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Cardiac Disease in Pregnancy


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

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Title: Cardiac Disease in Pregnancy

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 neonatal
  • Various hemodynamic changes in pregnancy make
    diagnosis of certain CV disease more difficult
  • Dyspnea, orthopnea, fatigability, syncope, and
    dizzy spells are common in pregnancy

Diagnosis Continued
  • Systolic murmurs occur in 95 percent of pregnant
  • 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

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

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
  • Some diseases negligible, some prohibitive

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
  • (MS, MR, AS, Tetralogy, VSD with mild pulmonary
    hypertension, PS)
  • Pregnancy before valve replacement (prosthetic)
    should be advised

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Left to Right Shunt
  • PDA
  • Loud continuous systolic diastolic machinery
  • 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

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

Eisenmenger Syndrome
  • Pregnancy carries 50 mortality
  • Fetal survival lt50 (R ? L shunt creates
  • Sudden death common, perpartum period most
  • 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)

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
  • Pulmonary artery catheter- many complications

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

Valvular Heart Disease
  • In general, regurgitant valvular lesions are well
    tolerated. Stenotic lesions greater risk for
  • 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
  • Class III symptoms with normal activity
  • Class IV symptoms at rest

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

Valvular Lesions with low Maternal or Fetal Risk
  • AS with low mean gradient ( lt50 mmHg) with LVEF
  • 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
  • Mild to moderate PS

Mitral Stenosis
  • More commonly results from rheumatic heart
  • 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

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

Mitral Stenosis- Treatment
  • If Rheumatic Heart history daily penicillin
  • 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

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

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)

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

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

Mechanical Heart Valves
  • Anticoagulant issues very difficult and
  • 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

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

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

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

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
  • With history of repair and no cyanosis currently
    and normal ventricular function, may tolerate

Cyanotic Congenital Heart Disease
  • Tetralogy of Fallot most common uncorrected
    cyanotic congenital heart lesion (not previously
  • 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

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
  • Pregnancy should be discouraged
  • Prognosis bleak with repeated syncope, hematocrit
    gt60, or RV systolic pressure gt120 mm Hg

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
  • Incidence 1/3000-1/4000 in USA
  • Usually older, multiparous, African descent,
    chronic hypertension, pre-eclampsia, tocolytics

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

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

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
  • Frequent episodes- beta blockers, calcium channel
    blockers, digoxin

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

Endocarditis Prophylaxis
  • See ACOG handout

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
  • Patients need to understand maternal and fetal

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

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)

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?

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

  • Thank you