Cardiac Disease in Pregnancy - PowerPoint PPT Presentation

Loading...

PPT – Cardiac Disease in Pregnancy PowerPoint presentation | free to download - id: 4693ca-M2YyN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Cardiac Disease in Pregnancy

Description:

... normal cardiac physiology in pregnancy and how it differs from the nonpregnant state Identify common maternal cardiac diseases ... Mitral Valve Prolapse Marfan ... – PowerPoint PPT presentation

Number of Views:1311
Avg rating:3.0/5.0
Slides: 47
Provided by: jhar79
Learn more at: http://www.seton.net
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Cardiac Disease in Pregnancy


1
Cardiac Disease in Pregnancy
  • John G. Harkins M.D., F.A.C.O.G.
  • Assistant Professor
  • Department of Obstetrics and Gynecology
  • The University of Texas Southwestern School of
    Medicine
  • Austin, Texas

2
Objectives
  • Provide an overview of normal cardiac physiology
    in pregnancy and how it differs from the
    nonpregnant state
  • Identify common maternal cardiac diseases
    (anatomic and physiologic)
  • Discuss rational and evidence based treatment
    algorithms for these maternal cardiac issues and
    strategies for optimizing maternal and fetal
    outcome 

3
Maternal Cardiac Physiology
  • Maternal cardiac and circulatory adaptations to
    pregnancy begin early in the first trimester and
    do not return to baseline until at least 6 weeks
    postpartum

4
Maternal Cardiac PhysiologyCardiovascular
Alterations
  • Increased blood volume
  • Average 40-45 increase in volume by third
    trimester individual variation apparent with
    some nearly doubling
  • Marked increases with twins and higher order
    gestations

5
Maternal Cardiac PhysiologyCardiovascular
Alterations
  • Expansion of maternal blood volume provides the
    following benefits
  • Allows the perfusion of the hypertrophied uterus
    and associated vasculature
  • Protects maternal and fetal circulation against
    postural hypotension and impaired venous return
    to the heart
  • Allows for significant blood loss during
    parturition

6
Maternal Cardiac PhysiologyCardiovascular
Alterations
7
Maternal Cardiac PhysiologyCardiovascular
Alterations
  • Decreased systemic vascular resistance
  • Decreased blood pressure
  • Decreased pulmonary vascular resistance
  • Increased heart rate
  • Increased cardiac output
  • CO SV x HR

8
Maternal Cardiac PhysiologyCardiovascular
Alterations
9
Maternal Cardiac Disease
  • Valvular Cardiac Disease
  • Mitral Stenosis
  • Mitral Insufficiency
  • Aortic Stenosis
  • Aortic Insufficiency
  • Pulmonic Stenosis

10
Maternal Cardiac Disease
  • Congenital Heart Disease
  • Septal Defects
  • Atrial Septal Defects
  • Ventricular Septal Defects
  • Atrioventricular Septal Defects
  • Patent Ductus Arteriosus
  • Cyanotic Congenital Heart Disease
  • Tetralogy of Fallot
  • Ebsteins Anomaly

11
Maternal Cardiac Disease
  • Pulmonary Hypertension
  • Eisenmenger syndrome
  • Mitral Valve Prolapse
  • Marfan Syndrome/Aortic Dissection
  • Aortic Coarctation
  • Infective Endocarditis
  • Ischemic Heart Disease
  • Myocardial Infarction

12
New York Heart Association (NYHA) Classification
(1979)
  • Class I uncompromised
  • No symptoms of cardiac disease
  • Class II limited symptomatology
  • These patients are asymptomatic at rest but
    develop symptoms (chest pain, shortness of
    breath, fatigue, palpitations) with physical
    exertion
  • Class III marked symptomatology
  • These patients are asymptomatic at rest but
    become symptomatic with even minimal physical
    activity
  • Class IV symptoms at rest

13
Maternal Cardiac Disease
  • Predictors of cardiac complications in pregnancy
    include
  • Prior heart failure, transient ischemic attack,
    stroke, or arrythmia
  • Left sided obstruction as defined by
  • Mitral valve area lt 2cm²
  • Aortic valve area lt 1.5cm²
  • Aortic valve peak gradient gt 30mm Hg
  • Ejection fraction lt 40
  • NYHA Class III or IV prior to pregnancy

