 per cent , NYHA class III – IV ). �Pulmonary hypertension �Cyanotic congenital heart disease. �Aortic pathology ( dilated aortic root > 4 cm , Marfan syndrome ). �Ischaemic heart disease. �Left heart obstructive lesions ( aortic , mitral stenosis ) �Prosthetic heart valves ( metal ). �Previous peripartum cardiomyopathy.

Fetal risks of maternal cardiac disease �Recurrence ( congenital heart disease ). �Maternal cyanosis ( fetal hypoxia ). �Iatrogenic prematurity. �FGR. �Effects of maternal drugs ( teratogenesis , growth restriction , fetal loss ).

Maternal risks: �-Endocarditis. �-Arrythmias. �- Paraxysmal embolic events. �-Heart failure &pulmonary hypertention. �- Death.

Risk factors for the development of heart failure �Respiratory or urinary infections. �Anaemia. �Obesity. �Corticosteroids. �Tocolytics. �Multiple gestation. �Hypertension. �Arrhymais. �Pain-related stress. �Fluid overload TREAT HEART FAILUR AS IN NON PREGNANT �

Management of labour and delivery �Management of labour in women with heart disease �Avoid induction of labour of possiblr. �Use prophylactic antibiotic. �Ensure fluid balance. �Avoid the supine position. �Discuss regional / epidural anaesthesia / analgesia with senior anaesthetist. �Keep the second stage short. �Use syntocinon judiciously.

Specific conditions Ischaemic heart disease � Mitral and aortic stenosis � Marfan syndrome � Pulmonary hypertension : � Peripartum cardiomyopathy ( CMP � Coarctation of Aorta � Prosthetic heart valves �

Strategies of anticoagulant regimen in pregnancy: �(1. ) Continue warfairn during pregnancy. ( or ) �(2. ) Replace warfarin with high dose heparin from 6 th – 12 th wks of gestation & 10 days before the delivery � (3. ) use high dose unfractionated or low molecular weight heparin throughout pregnancy.

Which option is chosen will depend on several factors: � 1. Type of mechanical valve : the risk of thrombosis is less with the newer bi-leaflet valves than first & 2 nd generation ball and cage valves. � 2. The position of the value replacement : Mitral position > risk Aortic position � 3. number of mechanical valves : Two valves give a high risk of thrombosis. � 4. The dose of warfarin required to maintain a therapeutic INR. � 5. Any previous history of embolic events.

according to risk of bacterial endocarditis : � - High-risk : Prosthetic valves , previous bacterial endocarditis , complex cyanotic congenital heart disease ( fallot's , transposition of great arteries , surgical systemic / pulmonary shunt ). acquired valvular disease. �Moderate risk : �Hypertrophic cardiomyopathy. Mitral value prolapse with mitral regurge. �

Stratification of cardiac conditions according to risk of bacterial endocarditis : �Negligible risk : �Secundum ASD. �Repaired ASD , VSD , PDA. �mitral prolapse with or without regurgitation. �Physiological Heart murmurs. �Pacemakers. � For high & moderate risk : �Endocarditis prophylaxis is recommended.