Cardiac Disease in Pregnancy - PowerPoint PPT Presentation

Loading...

PPT – Cardiac Disease in Pregnancy PowerPoint presentation | free to download - id: 44ba29-YjFjM



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:

Cardiac Disease in Pregnancy Dr. Brown, M.D. Diagnosis of Heart Disease In Pregnancy Pregnant women with heart disease are at greater risk for CV complications and ... – PowerPoint PPT presentation

Number of Views:2192
Avg rating:3.0/5.0
Slides: 59
Provided by: Own2682
Category:

less

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

Title: Cardiac Disease in Pregnancy


1
Cardiac Disease in Pregnancy
  • Dr. Brown, M.D.

2
Diagnosis of Heart Disease In Pregnancy
  • Pregnant women with heart disease are at greater
    risk for CV complications and neonatal
    complications
  • Various hemodynamic changes in pregnancy make
    diagnosis of certain CV disease more difficult
  • Dyspnea, orthopnea, fatigability, syncope, and
    dizzy spells are common in pregnancy

3
Diagnosis Continued
  • Systolic murmurs occur in 95 percent of pregnant
    women
  • Dependent edema, rales in the lower lung fields,
    visible neck veins, and cardiomegaly are all
    common in pregnancy
  • Certain findings suggestive of heart disease
  • Severe dyspnea, syncope with exertion,
    hemoptysis, paroxysmal nocturnal dyspnea, and
    chest pain with exertion

4
Diagnosis Continued
  • Physical signs of organic heart disease include
  • Cyanosis
  • Clubbing
  • Diastolic murmur
  • Sustained cardiac arrhythmias
  • Loud, harsh systolic murmurs
  • Changes of normal pregnancy must be recognized

5
Preconception Counseling
  • Several fundamental principals are important
  • CVS undergoes specific changes to meet needs of
    mother and fetus which may worsen disease
  • Cardiac risk varies among specific forms of heart
    disease
  • Some diseases negligible, some prohibitive

6
Preconception Counseling
  • If condition can be cured, do so before pregnancy
  • (ASD, PDA, some forms of coarctation)
  • If condition can be ameliorated, do so before
    pregnancy
  • (MS, MR, AS, Tetralogy, VSD with mild pulmonary
    hypertension, PS)
  • Pregnancy before valve replacement (prosthetic)
    should be advised

7
Preconception Counseling
  • Some CV disorders pose prohibitive risks to
    mother and high maternal mortality, pregnancy
    contraindicated
  • If already pregnant with such conditions,
    termination recommended
  • D E preferred to prostaglandins

8
Preconception Planning
  1. Dilated cardiomyopathy 15-60 MMR
  2. Primary pulmonary HTN 50 MMR
  3. Eisenmenger Syndrome 15-30 MMR
  4. Marfan Syndrome with aortic root dilatation
    25-50 MMR
  5. Coarctation of aorta 5
  6. Tetralogy of Fallot 12

9
Preconception Planning
  • Mothers heart condition determines likelihood of
    inheritance
  • Detailed family history important
  • Strong familial tendencies for PDA, ASD (and
    other diseases likelihood of inheritance well
    described)
  • Hypertrophic cardiomyopathy can be Mendelian in
    manner of inheritance
  • Risk of drugs needed for control of disease

10
Preconception Planning
  • Team approach important Ob, MFM, cardiologist
  • Check and correct other medical conditions
  • thyroid, anemia, infection, hypertension,
    vaccinations up to date

11
Maternal Cardiovascular Adaptations to pregnancy
  • Blood volume- plasma volume increases from 6-8
    weeks to 32 weeks by 45
  • Increase 1200-1600 mL
  • Increase greater in twins
  • Red cell mass increases 250-240mL-20-30
  • Iron supplements add to increase
  • Maternal demand of 500 mg, 300 mg for fetus, 200
    mg for normal daily losses
  • Protects against hemodynamic instability with
    blood loss

12
Maternal Cardiovascular Adaptations
  • Cardiac Output Heart rate x Stroke Volume
  • CO is the functional capacity of the heart
  • CO increases 30-50 during pregnancy
  • Increase is secondary to increase in both stroke
    volume and heart rate

