Transcript Heart Disease with Pregnancy [PPT]

Heart disease with pregnancy
Prof Uma Singh
Incidence of heart disease
• Varies between 0.1 – 4.0 %, average 1%
• Mortality due to heart disease has decreased
• Devpd countries – maternal mortality due to
heart disease has increased
• Pregnancy with heart disease has increased
• Devpd countries – rheumatic is decreasing
• Congenital heart disease with pregnancy is
also increasing
Hemodynamic changes in normal
pregnancy
PARAMETER
CHANGE (PERCENT)
Plasma volume
+40
Cardiac output
+43
Heart rate
+17
Mean arterial pressure
+4
Stroke volume
+27
Systemic vascular
resistance
Pulmonary vascular
resistance
-21
-34
Critical periods
•
•
•
•
•
Changes start from as – 6weeks
Max changes around –30 weeks
Intra partum period
Just after delivery
Second week of puerperium
Pregnancy changes mimic cardiac disease
• Symptoms – breathlessness, weakness,
oedema, syncope
• Tachycardia
• Splitting of 1st hear sound
• Murmur – systolic , breast bruit
• Displacement of apex beat – upwards to left
Symptoms of heart disease
•
•
•
•
•
Progressive dyspnea or orthopnea
Nocturnal cough
Syncope
Chest pain
Hemoptysis
Clinical findings of heart disease
•
•
•
•
•
•
•
•
•
Cyanosis
Clubbing of fingers
Persistent neck vein distention
Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent arrythmia
Persistent split second sound
Pulmonary hypertension
Investigations
• ECG – cardiac arrhythmias, hypertrophy
• Echocardiography – cardiac status and
structural anomalies
• X-ray chest – cardiomegaly, vascular
prominence
• Cardiac catheterization - rarely
NYHA (New York Heart Association)
Functional grading of heart disease
• Grade I: No limitation of physical activityasymptomatic 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 activitysymptoms at rest
Classification of Heart Disease
according to etiology
•
•
•
•
•
Congenital – non cynotic ( ASD, VSD, Pulm
stenosis, coarctation of aorta),
cyanotic (Fallots tetralogy, Eisenmenger’s
syndrome)
Rheumatic heart disease – MS, MR, AS, AR
Cardiomyopathy
Ischaemic heart disease
Others – conduction defects, syphilitic,
thyrotoxic, hypertensive,
Classification of Heart Disease during
pregnancy according to risk
• Low risk ( 0 – 1%) – ASD, VSD, PDA, MS1,2, 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
•
•
•
•
•
h/o heart failure, ischaemic 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%
Additional risk factors
•
•
•
•
•
•
•
•
•
Anaemia
Infections
Hypertension
Physical labour
Weight gain
Multiple pregnancy
Caffein , alcohol intake
Pain
Drugs – tocolytic
Effect of pregnancy on heart disease
• Worsening of cardiac status
• CCF, bacterial endocarditis, pulmonary
edema, pulmonary embolism, rupture of
aneurism
• No long term effect on basic defect
Effect of heart disease on pregnancy
•
•
•
•
•
Abortion
Preterm labour
IUGR
Congenital heart disease in baby – 5%
Intrauterine fetal demise
Management
Requires• High index of suspicion
• Timely diagnosis
• Effective management
• Team Approach•
•
•
•
•
•
Obstetrician
Cardiologist
Anesthetist
Neonatologist
CTV surgeon
Nursing Staff
Preconceptional Counseling
• No pregnancy unless must esp in high risk types
• Maternal mortality varies directly with functional
classification at pregnancy onset
• Optimal Medical/Surgical treatment pre-pregnancy
• Counselling– Maternal & Fetal risks
– Prognosis
– Social and cost considerations
– Hospital delivery- Preferable at tertiary care centre
Medical termination of pregnancy
• Termination advised in early pregnancy in high risk
group only – ( Primary pulmonary Ht, Eisenmenger
syndrome, Coarctation of aorta, Marfan syndrome
with dilated aortic root)
• Only in 1st trim, better before 8 weeks
• Suction evacuation preferred
• MTP also carries risk for life
Antenatal care
• Clear counseling of risk and prognosis
• ANC every 2 weeks upto 30 weeks then weekly
• On each visit-note-pulse rate, BP, cough dyspnea,
weight, anaemia, auscultate lung bases, reevaluate 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
•
•
•
•
•
•
•
Special Advice
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 diag and tmt of PIH, infections
Therapeutic/prophylactic cardiac interventions as
applicable– Benzathine Penicillin 12 lacs at 3 weeks - to prevent
recurrence of rheumatic fever
– Diuretics, Beta Blockers, Digitalis, Anticoagulants
