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CARDIOVASCULAR DISEASE IN

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cardiovascular disease in pregnancy dr s.a. ogunyemi lecturer/consultant cardiologist oau/oauthc ile-ife. heart disease in pregnancy heart disease usually congenital ... – PowerPoint PPT presentation

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Title: CARDIOVASCULAR DISEASE IN


1
  • CARDIOVASCULAR DISEASE IN
  • PREGNANCY
  • DR S.A. OGUNYEMI
  • LECTURER/CONSULTANT CARDIOLOGIST
  • OAU/OAUTHC
  • ILE-IFE.

2
HEART DISEASE IN PREGNANCY
  • Heart disease usually congenital or valvular
    occurs in 1-4 of preg.
  • Incidence is increasing
  • Hemodynamic changes associated with preg make
    diagnosis management difficult.
  • Consider patient Risks to the fetus.

3
CV Physiology of normal pregnancy
  • Blood volume maternal blood volume increase,
    plasma volume more rapid than RBC resulting in
    physiologic anaemia of preg
  • Cardiac function enhance myocardial performance,
    increase in LV systolic function
  • Cardiac output increase in CO ( gt50), increase
    in SV HR.

4
CV Physiology of normal pregnancy
  • In supine position the gravid uterus compress the
    IVC reducing venous return CO(25-30).
  • Intravascular pressures SP DP drop in
    pregnancy.

5
CV changes in normal pregnancy
  • Increase Decrease
  • Blood volume SAP
  • Heart rate DAP
  • Stroke volume Syst vascular resistance
  • Cardiac output Peri vascular resistance
  • Pulse pressure
  • LVEDP

6
Common causes.
  • Congenital heart disease
  • ASD,VSD,PDA, PS, Coarctation of Aorta,TOF
  • Congenital heart disease that has been corrected.
  • Rheumatic heart disease

7
  • Valvular heart disease
  • MS,MR, MVProlapse, AoS, AoR
  • TS, TR, PS, PR
  • Prosthetic heart valves
  • Infective endocarditis
  • Myocarditis Viral, TB, HIV/AIDS, Chagas disease

8
  • Peripartum cardiomyopathy
  • Hypertrophic cardiomyopathy
  • Coronary artery disease.
  • Arrhythmias
  • Heart blocks
  • Pericardial diseases
  • Pericarditis, Pericardial effusion

9
Clinical findings
  • Evaluation may be difficult due to normal and
    physiological changes.
  • Reduced exercise tolerance fatigue
  • Dizziness, syncopal attack
  • Palpitation
  • Dyspnoea orthopnea

10
Physical signs
  • Physical examination changes because of the
    increased hemodynamic burden
  • Slightly fast resting HR,
  • Slightly wide pulse pressure
  • warm extremities
  • Jugular venous distension

11
  • Edema of the ankles legs
  • Displaced LV apical impulse
  • RV heave
  • Palpable pulmonary impulse
  • Increased intensity of S1

12
  • Persistent splitting of S2
  • Presence of S3
  • Systolic ejection mummur
  • Diastolic mummur are unsual may be due to
    valvular abnormalities.

13
Investigations
  • Chest radiography
  • Usefulness limited due to potential hazard to the
    fetus from radiation exposure.
  • Abdominopelvic area should be shielded with lead
    to minimize exposure.
  • Increase lung markings
  • Horizontal positioning of the heart

14
  • Electrocardiography
  • Cardiac chamber hypertrophy
  • Myocardia ischemia
  • Sinus tachycardia
  • QRS axis deviation

15
  • Echocardiography
  • Cardiac structures, chambers, valves can be
    assessed.
  • Ventricular functions can also be measured.

16
Other tests
  • Exercise tolerance test
  • Radionuclide studies
  • Pulmonary artery catheterization
  • Cardiac catheterization.

17
Treatment
  • Requires collaboration of obstetrician
    cardiologist at regular intervals
  • Careful planning of delivery with the
    anestheologist.
  • CV Drugs avoided in the first trimester
  • Most CV Drugs cross the placenta secreted in
    breast milk.

18
Heart failure
  • Salt restriction activity limitation
  • Digoxin
  • Diuretic may cause impaired uterine blood flow
    placenta perfusion.
  • Thiazide associated with neonatal
    thrombocytopenia, jaundice, hyponatremia,
    bradycardia.

19
  • Hydralazine most commonly used vasodilator in
    pregnancy.
  • ACE inhibitors and ATII receptor blockers are
    contraindicated. Associated with premature
    delivery,LBW, detal hypotension, PDA,RDS death.

20
Arrhythmias
  • Any precipitating factor should be treated
  • Conservative treatment
  • DC Cardioversion
  • Digoxin may cause prematurity IUGR
  • Adenosine is used in SVT
  • Quinidine used for atrial VT
  • Amiodarone is associated with fetal hypothyroidism

21
Thrombosis thromboembolism
  • Indications for anticoagulant in pregnancy
    include
  • Mechanical heart valves
  • Rheumatic heart disease
  • AF cardiomyopathies.