13
Maternal Cardiovascular Adaptations
  • Stroke volume decreases after 32 weeks
  • Heart rate increases 15-20 bpm and maintains C.O.
    in late third trimester
  • Maternal posture significantly affects C.O.
  • Supine position decreases C.O. 20-30 second to
    caval compression and decrease venous return
  • 8 demonstrate supine hypotensive syndrome

14
Maternal Cardiovascular Adaptations
  • Uterine blood flow increases 10x (500-800mL/min)
  • This represents 2-17 by term of total C.O.
  • Renal blood flow increases by 50
  • Arterial blood pressure decreases in pregnancy
  • Peripheral vascular resistance falls greater than
    C.O. increases

15
Maternal Cardiovascular Adaptations
  • Nadir of BP occurs at 24-32 weeks
  • Rise to nonpregnant values by term
  • Diastolic fall greater than systolic
  • Always use same Korotkoff for diastolic pressure
  • Ambulatory BP measurement needs further pregnancy
    study before use understood

16
Maternal Cardiovascular Adaptations
  • Systemic vascular resistance decreases from five
    weeks secondary to progesterone, PG, endothelium
    derived relaxant factor
  • Venous complications increase progressively in
    pregnancy
  • With decrease in venous vascular resistance
    more sensitive to autonomic blockade

17
Maternal Cardiovascular Adaptations
  • Increase during pregnancy
  • Cardiac Output 40
  • Heart rate 17
  • Decrease during pregnancy
  • SVR -20
  • PVR -35
  • COP/PCWP -28
  • COP -14
  • (colloid osmotic pressure)
  • CVP NS
  • PCWP NS

18
Maternal Cardiovascular Adaptations
  • Intrapartum 1st stage of labor 12-31 increase in
    CO secondary to increase in stroke volume
  • 2nd stage of labor CO increases by 50
  • Left lateral decubitous position and pain control
    partially alleviate CO changes
  • Systolic and diastolic BP up 35 and 25 mm Hg
    respectively in labor
  • For these reasons, women with CV disease
    decompensate in labor, particularly during the
    2nd stage

19
Maternal Cardiovascular Adaptations
  • Postpartum- greatest risk for pulmonary edema in
    women with CVD is immediately postpartum
  • Immediate puerperium-80 increase in CO within 15
    minutes of vaginal delivery with local
    anesthesia, 60 increase with caudal anesthesia
  • Decrease venocaval obstruction, autotransfusion
    from uterus mobilization of extra vascular
    fluid?venous return

20
Maternal Cardiovascular Adaptations
  • Cardiac output returns to prelabor level one hour
    p.p.
  • Cesarean section does not cause as dramatic a
    shift in hemodynamics, but still CO increases by
    25
  • Vaginal delivery 500 cc blood loss, Cesarean
    section 1000 cc blood loss
  • SV, CO, SVR return to prepregnancy levels by 12
    weeks postpartum

21
General Guidelines to management
  • Activity restrictions
  • Diet modifications
  • Team approach
  • Infection control
  • Immunizations, SBE prophylaxis, prophylaxis
    against Rheumatic fever
  • Interruption of pregnancy
  • Counseling
  • Contraception
  • CV surgery
  • CV drugs

22
Left to Right Shunt
  • Atrial Septal Defect
  • May be undiscovered before pregnancy since
    symptoms often absent
  • Be alert to uncorrected defect in immigrant from
    underdeveloped country
  • Surgical closure of ostium secundum ASD usually
    straight forward and done before pregnancy
  • If no pulmonary hypertension usually no problem
    in pregnancy

23
Left to Right Shunt
  • Complicated ASD
  • Advanced age, uncorrected large ASD, chronic
    arrhythmia (AF), RV dysfunction, pulmonary
    hypertension
  • Pregnancy not advised if these sequelae present
  • SBE uncommon with ostium secundum and prophylaxis
    not warranted
  • Ostium primum- Downs syndrome, endocarditis,
    pulmonary hypertension

