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Congenital heart disease

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Congenital heart disease

  2. 2. Cardiac Disease in Pregnancy: Congenital Heart Disease <ul><li>Increased CO and blood volume on already stressed hemodynamic system </li></ul>Lesions with volume overload Lesions with obstruction <ul><li>Atrial septal defect </li></ul><ul><li>Ventricular septal defect </li></ul><ul><li>Patent ductus arteriosus </li></ul><ul><li>Aortic stenosis </li></ul><ul><li>Coarctation of the aorta </li></ul><ul><li>Pulmonary stenosis </li></ul><ul><li>Tetrology of Fallot </li></ul>
  3. 3. Atrial Septal Defect <ul><li>It is the second common congenital heart disease after congenital aortic valve stenosis. Many are asymptomatic until adult age. </li></ul><ul><li>The defect results in slight to moderate left to right shunting of blood. The shunt is more marked if the septal defect is associated with mitral valve prolapse. Pulmonary hypertension is a rare sequela. A systolic murmur is heard on the left side of the sternum. It is tolerated during pregnancy. However, the defect is better being surgically corrected before pregnancy. Peripartum prophylaxis against SBE is required for all cases with atrial septal defect. </li></ul>
  4. 4. Source :Wikimedia Commons
  5. 5. Ultrasound picture of the heart, an echocardiogram. It depicts a atrial septal defect, of the ostium secundum type Source :Wikimedia Commons
  6. 6. Ventricular Septal Defect <ul><li>It results in left-to-right shunt. This can be significant if the defect is wider than the aortic orifice. </li></ul><ul><li>Arrhythmias are commonly associated. </li></ul><ul><li>A to-and-fro murmur is usually heard to the left of the sternum. </li></ul><ul><li>A marked shunt can result in pulmonary hypertension and reversal of the shunt, cyanosis or Eisenmenger syndrome. </li></ul>
  7. 7. Source :Wikimedia Commons Ventricular septal defect
  8. 8. Ventricular septal defect Source :Wikimedia Commons
  9. 9. VSD in Pregnancy <ul><li>Pregnancy is well tolerated in uncomplicated cases. </li></ul><ul><li>Advanced cases should be strongly advised against pregnancy, and induction of abortion should be advised if recognized. </li></ul><ul><li>The defect should be surgically corrected in children and if recognized before pregnancy, however antibiotic prophylaxis is recommended in the peripartum. </li></ul>
  10. 10. Patent Ductus Arteriosus <ul><li>This is a common defect in adults, and the main effect is a left-to-right shunt. In the patient with an uncorrected patent ductus, pregnancy is usually well tolerated. </li></ul><ul><li>However, with large shunt, pulmonary hypertension and reversal of the shunt occurs, which will markedly worsen the prognosis. </li></ul>
  11. 11. Source :Wikimedia Commons PDA
  12. 12. Cyanotic heart disease
  13. 13. Tetralogy of Fallot <ul><li>It is one of the most common forms of cyanotic heart disease in adults. </li></ul><ul><li>The primary cardiac defects are: </li></ul><ul><li>1- Intraventricular septal defect </li></ul><ul><li>2- Pulmonary valve or artery stenosis </li></ul><ul><li>3- Displaced aorta which overrides the ventricular defect </li></ul><ul><li>4- Right ventricular hypertrophy </li></ul>
  14. 14. Source :Wikimedia Commons
  15. 15. Digital clubbing with cyanotic nail beds in and tetralogy of Fallot Source :Wikimedia Commons
  16. 16. <ul><li>Pathophysiology: Right-to-left shunting secondary to the large ventricular septal defect and pulmonary artery stenosis, resulting in cyanosis. </li></ul><ul><li>Uncorrected tetralogy of Fallot imposes a significant risk to both mother and fetus. </li></ul><ul><li>disease complicated by severe maternal hypoxemia is likely to lead to miscarriage, preterm delivery, or fetal death. </li></ul><ul><li>There is a relationship between chronic hypoxemia, polycythemia, and pregnancy outcome. </li></ul>Tetralogy of Fallot
  17. 17. Tetralogy of Fallot <ul><li>Surgical correction improves maternal and fetal prognosis. </li></ul><ul><li>Vaginal delivery is preferred. </li></ul><ul><li>Pulmonary artery catheter monitoring has limitations because of the sometimes bizarre anatomical abnormalities. </li></ul><ul><li>For labor pain, epidural opiates may suffice. There is controversy regarding epidural analgesia versus general anesthesia for cesarean delivery in these women </li></ul>