14
Mitral Stenosis
  • Most commonly caused by rheumatic endocarditis
  • Relatively fixed cardiac output
  • Degree of stenosis is directly associated with
    risk
  • Patients with mitral stenosis are at risk for
    atrial fibrillation, mural thrombi, pulmonary
    edema, and passive pulmonary hypertension
  • Epidurals and SVD generally advisable but must
    avoid drops in preload to maintain CO

15
Mitral Stenosis
16
Mitral Insufficiency
  • Incomplete coaptation of the mitral valve allows
    regurgitation of blood from LV back into LA
    leading to LV hypertrophy
  • Usually caused by Rheumatic fever, MVP, or LV
    dilatation (cause AND effect)
  • Usually asymptomatic in nonpregnant patients
  • Extremely well tolerated in pregnancy due to
    decrease in SVR (afterload) resulting in less
    regurgitation

17
Mitral Insufficiency
18
Aortic Stenosis
  • May be congenital (i.e., bicuspid aortic valve)
    or acquired (rheumatic fever)
  • A disease of fixed cardiac output
  • In severe cases, cardiac output may not be able
    to adequately maintain cerebral or cardiac
    perfusion
  • Limitation of physical activity during pregnancy
    is essential
  • Any decrease in preload (orthostasis, a-
    adrenergic blockade from epidural, hemorrhage,
    etc.) may result in stroke or sudden cardiac
    death
  • Maternal mortality 5-15 depending on severity of
    lesion

19
Aortic Stenosis
20
Aortic Insufficiency
  • Mostly rheumatic in origin but may also be
    secondary to connective tissue disease or
    congenital
  • LV hypertrophy and dilatation are secondary to AI
  • Very well tolerated in pregnancy due to
  • Decrease in SVR (afterload)
  • Physiologic increase in HR allows less time for
    regurgitant backflow

21
Aortic Insufficiency
22
Pulmonic Stenosis
  • Usually congenital
  • Can be associated with Tetralogy of Fallot or
    Noonan syndrome
  • Can cause RA and RV enlargement
  • Severe stenosis associated with right sided heart
    failure and atrial arrythmias

23
Pulmonic Stenosis
24
Septal Defects
  • Atrial Septal Defect (ASD)
  • Most common congenital lesion seen in pregnancy
  • Rarely symptomatic
  • Characterized by high pulmonary blood flow and
    normal pulmonary artery pressure
  • Paradoxical embolism

25
Atrial Septal Defect (ASD)
26
Ventricular Septal Defect(VSD)
  • Size of defect is most important factor in
    determining severity and 90 close in childhood
  • If effective size exceeds that of aortic valve,
    symptoms develop rapidly and must be surgically
    corrected
  • Adults with unrepaired sizable VSDs can develop
    LV hypertrophy, LV failure, and pulmonary
    hypertension

27
Ventricular Septal Defect
28
Patent Ductus Arteriosus(PDA)
  • Uncommon in pregnant women due to high rate of
    detection and repair in childhood
  • Severity is related to size of PDA
  • As with all high pressure left to right shunting,
    pulmonary hypertension can develop
  • Sudden drops in SVR (massive hemorrhage,
    epidural, etc.) may cause reversal of flow
    through PDA and be fatal

29
Patent Ductus Arteriosus
30
Cyanotic Heart Disease
  • Congenital heart lesions that shunt blood from
    the right heart to the left heart and bypass the
    pulmonary capillary bed
  • This results in deoxygenated blood being placed
    back into the systemic circulation
  • The magnitude of the shunting, and hence the
    degree of cyanosis, is inversely related to SVR
  • When hypoxemia stimulates erythropoetic centers
    such that hematocrit is at or above 65,
    pregnancy wastage is virtually 100