24
Left to right shunt
  • VSD- great spectrum and risk dependent upon size,
    location (muscular vs. membranous)
  • Echocardiogram is diagnostic
  • Usually tolerate pregnancy well with left to
    right shunt. SBE prophylaxis indicated
  • Higher the PVR, the greater the risk and patient
    may be best served by early termination

25
Left to Right Shunt
  • PDA
  • Loud continuous systolic diastolic machinery
    murmur
  • Usually corrected in infancy
  • Closure should be accomplished prior to pregnancy
  • SBE prophylaxis required
  • Uncomplicated PDA usually well tolerated but the
    development of pulmonary hypertension is an
    indication for termination

26
Eisenmenger Syndrome
  • Congenital communication between systemic and
    pulmonary circulation and increased PVR either
    where PVRSVR (no shunt) or PVRgtSVR (right to
    left shunt)
  • Most common lesion is large VSD, followed by PDA
  • Once Eisenmenger pathophysiology in place,
    pulmonary hypertension irreversible and VSD
    inoperable

27
Eisenmenger Syndrome
  • Pregnancy carries 50 mortality
  • Fetal survival lt50 (R ? L shunt creates
    cyanosis)
  • Sudden death common, perpartum period most
    dangerous
  • Any decreased venous return yields inability of
    right heart to pump through high PVR? hypotension
    and shock unresponsive to medical management
  • Pregnancy management- maintain pulmonary blood
    flow and venous return (preload)

28
Eisenmenger Syndrome
  • Cause of death sudden death, PE, CHF,
    pulmonary artery rupture
  • Pregnancy management bed rest, supplemental O2,
    anticoagulants, low threshold for hospitalization
  • Intrapartum-epidural may increase right to left
    shunt and increase hypoxia (low dose epidural or
    intrathecal narcotics)
  • PPH causes hypotension and decreased venous
    return
  • Pulmonary artery catheter- many complications

29
Primary Pulmonary Hypertension
  • Same principles as Eisenmenger apply to its
    management
  • Mortality 50
  • Treatments include vasodilators
  • 25 lower pulmonary artery pressure with
    prostacylin infusion- favorable and predicts
    response to nifedipine and good prognosis

30
Valvular Heart Disease
  • In general, regurgitant valvular lesions are well
    tolerated. Stenotic lesions greater risk for
    decompensation
  • gt60 have worsening of NYHA Class, 38 CHF, 23
    adverse perinatal outcome (PTL, IUGR, stillbirth)
  • Class I Asymptomatic
  • Class II symptoms with greater than normal
    activity
  • Class III symptoms with normal activity
  • Class IV symptoms at rest

31
Valvular Lesions with High Maternal or Fetal Risk
  • Severe AS
  • AR Class III-IV
  • MS Class II-IV
  • AS or MS with severe pulmonary hypertension
    (pulmonary pressure gt 75 of systemic pressure)
  • Aortic or mitral valve disease with LVEF lt40
  • Mechanical Valves requiring anticoagulation
  • AR in Marfans Syndrome

32
Valvular Lesions with low Maternal or Fetal Risk
  • AS with low mean gradient ( lt50 mmHg) with LVEF
    gt50
  • AR class I-II with normal LV function
  • MR class I-II with normal LV function
  • MVP with up to moderate MR and normal LV function
  • Mild to moderate MS (valve area gt 1.5 cm2,
    gradient lt 50 mm Hg) and no pulmonary
    hypertension
  • Mild to moderate PS

33
Mitral Stenosis
  • More commonly results from rheumatic heart
    disease
  • Complications pulmonary edema, RV failure,
    arrhythmias, PE
  • Pregnancy detrimental to MS increase blood
    volume, increase risk of pulmonary edema,
    tachycardia decreases LV filling time? elevated
    LA pressure? pulmonary edema

34
Mitral Stenosis
  • Severity of MS based on the valve area 4-5 cm2
    normal, gt1.5 cm 2 mild, lt1 cm2 severe
  • Likelihood of maternal or fetal complications
    associated with severity based on valve area more
    than NYHA class
  • Overall 35 maternal complications, 30 fetal or
    neonatal complications