  18. 18. Eisenmenger Syndrome <ul><li>It consists of pulmonary hypertension and either right-to-left or bidirectional shunting through ASD, VSD or PDA. </li></ul><ul><li>It is usually a long-term secondary sequela to a congenital cardiac defect that results in left-to-right shunt. </li></ul><ul><li>The maternal and fetal prognoses are very bad. </li></ul><ul><li>It cannot be corrected surgically. </li></ul><ul><li>Termination of pregnancy at 1 st trimester. </li></ul><ul><li>Regional anesthesia should be avoided. </li></ul>
  19. 19. Clubbing secondary to pulmonary hypertension in a patient with Eisenmenger's syndrome Source :Wikimedia Commons
  20. 20. Coarctation of the Aorta <ul><li>It is uncommon in pregnancy </li></ul><ul><li>There is a stenotic ring at the level of the left subclavian artery and is recognized by hypertension in the right arm only. </li></ul><ul><li>The presenting symptoms may be chest pain or leg fatigue in severe cases. </li></ul><ul><li>Collateral blood flow may be recognized by palpable pulsations or audible bruits over the ribs or notching of the inferior surface of the ribs on chest X-ray. </li></ul>
  21. 21. Schetch showing heart with coarctation of the aorta Coarctation of the aorta Source :Wikimedia Commons
  22. 22. <ul><li>There is a risk of aortic dissection which may be caused by the hyperdynamic circulation of pregnancy, internal rupture or medial degeneration. </li></ul><ul><li>They may develop rupture of a cerebral aneurysm. </li></ul><ul><li>The coarctation is better surgically corrected before pregnancy. </li></ul><ul><li>Management in pregnancy is mainly: Control of hypertension and Preventing bacterial endocarditis. Regional anesthesia is better. </li></ul>Coarctation of the Aorta
  23. 23. PULMONARY HYPERTENSION <ul><li>A hemodynamic observation and not a diagnosis—is defined in nonpregnant individuals as a mean pulmonary pressure 25 mm Hg. </li></ul>
  24. 25. Diagnosis <ul><li>Symptoms  vague, and dyspnea with exertion is the most common. </li></ul><ul><li>With class II disorders, orthopnea and nocturnal dyspnea are usually also present. Angina and syncope. </li></ul><ul><li>CXR :enlarged pulmonary hilar arteries and attenuated peripheral markings. </li></ul><ul><li>Echocardiography and is confirmed by right-sided catheterization </li></ul>
  25. 26. Prognosis <ul><li>idiopathic pulmonary hypertension </li></ul><ul><li>has a 3-year survival rate of 60 percent, whereas for </li></ul><ul><li>collagen-vascular diseases, this rate is only 35 percent </li></ul><ul><li>(McLaughlin and colleagues, 2004). </li></ul>
  26. 27. Pulmonary Hypertension and Pregnancy <ul><li>Especially with idiopathic pulmonary hypertension. </li></ul><ul><li>class II being common—the prognosis is </li></ul><ul><li>much better. </li></ul><ul><li>Treatment of symptomatic pregnant women includes limitation </li></ul><ul><li>of activity and avoidance of the supine position in late pregnancy. Diuretics, supplemental oxygen, and vasodilator drugs </li></ul>
  28. 29. Mitral Valve Prolapse <ul><li>pathological connective tissue disorder—often termed myxomatous degeneration </li></ul><ul><li>Most asymptomatic and are diagnosed </li></ul><ul><li>by routine examination or while undergoing echocardiography </li></ul><ul><li>For women who are symptomatic, -blocking drugs are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias. </li></ul>
  29. 30. Peripartum Cardiomyopathy <ul><li>1. Development of cardiac failure in the last month of pregnancy or within 5 months after delivery </li></ul><ul><li>2. Absence of an identifiable cause for the cardiac failure </li></ul><ul><li>3. Absence of recognizable heart disease prior to the last month of pregnancy, and </li></ul><ul><li>4. Left ventricular systolic dysfunction demonstrated by classic echocardiographic criteria such as depressed shortening fraction or ejection fraction. </li></ul>In 1997, the National Heart, Lung, and Blood Institute and the Office of Rare Diseases convened a workshop that established the following diagnostic criteria (Pearson and associates, 2000): Persistence > 6 months postpartum carries a bad prognosis
  30. 31. Idiopathic Cardiomyopathy in Pregnancy <ul><li>signs and symptoms: CHF  Dyspnea ,orthopnea, cough, palpitations, and chest pain (Sheffield and Cunningham, 1999). </li></ul><ul><li>The hallmark finding usually is impressive cardiomegaly ( Fig. 44-3). </li></ul><ul><li>Echocardiographic : EF < 45 percent or a fractional shortening < 30 percent, or both, and an end-diastolic dimension greater than 2.7 cm/m2 (Hibbardand colleagues, 1999) </li></ul>
  31. 32. FIGURE 44-3 Cardiomyopathy with mild pulmonary edema. Anterior-posterior projection chest radiograph of a woman with an abnormally enlarged heart ( black arrows) and mild perihilar opacification consistent with dilated cardiomyopathy.