– Surgical treatment as applicable - balloon mitral valvotomy
Indications for admission
Elective admission• NYHA 1 – 2 weeks before EDD
• NYHA 2 – 28 to 30 weeks
• NYHA-III/IV- Irrespective of POG as soon as patient
comes
• To Change from oral anticoagulants to heparin-early
pregnancy, 36 weeks in patients on anticoagulant
Emergency admission• Deterioration of functional grade
• Symptoms and signs of complications- Fever/
persistent cough/ basal crepts/ tachyarrhythias (P/R
>100 min)/ JVP>2cm/Anaemia/ Infections/
PET/Abnormal weight gain /other medical disorders
Labor and Management
• Institutional delivery
• Induction of Labor
– Only for obstetric indications
– Oxytocin preferred- Higher concentration with
restricted fluid
– Intracervical foley instillation esp in congenital heart
disease
– PGE2 Gel may be employed- Vasodilatation - use with
caution
Management in first stage of labor
• Confined to bed- propped up or semi
recumbent
• Intermittent oxygen inhalation 5-6 l/min
• Sedation and analgesia- (Epidural,
pethidine, tramadol)
• Cautious use of I.V. fluids (not >75ml/hr
except in aortic stenosis and VSD)
• Stop anticoagulants
• Digitalise if in CHF,P.R.>110/ min,
R/R >24/min
Management in first stage of labor
•
•
•
•
Diuretics in pulmonary congestion
Deriphyllin if bronchospasm
Prevention of infective endocarditis
Cardiac monitoring and pulse oximetry
±pulmonary artery catheterisationcontinuous haemodynamic monitoring
• Evaluation by Anaesthetist and
cardiologist
SABE Prophylaxis
Not recommended for all
• At risk for infection
•Severe lesions
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•
•
•
•
•
•
•
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
• Propped up/sitting position, oxygen
• Watch for signs of pulm edema
• Sedation
• Antibiotics
Indications for LSCS• Mainly obstetrical
• Coarctation of aorta
• Marfan syndrome with dilated root of aorta
– Prefer epidural anaesthesia
– Narcotic conduction analgesia/GA in Pulmonary
hypertension and pts having intracardiac shunts
• Advice at time of discharge:
• Continue medical treatment
• Avoid infection
• Reassesment 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, puerperial can be done
MCQs
Text book of Obstetrics, Dr J B
Sharma, 1st edition
Page 529 to 536
1. Pregnancy is contra indicated with
•Mitral stenosis
•Aortic stenosis
•Fallots tetralogy
•Eisenmengers syndrome
2. Pregnancy is contra indicated with
•Mitral stenosis
•Aortic stenosis
•Fallots tetralogy
•Eisenmengers syndrome
2. Third stage of labour in a case of
heart disease should be managed by
•Ergometrine
•Oxytocin
•Misoprostol
•Carboprost
Third stage of labour in a case of
heart disease should be managed by
•Ergometrine
•Oxytocin
•Misoprostol
•Carboprost
3. In pregnancy with heart disease
risk of cardiac failure increases at
•10-12 weeks
•20-22 weeks
•30-32 weeks
•40-42 weeks
3. In pregnancy with heart disease
risk of cardiac failure increases at
•10-12 weeks
•20-22 weeks
•30-32 weeks
•40-42 weeks
4. A pregnant women suffering from
heart disease gets breathless on doing
minimal activity but is comfortable at
rest. Her cardiac function status is
•NYHA Class 1
•NYHA Class 2
•NYHA Class3
•NYHA Class 4
4. A pregnant women suffering from
heart disease gets breathless on doing
minimal activity but is comfortable at
rest. Her cardiac function status is
•NYHA Class 1
•NYHA Class 2
•NYHA Class3
•NYHA Class 4
5. Which of the following contraceptive is
contraindicated in a woman with heart
disease?
• OCP
• POP
• Lng IUS
• Diaphragm
5. Which of the following contraceptive is
contraindicated in a woman with heart
disease?
• OCP
• POP
• Lng IUS
• Diaphragm
6. A 24 year old pregnant Gr2 P1 woman, having
prosthetic valve was being given warfarin. She
should be switched to heparin at
a) 32 weeks
b) 36 weeks
c) 40 weeks
d) at onset of labour
6. A 24 year old pregnant Gr2 P1 woman, having
prosthetic valve was being given warfarin. She
should be switched to heparin at
a) 32 weeks
b) 36 weeks
c) 40 weeks
d) at onset of labour
7. A pregnant woman suffering from mitral
stenosis is breathless even when lying down.
Her NYHA cardiac function status is
a) class 1
b) class 2
c) class 3
d ) class 4
7. A pregnant woman suffering from mitral
stenosis is breathless even when lying down.
Her NYHA cardiac function status is
a) class 1
b) class 2
c) class 3
d ) class 4