35
Mitral Stenosis- Treatment
  • If Rheumatic Heart history daily penicillin
    prophylaxis
  • Gentle diuresis, B blocker prn tachycardia
  • Typical AF management, remember anticoagulation
  • Percutaneous balloon mitral valvotomy ideally
    before pregnancy, but safe in pregnancy
  • Labor adequate pain control to prevent
    tachycardia, epidural lowers SVR in patient who
    has decreased ability to increase CO? hypotension
  • Intra-thecal narcotics ideal

36
Aortic Stenosis
  • Most common cause- congenital bicuspid valve
  • Much smaller number subaortic stenosis
    hypertrophic cardiomyopathy
  • Severity graded by average valve area or peak
    gradient across valve
  • Peak gradient gt50 mm Hg and/or lt or to 1 cm
    squared defines severe disease

37
Aortic Stenosis
  • AS creates fixed stroke volume and difficulty in
    achieving increased CO of pregnancy
  • Rate control NB bradycardia -gt decreased CO and
    hypotensive tachycardia -gt decreased ventricular
    filling time -gt decreased CO and risk for
    myocardial ischemia
  • If severe AS valvuloplasty before pregnancy.
  • Moderate to severe AS 70 maternal morbidity
    (CHF, angina, rarely sudden death)

38
Aortic stenosis
  • Mild to moderate AS- conservative management
  • Severe, symptomatic AS- balloon vavluloplasty
    consideration
  • During labor prevent hypotension and tachycardia
    with generous hydration, cautious epidural use
  • Shorten second stage
  • Active management of PPH to avoid hypotension and
    tachycardia

39
Mitral Valve Prolapse
  • MVP is the most common cardiac condition in
    Obstetrics
  • MVP affects 4 of the population and 12-17 of
    women of childbearing age
  • Redundant valve prolapse into ventricle during
    systole
  • Most asymptomatic, some chest pain, dyspnea,
    weakness, palpitations
  • Little effect on pregnancy

40
Mechanical Heart Valves
  • Anticoagulant issues very difficult and
    controversial
  • Women who desire childbearing should consider
    valve repair or biologic if possible
  • Warfarin safest for mother but poses greatest
    risk to fetus
  • ACC/AHA 1998 guidelines issues and recommendations

41
Coarctation of the Aorta
  • Most commonly distal to the left subclavian
    artery, a discrete narrowing
  • Proximal hypertension, distal hypoperfusion
  • Severity determined by gradient across the coarct
  • Open surgical repair vs. balloon angioplasty
  • Associated intracranial aneurysms and intrinsic
    aortapathy dissection, aneurysm, rupture
  • Maternal mortality 5
  • Vaginal delivery safe, epidural ideal, assisted
    delivery to shorten second stage

42
Marfans Syndrome
  • Autosomal dominant condition- multiple mutations
    in fibrillin gene on chromosome 15
  • Manifestations MVP, MR, aortic root dilatation,
    AR, dissection or rupture of aortic root
  • Mean age of death 32 years
  • Aortic root diameter critical, surgical
    replacement if root diameter gt5.5 cm

43
Marfans Syndrome
  • Aortic root diameter may predict pregnancy risk
  • As high has 50 mortality (root diameter gt
    4.5cm, AR, LV dysfunction, or coarctation)
  • Follow root with monthly echocardiography
  • Treat hypertension aggressively (B-blocker)
  • Uncomplicated- deliver vaginally, high risk (see
    above) elective cesarean section to minimize
    likelihood of hypertension? dissection

44
Cyanotic Congenital Heart Disease
  • This category includes any malformations that
    involve a right to left shunt creating
    deoxygenated blood in the systemic circulation
    and cyanosis
  • Tetralogy of Fallot, transposition of the great
    vessels, double outlet right ventricle, and
    others
  • With history of repair and no cyanosis currently
    and normal ventricular function, may tolerate
    pregnancy

45
Cyanotic Congenital Heart Disease
  • Tetralogy of Fallot most common uncorrected
    cyanotic congenital heart lesion (not previously
    repaired)
  • Large defect high in the ventricular septum
  • Pulmonary stenosis
  • Dextraposition of the aorta-overrides the right
    ventricle and sits outside the VSD
  • Right ventricular hypertrophy

