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Cardiovascular Disease in Pregnancy

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... Cyanotic heart disease Severe obstructive lesion ... Cardiovascular Disease in Pregnancy: New Guideline 20003 Author: Songsak Last modified by: acer – PowerPoint PPT presentation

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Title: Cardiovascular Disease in Pregnancy


1
Cardiovascular Disease in Pregnancy
Songsak Kiatchoosakun M.D. Cardiology,
Medicine Khon Kaen University
2
Introduction
  • Pregnancy, labor and delivery are associated with
    burdens on the cardiovascular system
  • The outcome of pregnancy is related to functional
    class and underlying heart disease

3
Hemodynamic Modifications during Pregnancy
  • Blood volume starts to rise at 5th week
  • Systemic vascular resistance and blood pressure
    are decreased
  • Resting heart rate increases by 10-20 beats/min
  • Cardiac output increases by 30-50

4
High Risk Pregnancy
  • Advise avoidance of pregnancy
  • Mitral stenosis with functional class II-IV
  • Mitral and aortic regurgitation with functional
    class III, IV
  • Severe pulmonary hypertension
  • Left ventricular dysfunction
  • Marfans syndrome with dilated aortic root
  • (gt 40 mm)
  • Cyanotic heart disease
  • Severe obstructive lesion (aortic stenosis,
    pulmonary stenosis)

5
High Risk Pregnancy
  • Close follow up required
  • Prosthetic valve
  • Mild to moderate valvular heart disease
  • Marfans syndrome without aortic root dilatation

6
Signs and Symptoms in Normal Pregnancy
  • History
  • Dyspnea
  • Orthopnea
  • Palpitation
  • Physical examination
  • Edema
  • Systolic murmur lt grade II/VI
  • Increased of S1, P2

7
Suspicious Symptoms and Signs of Cardiac Disease
in Pregnancy
  • Progressive dyspnea
  • Syncope
  • Chest pain
  • Cyanosis
  • Left parasternal heave
  • A grade III/VI or greater systolic murmur
  • Any diastolic murmurs
  • S4 gallop
  • Fixed split of S2
  • Opening snap

8
Cardiovascular Disease in Pregnancy
  • Valvular Heart disease
  • Rheumatic heart disease
  • Prosthetic heart valves
  • Hypertension
  • Congenital heart disease
  • Peripartum cardiomyopathy
  • Marfan syndrome and aortic regurgitation
  • Arrhythmias

9
Valvular Heart Disease and Maternal Outcomes

Hameed A. J Am Coll Cardiol 200137893
10
Valvular Heart Disease and Fetal Outcomes

Hameed A. J Am Coll Cardiol 200137893
11
Mitral Stenosis
  • Most common valve disease in pregnancy
  • Valve area lt 1.5 cm2 increases risk of
  • Pulmonary edema
  • Heart failure
  • Arrhythmias
  • Intrauterine growth retardation
  • Closed follow up is necessary
  • Doppler echo at 3 and 5 month and monthly
    thereafter

12
Diagnostic Assessment
  • Echocardiography
  • Confirm diagnosis
  • Determine the severity of stenosis
  • Pulmonary artery pressure and RV function
  • Mitral valve score to determine the success of
    percutaneous mitral balloon valvuloplasty

13
Medical Management
  • Most pregnant woman with mitral stenosis can be
    managed medically
  • Limit activity
  • Restrict salt and fluid
  • Diuretic if needed

14
Medical Management
  • Digoxin is useful in atrial fibrillation
  • Rheumatic prophylaxis
  • Penicillin V 250 mg X 2
  • Benzathine Penicillin IM q 3 weeks
  • Betablocker

15
Beta-blocker in Pregnancy
  • Beta-1 selective agents metoprolol and atenolol
    limits the risk interaction with uterine
    contraction
  • Cross placenta and excrete in breast milk
  • No serious adverse effects on neonates
  • Fetal bradycardia and hypoglycemia have been
    reported

16
Percutaneous Balloon Mitral Valvuloplasty (PBMV)
  • Should be considered after failure of aggressive
    medical treatment
  • Radiation exposure and technical difficulties are
    major limitations
  • Transesophageal echocardiography guidance may
    decrease the fluoroscopy time and maternal
    complications