22
  • Warfarin is associated with spontaneous abortion,
    optic nerve atrophy, microcephaly, mental
    retardation death from ICH.
  • Warfarin embryopathy - nasal bone hypoplasia
    epiphyseal stippling
  • Risk to mother fetus during labor delivery

23
  • Heparin drug of choice in pregnancy

24
THANK YOU FOR YOUR ATTENTION
25
INTRODUCTION.
  • Pregnancy is a physiologic state from conception
    to parturition, normally lasted for 40weeks or
    280days.
  • It creates a state of profound hemodynamic
    changes in the woman which result in significant
    effects on the course of preexisting heart
    diseases, or could create a temporary or
    permanent cardiac dysfunction.

26
Symptoms Signs of Normal Hemodynamic Changes.
  • Symptoms
  • Fatigue,
  • Dyspnoea,
  • Lassitude,
  • Decrease exercise tolerance.
  • supine hypotension syndrome.
  • Signs.
  • Pallor
  • Mild pitting pedal oedema
  • Tachycardia
  • Collapsing pulse
  • Jugular venous distension
  • Displaced apex beat
  • Widely split 1st 2nd heart sounds
  • Third heart sound
  • Soft ejection systolic murmur

27
(No Transcript)
28
CLASSIFICATION
  • Preexisting Cardiovascular diseases
  • Chronic hypertension.
  • Rheumatic heart disease.
  • Congenital heart disease-VSD,ASD PDA
  • Cardiomyopathy-Dilated, Restrictive,Hypertrophic.
  • Ischaemic heart disease.
  • Others- Marfan syndrome, MVP, Prosthetic valves.




29
Classification cont
  • Cardiovascular disorder acquired during
    pregnancy.
  • Hypertensive disorder of pregnancy
  • Gestational HT
  • Preeclampsia/ Eclampsia denovo.
  • Preeclampsia superimposed on chronic HT.

30
Classification cont
  • Peripartum Cardiomyopathy.
  • Acute myocardial infarction.
  • Arrhythmias.
  • Thromboembolic Diseases.

31
Heart Diseases in Pregnancy.
  • . Report on Maternal death in UK
  • revealed that before 1961, most cardiac deaths
    were due RHD. But the pattern has changed with
    more women with congenital or acquired cardiac
    diseases surviving into childbearing years.
  • . Heart diseases occurs in 1-4 of pregnant pt.
  • . Nearly half of the pt in class 1 NYHA prior to
    pregnancy will develop heart failure during
    20-34wks GA, labour and delivery or the first
    12-24hrs postpartum.
  • . There is need for risk assessment in pt with
    preexisting heart diseases and preconception
    counseling.

32
Risk Assessment of pt with preexisting heart
disease
  • .Low Risk
  • -Small left to right shunt
  • -Repaired lesion without residual cardiac dysfxn
  • -Isolated mitral valve prolapse without
    significant regurgitation
  • -Bicuspid aortic valve without stenosis
  • -Mild to moderate pulmonary stenosis
  • -Valvular regurgitation with normal ventricular
    systolic function.
  • MR, AR.

33
Moderate risk
  • Unrepaired or palliated cyanotic congenital heart
    diseases
  • Large left to right shunt
  • Uncorrected coartation of the aorta
  • Mitral stenosis
  • Moderate aortic stenosis
  • Prosthetic valve
  • Severe pulmonary stenosis
  • Moderate to severe systemic ventricular dysfxn.

34
High risk
  • NYHA III IV
  • Eisenmenger syndrome
  • Significant pulmonary HT
  • Marfan syndrome
  • Severe aortic stenosis
  • EF lt 20
  • Pregnancy is not advised.
  • Sterilization is preferred contraception.
  • Therapeutic abortion is advised.
  • Labour delivery should be in ICU with pulmonary
    arterial cath. cardiologist supervision.

35
Investigations.
  • ?CXR
  • ECG
  • ECHO
  • Doppler
  • Plethymography
  • CT, ?MRI
  • Cardiac catherization
  • Pulmonary artery catherization
  • ?Stress testing
  • Others- EU, Cr LFT FBC Blood sugar TFT
    Renal USS.

36
Drug Treatment.
  • Anti-HT
  • Hydralazine, labetalol and methyl dopa are first
    line agent.
  • Calcium channel blockers can be used
    amlodipine, diltizem.
  • Beta blockers should be used with caution and
    fetal HR monitoring.
  • ACEI ARB are contraindicated.
  • Diuretics is potentially unsafe but use in Heart
    failure.

37
Anti-arrhythmic
  • Digoxin, Adenosine, Quinidine, Diltizem are safe
  • Amiodarone is unsafe.
  • IUGR
  • Prematurity
  • Hypothyroidism.

38
Drug treatment cont
  • Warfarin is contraindicated.
  • LMWH is anticoagulant of choice
  • UFH need frequent lab monitoring and ass with
    more complications such as maternal fetal
    hage, thrombocytopenia, osteoporosis.
  • Low dose aspirin is safe.
  • Statins are contraindicated.
  • Nitrates Hydralazine are useful alternative to
    ACEI in the treatment of AMI
  • Antibiotic prophylaxis is essential in pt with VV
    Cong. heart dx postpartum.
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