Heart disease with pregnancy

Definition: It is the presence of any organic cardiac lesion during

pregnancy

Incidence: Overall 0.5-2%

70% RHD , 30% CHD, 10% Others

In developed countries CHD are the commonest.

During pregnancy there is increased cardiac work due to:

Inc. Ht rate x Inc. S.V = Inc. C.O.P 40%

Inc. bl. volume 40%

Decreased peripheral resistance---->drop in B.P

Dec. B.P+Inc. C.O.P ----->Hyperdynamic circ.--->fn. murmurs.

Functional classification of cardiac dz.:

ClassI : Asymptomatic

ClassII : Symptomatic with moderate exertion

ClassIII : Symptomatic with mild exertion

ClassIV : Symptomatic at rest.

EFFECTS OF PREGNANCY ON CARDIAC DZ.:

1-Deterioration of the cardiac condition one grade.

2-Precipitates Heart failure at any time during gestation esp.:

a)Between 28-32 wks.Why?

b)During 1st&2nd stage of Labor due to ut. contractions &

bearing down.

c)After the 3rd stage due to overload of the circulation by placental

blood.

3-Infective endocarditis especially postpartum.

4-Recurrence of Rheumatic activity.

5-Arrhythmias e.g Atrial fibrillation .

6-Thromboembolic complications due to slow circulation.

EFFECTS OF CARDIAC DZ. ON PREGNANCY:

1-Chronic anoxia ------->IUGR [Oligohydramnious] , IUFD.

------->If severe e.g cyanotic HD-->Abortion

2-Tissue congestion ----> Preterm labor , polyhydramnios

----> If severe----> postpartum hge.

3-Wih CHD there 6 fold increased incidence of CFMF

CLINICAL PICTURE

HISTORY &SYMPTOMS :

-Type of patient: -Rheumatic fever during childhood.

-Long-standing history of cardiac disease

-Type of treatment before pregnancy

-Symptoms of heart dz:

*General: Edema , easy fatigability-Class-

*Heart : Palpitation , Anginal pains.

*Chest : PND , Cough & expectoration , haemoptysis (MS)

*Abdomen: Tender right hypochondrium

-Symptoms of heart failure may arise durin pregnancy (28-32wks).

-Obstetric C/O;

-Decreased abdominal enlargment (Oligohydramnious& IUGR are common)

-Decreased F.K

EXAMINATION & SIGNS :

Signs in pregnancy that mimic heart dz:

General: Tachycardia-bounding pulse-Capillary pulsations

Edema - plethoric facies.

Local : Apex beat displaced upwards & to the left

Splitting of S1 , Audible S3 , Systolic Fn. murmur

Left axis deviation in ECG.

SURE SIGNS OF HEART DISEASE:

General: Pulse arrhythmia e.g AF

Local : Inspection:----------

Palpation : Palpable thrill

Auscultation:

Ht.sounds: Accentuated S1 or splitting of S2

Murmurs : Any murmur with thrill

Any diastolic murmur

Any systolic murmur > G2

Additional sounds: Pericardial rub or gallop

ECG : Arrhythmias , Heart block

Cardiac lesions poorly tolerated in pregnancy & *Indications for

termination in the 1st trimester

-Class III & IV if before preg. whatever the lesion is *.

-Cyanotic heart dz. congenital or aquired [Eisenmenger synd]*

-Primary pulmonary hypertension.*

-Pulmonary hypertension complicating : AS, MI, AI, Coarctation of the aorta.

-Peripartum cardiomyopathy *

-Mitral Stenosis (now surgery is available instead)

-Metallic valve prosthesis

-Marfan's syndrome with dilated aortic root. *

-Heart failure in previous pregnancy.*

-Rh. activity or SBE in the past 2 yr

MANAGMENT

TERMINATION IS ONLY ATTEMPTED IN THE 1ST TRIMESTER WHEN INDICATED.

I.DURING PREGNANCY :

Class I & II :Under supervision of obstetrician&cardiologist

ANV every 2 wks till 28wks then weekly till delivery.

1-Rest physical & mental . Mild sedation is advised.

2-Diet : restrict CHO , fats & salts

Fe suplementation [anemia is not allowed]

3-Prophylactic AB---> LAP 1.2 MU Benzathine penicillin/2wks

4-Avoid intercurrent infections , anemia & fever.

Hospitalization is adviced between 28-32wks & from 36 wks.

ClassIII :

Hospitalization throughout pregnancy

1-As class I &II

2-Diuretics to limit the expansion of the intravascular volume .

3-Digitalization to improve cardiac work , relief symptoms , avoid arrhyhtmias & ht. failure.

ClassIV :

Must be changed to Class III by ttt of ht.failure the managed similarly.

II. DURING LABOR :

NO INDUCTION OF LABOR IN CARDIAC PATIENT,

-Care of First stage :

*Strict intrapartum monitoring of mother & fetus.

*Semisitting or better left lateral ,& NO bearing down.

*Sedation & adequate pain relief.

*Avoid oxytocin

*Avoid I.V fluids (limited to 75ml/hr)

*Antibiotics prophylaxis to SBE started by the end of 1st stage.

Prophylactic AB advised to cardiac patients are:

Crystalline Penicillin G 2 MU ,OR , Ampicillin 1 gm

+Gentamycin 1.5 mg/kg[not>80mg], OR , Streptomycin 1 gm.

*AB regimen started 1hr before the procedure and repeated for 48 hrs postpartum [dose / 12 hrs]

*Penicillin,gentamycin can be administered IV or IM,Streptomycin IM

*Allergic pts to penicillin should recieve Vancomycin 1gmIVI in 30min

-Second stage:

*Conducted under local anesthesia e.g pudendal nerve block

*Shortened by forceps or better ventouse to avoid bearing down.

-Third stage :

*Avoid giving methergine

*Depend mainly on ut.massage

*Dieuretics (Lasix IV) may be given to decrease cardiac overload.

*In case of atonic PPH Syntocinone is safer than Methergine & Pitocin.(why?)

III.Postpartum care of mother & neoborn:

Mother: *Hospitalization for 1-2 wks (Why?)

*Prophylactic AB continued.

*Breast feeding allowed for class I&II .

*Contraception councelling.

Neoborn: *Care of LBW and/or premature.

ANTICOAGULANTION DURING PREGNANCY & LABOR

Indications: - Prosthetic Metallic Valve Replacement ,

-Atrial fibrillation ,

-D.V.T (C/P ??).

Available anticoagulant drugs:

	HEPARIN	WARFARIN
Teratogenecity