Oh’s (66) - Cardiac Disease In Pregnancy Flashcards
Percentage of pregnancies with cardiac disease
0.2 to 4%
Types of cardiac disease that cause of maternal death
Sudden Adult Death Syndrome (31%) Ischaemia 22% Cardiomyopathy 18% Dissection 14% Valves 7% Essential Hypertension 4% Other 5%
Are patients who die in pregnancy usual known to have cardiac disease?
No - on 17% had pre-exisiting cardiac disease
Cardiovascular changes in pregnancy
Blood volume rises by 50%
Red cell mass rises but more slowly (dilution all anaemia)
CO increases by 50% (increased SV, in HR in 3rd tri)
SVR and BP falls in first trimester, rising to term
Factors that increase CO/DO2 etc during labour
Anxiety, pain, contractions
Post delivery - increased intra cardiac pressure as caval pressure released (auto transfusion)
WHO Risk Classification for cardiac disease in pregnancy
Classes 1 to 4
Low, medium, high
Class 4 - DO NOT GET PREGNANT
European Society Class 1 (modified WHO)
No detectable increase in mortality
Uncomplicated:
pulmonary stenosis
PDA
MV prolapse
Successfully repaired lesions (ASD, VSD, PDA)
Isolated ectopic
European society class 2
Small increase in mortality
Operated ASD/VSD
Repaired TOF
Arrhythmia
European Society Class 2-3
Mild LV impairment
HOCM
Marfans without dilatation
ESC Class 3
SIgnificant risk of severe mortality
Mechanical valve
Fontan
Systemic RV
Unprepared cyanotic disease
ESC Class 4
Extremely high risk of death
PAH (any cause) LVEF <30% NYHA 3-4 Severe mitral stenosis Aortic root >45mm
Antenatal approach
Joint cardiac, obs and anaesthetic clinic
Routine antenatal appts
Deliver at 32-34/40
Plan for VTE
Intrapartum principles
Have appropriate cardiology support
Aim vaginal delivery (less fluid shifts, less thrombosis)
Planned CS if condition worsening
Goals:
Reduce CVS stress - early epidural
Limit the length of the second stage
Consider ECG, IABP and CVP monitoring
Problems is mitral disease and management
Stenosis is poorly tolerated
Risk of pulmonary oedema, AF (LA enlarges)
Tx-
Anticoag (high risk of thrombus)
Dieretics
Beta block - sinus rhythm
Delivery - IABP, treat drops in SVR with vasoconstrictors/volume
Problems and management with aortic disease
Do not tolerate blood loss, tachycardia or caval compression
Avoid fluid depletion
Strict BP control in dissection (B-blockers, methyldopa) Serial echos (use valve areas and not flows, altered in pregnancy)
Issues with the fontan circ
Palliates a singles ventricle circulation that cannot be repaired into two ventricle circ.
Decompensation - arrhythmia, failure, chest pain, hypoxia
Maintain pre-load and forward flow through pulmonary vessels
Issues with IHD in pregnancy
3-4x risk of MI in pregnancy
Mortality 45%
Look out for any patient with chest pain
DD - aortic dissection, PE
Treat as per non-preg: Angio + PCI
Aspirin, clopoidogrel and b blockers safe in pregnancy
Commonest cause of MI post parturition
Coronary artery dissection
80% of pts have no risk factors
Use of ergometrine - RISK OF CORONARY VASOSPASM
Considerations in ventricular dysfunction
May be unmasked by pregnancy
Pricipitates a peripartum cardiomyopathy
Tx: In failure: Bed rest Dieuretics Anti coag Early delivery Inotropic support (This may be a bridge to transplant)
Peripartum Cardiomyopathy definition:
Rare idiopathic heart failure that presents in the last month of pregnancy
OR
Within 5 months of delivery.
Diagnosis of exclusion
LVEF almost always <45%
Risk factors for peripartum cardiomyopathy
Multip
Twins
Extremes of age
Symptoms of peripartum cardiomyopathy
SOB
Peripheral oedema
Fatigue
May mimiic normal pregnancy or pre-eclampsia
Treatment of peri-partum cardiomyopathy
Salt restriction
Dieurtetics
Beta blockers
Peripheral vasodilator
Risk of thrombotic complications
If in shock -
IABP
ECMO
?Bromocriptine