46
Tetralogy of Fallot
  • Special problem in pregnancy- decreased SVR
    causes greater right to left shunt intensifying
    hypoxemia leading to syncope or death
  • Maintenance of venous return critical (labor
    issues)
  • Pregnancy should be discouraged
  • Prognosis bleak with repeated syncope, hematocrit
    gt60, or RV systolic pressure gt120 mm Hg

47
Peripartum Cardiomyopathy (PPCM)
  • First defined in 1971 Symptoms of CHF that
    become apparent in last month of pregnancy or
    within 5 months postpartum with no pre-existing
    disease and no other etiology for heart failure
  • Echocardiographic criteria ejection fraction
    lt45 and end diastolic dimension gt2.72 cm/m
    squared
  • Incidence 1/3000-1/4000 in USA
  • Usually older, multiparous, African descent,
    chronic hypertension, pre-eclampsia, tocolytics

48
Peripartum Cardiomyopathy
  • Treatment similar to any cause of CHF
  • Preload reduction (Na and fluid reduction,
    diuretics, nitrates)
  • Afterload reduction (hydralazine, ACE inhibitors
    PP)
  • Inotropes- digoxin
  • Data on prognosis limited-echo after 6 mo?
  • 18-50 mortality
  • 50 recurrence in future pregnancies

49
Ischemic Heart Disease
  • Rare lt1/10,000 pregnancies
  • Rare risk with ergonovine, PGE, PGE2, ritodrine
  • Most cases with known cardiac risks
  • Delivery within 2 weeks 50 mortality
  • Treatment of MI same as non-pregnant treatment
    (thrombolytics t-PA ect. Caution placental
    abruption, fetal intracranial bleeding)
  • Vaginal delivery preferred

50
Maternal Arrhythmias
  • SVT common in young women without structural
    heart disease
  • Pregnancy treatment of SVT unchanged
  • Vagal maneuvers first, then IV adenosine
    (adenosine associated with occasional fetal
    bradycardia)
  • Frequent episodes- beta blockers, calcium channel
    blockers, digoxin

51
Maternal Arrhythmias
  • Atrial fibrillation and flutter usually
    associated with underlying conditions
    hyperthyroidism, COPD, PE, cardiomyopathy,
    cardiac valve lesions (AS, MS)
  • Treatment unaltered by pregnancy and depends upon
    clinical scenario
  • Eg. new AF with MS can lead to pulmonary edema,
    hemodynamic instability-cardioversion

52
Endocarditis Prophylaxis
  • See ACOG handout

53
Key Points
  • Preconception considerations
  • Optimization of maternal status
  • Repair defects prior to pregnancy if indicated,
    medication adjustments
  • Discussion of fetal risks
  • Awareness of risk of transmission of defect to
    offspring
  • Patients need to understand maternal and fetal
    risks

54
Key Points
  • Antepartum Consideration
  • Maternal risks vary greatly, depending on the
    specific lesion, severity of lesion, and
    prepregnancy functional status
  • Anticoagulation consideration

55
Key Points
  • Intrapartum considerations
  • Labor most dangerous time period for many types
    of heart disease. NB cardiac output increases
  • Vaginal delivery preferred over cesarean section
    for most patients less blood loss, fewer
    postpartum infections, less VTE
  • Assisted second stage
  • SBE prophylaxis ACC/AHA
  • Telemetry for arrhythmias
  • Active third stage management, particularly if
    lesions preload dependent (AS, MS)

56
Key Points
  • Anesthetic Considerations
  • Regional anesthetic appropriate for most with
    cardiac disease avoids tachycardia (NB in MS-L
    ventricular filling), decreased cardiac work,
    allows assisted vaginal delivery
  • Severe stenotic lesions will not tolerate sudden
    decrease in SVR slow epidural or intrathecal
    narcotics. GA for cesarean section?

57
Key Points
  • Postpartum considerations
  • Patients remain at high risk for VTE during
    postpartum period appropriate prophylactic
    anticoagulation important
  • Patients with certain cardiac conditions (eg,
    Eisenmengers syndrome) have a higher risk of
    death during postpartum period and may require
    hospitalization

58
  • Thank you
About PowerShow.com