Heart disease with the pregnancy🖤 Flashcards
Mortality due to heart disease
Decrease or increase
Decrease
Pregnancy with heart disease has increase or decrease
Increase
Congenital heart disease with pregnancy increase or decrease
Increase
Hemodynamic changes in normal pregnancy
1. Plasma volume.
2. Cardiac output.
3. Heart rate.
4. Main arterial pressure.
5. Struck volume.
6. Systemic vascular resistance
7. Pulmonary vascular resistance.
جدول
40+
43 +
17 +
4+
27 +
21 -
34 -
What’s the critical period in pregnant women to get cardiac disease ?
- 6-30 wks
- Intra partum period
- after delivery
Pregnancy changes mimic cardiac disease? 5
• Symptoms – breathlessness, weakness, edema, syncope
• Tachycardia
• Splitting of 1st hear sound
• Murmur – systolic , breast bruit
• Displacement of apex beat – upwards to left
Symptoms of heart disease? 5
• Progressive dyspnea or orthopnea
• Nocturnal cough
• Syncope
• Chest pain
• Hemoptysis
Clinical findings of heart disease 9
• Cyanosis
• Clubbing of fingers
• Persistent neck vein distention
• Systolic murmur grade 3/6 or greater • Diastolic murmur
• Cardiomegaly
• Persistent arrhythmia
• Persistent split second sound
• Pulmonary hypertension
If you suspect the pregnant women maybe has cardiac disease what’s the investigation you want required?
• ECG – cardiac arrhythmias, hypertrophy
• Echocardiography – cardiac status and structural anomalies
• X-ray chest – cardiomegaly, vascular prominence
• Cardiac catheterization - rarely
Functional grading of heart disease?
•Grade I: No limitation of physical activity- asymptomatic with
normal activity
• Grade II: Mild limitation of physical activity -Symptoms with
normal physical activity
• Grade III: Marked limitation of physical activity -Symptoms
with less than normal activity, comfortable at rest
• Grade IV: Severe limitation of physical activity- symptoms at
rest
Classification of Heart Disease according to etiology :6
- Congenital - non cyanotic:
ASD, VSD, Pulmonary stenosis, coarctation of aorta - cyanotic :
fallot’s tetralogy
Eisenmenger’s syndrome - Rheumatic heart disease : – MS, MR, AS, AR
- Cardiomyopathy
- Ischemic heart disease
- conduction defects, syphilitic,
thyrotoxic, hypertensive
Classification of Heart Disease during pregnancy according to risk :
- Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-1,2, corrected FT
- Medium risk ( 5 – 15 %) – MS-3,4, MS with atrial fibrillation, AS, uncorrected FT.
- High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement.
Poor prognostic indicators 7.
• h/o heart failure, ischemic attack, stroke
• Arrhythmias
• Base line NYHA class 3 and 4
• MV area below 2cm sq, AV area below 1.5
• Ejection fraction less than 40%
• Oxygen saturation less than 80% Increased of fetal growth restriction
• Less than 20% chance
risk factors for pregnant women to get cardiac disease? 9
• Anemia
• Infections
• Hypertension
• Physical labor
• Weight gain
• Multiple pregnancy
• Caffeine , alcohol intake
• Pain
• Drugs – tocolytic
Effect of pregnancy on heart disease 6
• Worsening of cardiac status
• CCF,
• bacterial endocarditic,
• pulmonary edema,
• pulmonary embolism,
• rupture of aneurism
How are you gonna manage pregnant women with the cardiac disease ? require
• High index of suspicion
• Timely diagnosis
• Effective management
• Team Approach : 1.Obstetrician 2. Cardiologist 3 Anesthetist 4. Neonatologist 5. CTV surgeon 6. Nursing Staff
Preconceptional counseling 4.
• No pregnancy specially in high risk types
• Maternal mortality varies directly with functional classification at pregnancy
onset
• pre-pregnancy Optimal Medical/Surgical treatment
• Counseling- :
• Maternal & Fetal risks
• Prognosis
• Social and cost considerations
• Hospital delivery- Preferable at tertiary care centre
• Use of anticogulants
When Medical termination of pregnancy use?
- early pregnancy in high-risk group only ( 1. Primary pulmonary HTN, 2. Eisenmenger syndrome, 3. Coarctation of aorta, 4. Marfan syndrome with dilated aortic root ).
- Only in 1st trim, better before 8 weeks.
- Suction evacuation preferred.
- MTP also carries risk for life.
Patient with the cardiac disease what’s the best method for the medical termination?
Suction evacuation.
Antenatal care for pregnant women with the cardiac disease 6
• Clear counseling of risk and prognosis.
• ANC every 2 weeks up to 30 weeks then weekly.
• On each visit-note-pulse rate, BP, cough dyspnea, weight, anemia, auscultate lung bases, re-evaluate functional grade.
• Ensure treatment compliance.
• Exclude fetal congenital anomaly by level-III USG and fetal ECHO at 20 weeks in maternal congenital heart disease.
• Fetal monitoring.
The pregnant women with cardiac diseases, what you gonna use as a treatment Anticoagulants
Heparin and the first 12 weeks to decrease risk.