17
Surgical Intervention
  • Indicated in patients who failed medical
    treatment
  • Should be performed between 24-28 weeks
    gestation
  • Maternal mortality rate 1.5-5
  • Fetal mortality rate 20-30 in open heart
    surgery
  • Closed mitral valvotomy is preferable
  • safe for mother
  • fetal mortality of 2-12

18
Regurgitation Valve Disease
  • Pregnancy is generally well tolerated even in
    severe valve regurgitation
  • The decrease in vascular resistance and
    tachycardia during pregnancy reduces the
    regurgitation fraction
  • Medical therapy in patients with heart failure
  • Nitrate
  • Dihydropyridine calcium blockers
  • ACE inhibitors and ARB are contraindicated

19
Pregnancy with Heart Valve Prostheses
  • Problems
  • Hypercoagulable state during pregnancy
  • Use of oral warfarin is associated with fetal
    anomalies (nasal hypoplasia, epiphysis stippling,
    CNS anomalies)
  • Overall risk is 5
  • Dose related low risk if daily dose lt 5 mg

20
Regimens of Anticoagulant
  • Regimen 1-Warfarin sodium through out pregnancy
    with unfractionated heparin sodium near term
  • Regimen 2-Substitution or warfarin with
    unfractionated heparin between 6-12 weeks and
    near term
  • Regimen 3-Unfractionated heparin through
    pregnancy

21
Fetal Complications
Chan WS. Arch Intern Med 2000160191
22
Maternal Complications
Chan WS. Arch Intern Med 2000160191
23
Conclusions
  • Risk of embryopathy (4-6) when warfarin is used
    during 6-12 week of gestation
  • Subcutaneous heparin does not provide adequate
    anticoagulation
  • No advantage in the use of heparin during 6-12
    week of gestation to prevent fetal wastage
  • Heparin in first trimester is associated with
    high incidence of thromboembolism

24
Recommendations
  • Warfarin therapy throughout pregnancy is the
    safest therapeutic option for the mother
  • Patients who choose not to take warfarin should
    receive unfractionated heparin or low molecular
    weight heparin (aPTT 2-3 time control, predose
    anti Xa 0.7)
  • Warfarin should be replaced by heparin at the
    36th week to avoid neonatal intracranial
    hemorrhage

25
Hypertension in Pregnancy
  • Complicates 6-8 of all pregnancies
  • Complications
  • Cerebral hemorrhage
  • Hepatic failure
  • Acute renal failure
  • Abrutio placenta
  • Pregnancy outcomes relate with underlying causes
    of HT

26
Pharmacological Treatment
  • Methydopa first line agent 750 mg-4 g
  • Betablocker
  • Calcium channel blocker
  • Hydralazine
  • Diuretics
  • Contraindicated in preeclampsia
  • May reduce uteroplacental flow
  • ACEI and ARB blocker renal agenesis

27
Cardiovascular Drugs in Pregnancy
  • Drug Use in pregnancy Safety
  • Digoxin HF, arrhythmia Safe
  • Beta-blocker HT,MS, IHD Safe
  • Nifedipine HT Safe
  • Hydralazine HT, HF Safe
  • Nitrate IHD Limited data
  • Diuretics HF,HT /-
  • ACEI HT, HF Unsafe
  • Amiodarone Arrhythmias Unsafe

28
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29
Cardiovascular Evaluation in Pregnancy
  • History
  • Physical examination
  • Investigations
  • ECG
  • Echocardiography

30
Management
  • Low risk patients
  • HT stage I without end organ damage
  • Control of HT before conception
  • Frequent supervision is essential
  • High risk patients
  • Severe HT with end organ damage and co-morbidity
    condition
  • Need frequent assessment

31
Hypertensive Disorder
  • Classification and definition
  • Chronic HT HT prior or before 20 wks of
    gestation
  • Preeclampsia-eclampsia proteinuria with new
    HTafter 20 wks of pregnancy
  • Pre-eclampsia superimposed on chronic HT
    increased BP (30/15) change in proteinuria or
    target organ damage
  • Gestational HT new HT after 20 wks of pregnancy
    without proteinuria
  • Transient HT elevated HT during or after
    pregnancy without sings of preeclampsia
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