31
Tetralogy of Fallot
  • The most common cyanotic heart lesion encountered
    in pregnancy
  • VSD
  • Overriding aorta (receives blood from RV and LV)
  • RV hypertrophy
  • Pulmonary stenosis
  • Surgical correction allows for excellent
    obstetrical outcomes
  • Uncorrected Tetralogy of Fallot is associated
    with 4-15 maternal and 30 fetal mortality

32
Tetralogy of Fallot
33
Ebsteins Anomaly
  • Few women with uncorrected Ebsteins anomaly
    reach their reproductive years
  • Pregnancy increases volume overload and hence
    exacerbates RV failure and cyanosis
  • In the absence of significant cyanosis, pregnancy
    is otherwise well tolerated

34
Ebsteins Anomaly
35
Pulmonary Hypertension
  • WHO Classification 2004
  • Class I
  • Idiopathic
  • Familial
  • Associated with collagen vascular disorders,
    congenital left to right shunts, HIV disease,
    thyrotoxicosis, SCA, antiphospholipid antibody
    syndrome, portal hypertension
  • Class II associated with left sided heart
    disease

36
Pulmonary Hypertension
  • Class III associated with lung disease
  • Chronic obstructive pulmonary disease (COPD)
  • Interstitial lung disease
  • Class IV Pulmonary hypertension due to chronic
    thromboembolic disease
  • Class I disorders have poorest prognosis in
    pregnancy and 80 of maternal deaths occur
    postpartum

37
Pulmonary Hypertension
  • Class II disorders are the most common in
    pregnancy (VSD, PDA, severe mitral stenosis) and
    are associated with better maternal outcome
  • Severe disease regardless of class is associated
    with at least a 50 chance of maternal mortality

38
Pulmonary Hypertension
  • Management
  • Minimizing activity
  • Avoiding supine position as gestation progresses
  • Use of diuretics, O², and vasodilators to treat
    symptoms
  • At delivery, avoiding hypotension is critical as
    most maternal deaths in patients with pulmonary
    hypertension are due to decreased venous return
    to the heart

39
Eisenmengers Syndrome
  • Occurs in the presence of pulmonary hypertension
    caused by an underlying congenital left to right
    shunt (usually ASD, VSD, or PDA)
  • As pulmonary hypertension worsens, PA pressure
    equals systemic pressure and the shunt becomes
    bidirectional or entirely right to left
  • Eisenmengers syndrome is associated with a
    30-50 chance of maternal mortality during
    pregnancy, delivery, or postpartum
  • RV failure and cardiogenic shock is the most
    common cause of maternal mortality

40
Eisenmengers Syndrome
41
Mitral Valve Prolapse
  • Cardiac complications from MVP are rare
  • Pregnancy outcomes are excellent
  • ACOG specifically refers to MVP and states that
    MVP never needs infective endocarditis
    prophylaxis
  • ACOG Committee Opinion 421, Nov. 2008.

42
Marfan Syndrome
  • Autosomal dominant connective tissue disorder
  • Manifestations include ocular, skeletal, and
    cardiovascular abnormalities
  • In pregnancy, aortic root or splenic artery
    aneurysm or dissection is most common site of
    complications
  • Aortic root dilatation of 40 mm is associated
    with up to a 50 risk of maternal mortality

43
Aortic Coarctation
  • Associated with VSD and PDA as well as
    intracranial aneurysms in the circle of Willis
  • NYHA Class I or II have 3-4 risk of mortality
  • Anomalous or bicuspid aortic valves, other
    associated cardiac lesions, aneursms in the
    circle of Willis or aortic aneurysms all increase
    maternal mortality to 15

44
Aortic Coarctation
45
Infective Endocarditis
46
Ischemic Heart Disease/ Myocardial Infarction
  • Incidence of pregnancy complicated by ischemic
    heart disease increasing
  • Incidence of acute myocardial infarction in
    pregnancy estimated to be 1-6/100,000
  • Risk factors appear to be consistent with
    nonpregnant population
  • Mortality risk adversely affected by pregnancy
    and increases with advancing gestational age
  • Treatment is essentially standard and
    intervention warranted only for obstetrical
    indications
About PowerShow.com