What’s the advantage of the heparin?
Doesn’t cross the placenta.
What’s the disadvantage for Heparin?
maternal osteoporosis, hemorrhage, thrombocytopenia, thrombosis
Why we doesn’t use Warfarin in the pregnant woman with the cardiac disease?
abnormalities of fetal bone and cartilage formation
What’s you gonna use for pregnant women with cardiac disease, heparin, or warfarin?
Heparin in the first 12 weeks to the decrease the risk.
How you gonna treat pregnant women with prosthetic valves?
- Heparin in the first trimester.
- Then converted to warfare at 13 weeks tell 36 weeks.
- Then converted to heparin at 36 weeks till delivery.
Special Advice pregnant women with cardiac disease? 8.
• Rest, Avoid undue excitement/strain • Diet/ Iron and vitamins
• Hygiene, dental care to prevent any infection
• Dietary salt restriction (4-6g/d)
• Avoid smoking, drugs – betamimetics
• Early diagnosis and treatment of PIH, infections
• Therapeutic/prophylactic cardiac interventions as applicable :
1. Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence of
rheumatic fever
2. Diuretics, Beta Blockers, Digitalis, Anticoagulants.
3. Surgical treatment as applicable - balloon mitral valvotomy
What’s the indication to admit pregnant women with cardiac disease: 2 type.
Elective admission:
1. NYHA 1 – 2 weeks before EDD
2. NYHA 2 – 28 to 30 weeks
3. NYHA-III/IV- Irrespective of POG as soon as patient comes
4. To Change from oral anticoagulants to heparin-early pregnancy, 36 weeks in patients on anticoagulant.
Emergency admission:
1. Deterioration of functional grade
2. Symptoms and signs of complications- Fever/ persistent cough/ basal crept/ tachyarrhythmia’s (P/R >100 min)/
JVP>2cm/Anemia/ Infections/ PET/Abnormal weight gain /other medical disorders
Labor and Management for pregnant women with the cardiac disease?
• Institutional delivery
• Induction of Labor:
1. Only for obstetric indications
2. Oxytocin preferred- Higher concentration with restricted fluid
3. Intracervical Foley instillation specially in congenital heart
disease
4. PGE2 Gel may be employed- Vasodilatation - use with caution
Management in first stage of labor in the pregnant woman with the cardiac disease
- Confined to bed- propped up or semi recumbent
- Intermittent oxygen inhalation 5-6 l/min
- Sedation and analgesia- (Epidural, pethidine)
- Cautious use of I.V. fluids
- Stop anticoagulants
- Digitalise if in : (( CHF,P.R.>110/ min,
R/R >24/min )) - Diuretics in pulmonary congestion
- Deriphyllin if bronchospasm
- Prevention of infective endocarditic
- Cardiac monitoring and pulse oximetry ±pulmonary artery catheterization- continuous
hemodynamic monitoring - Evaluation by Anesthetist and cardiologist
SAPE prophylaxis not recommended in the patient has? 2
- At risk For the infection
- Severe lesion.
SAPE prophylaxis
Ampicillin-2G IV/IM + Gentamicin 1.5mg/kg (max120)
6 hours later
Ampicillin-1G I.V./IM or 1G P.O.
If
Allergic to Penicillin
Vancomycin-1G I.V. or Clindamycin – 600mg IV + Gentamicin-1.5mg/kg
Management of second stage of labor
• Delivery in propped up position
• Avoid forceful bearing down
• Adequate pain relief-epidural/pudendal block
• avoid spinal/Saddle block
• Cut short second stage of labor:
• episiotomy, vacuum, forceps – not always must
• Strict Cardiovascular monitoring
Third stage of labor management of the pregnant women with cardiac disease
• AMTSL-10 U oxytocin IMI
• Avoid bolus syntocinon/Ergometrine • Propped Up, oxygen inhalation
• Furosemide I.V. 40 mg
• Pethidine/morphine (15mg)
• Watch for signs of CHF & Pul. Edema • Treat PPH energetically
First Hour After Delivery for pregnant women with the cardiac disease
•Propped up/sitting position,
• oxygen
•Watch for signs of pulmonary edema •Sedation
•Antibiotics
Indications for LSCS for pregnant women with cardiac disease
• Mainly obstetrical
• Coarctation of aorta
• Marfan syndrome with dilated root of aorta:
1. Prefer epidural anesthesia
2. Narcotic conduction analgesia
3. GA in Pulmonary hypertension and pts having intracardiac shunts
Advice at time of discharge for pregnant lady her delivered baby with cardiac disease
- Continue medical treatment
- Avoid infection
- Reassessment after 6 weeks or earlier if some complication
occurs - Iron supplementation
- Cardiological consultation for definitive management of heart
disease
Contraceptive advice at time of discharge:
• Contraception- Barrier.
• Progesterone – good option- DMPA, Norplant
• IUCD-Less preferred
• COC – contraindicated
• Sterilization- vasectomy- ((best ))
• Tubal ligation-Interval, puerperal can be done
Effect of heart disease on pregnancy? 5.
• Abortion
• Preterm labor
• IUGR
• Congenital heart disease in baby – 5%
• Intrauterine fetal demise