  32. 33. Management. Therapy consists of treatment for heart failure <ul><li>Diuretics are given to reduce preload, and afterload reduction is accomplished with hydralazine or another vasodilator. </li></ul><ul><li>Because of marked fetal effects angiotensinconverting enzyme inhibitors are withheld until the woman is delivered </li></ul><ul><li>Digoxin is given for its inotropic effects unless complex arrhythmias are identified. </li></ul>
  33. 34. Long-Term Prognosis There seems to be no doubt that women with peripartum cardiomyopathy who regain ventricular function within 6 months have a good prognosis (Lampert and associates, 1997).
  34. 35. Hypertrophic Cardiomyopathy <ul><li>Concentric left ventricular hypertrophy may be familial </li></ul><ul><li>Termed idiopathic hypertrophic subaortic stenosis. </li></ul><ul><li>Management is similar to that for aortic stenosis. </li></ul><ul><li>If symptoms develop, especially angina, -adrenergic or calcium-channel blocking drugs are given. The route of delivery is determined by obstetrical indications. </li></ul><ul><li>Spinal analgesia is contraindicated, and even carefully administered </li></ul><ul><li>epidural analgesia is controversial </li></ul>
  35. 36. Infective Endocarditis <ul><li>Diagnosis is made using the Duke criteria, which include positive blood cultures for typical organisms and evidence of endocardial involvement (Karchmer, 2005). </li></ul>
  36. 38. Obstetrical Procedures <ul><li>Only a few regimens are recommended by the American College of Obstetricians and Gynecologists (2008) for prophylaxis </li></ul><ul><li>30 to 60 minutes before the procedure </li></ul><ul><li>ampicillin, 2 g, </li></ul><ul><li>cefazolin or ceftriaxone, 1 g given intravenously. </li></ul><ul><li>For penicillin-sensitive patients </li></ul><ul><li>if there is a history of anaphylaxis - Clindamycin, 600 mg is given intravenously. </li></ul><ul><li>The recommended oral regimen is 2 g of amoxicillin. </li></ul><ul><li>If enterococcus infection is of concern, vancomycin is also given. </li></ul>
  37. 39. Arrhythmias <ul><li>Bradyarrhythmias </li></ul><ul><li>Tachyarrhythmias </li></ul><ul><li>Atrial flutter or fibrillation </li></ul><ul><li>Ventricular tachycardia** uncommon </li></ul><ul><li>QT-interval prolongation </li></ul>
  38. 40. Bradyarrhythmias <ul><li>including complete heart block, are compatible </li></ul><ul><li>with a successful pregnancy outcome. Some women </li></ul><ul><li>with complete heart block have syncope during labor and delivery, </li></ul><ul><li>and occasionally temporary cardiac pacing is necessary </li></ul>
  39. 42. Tachyarrhythmias <ul><li>Paroxysmal supraventricular tachycardia is encountered most frequently. </li></ul><ul><li>If vagal maneuvers do not stimulate conversion, treatment consists </li></ul><ul><li>of adenosine followed by calcium-channel or -blocking drugs </li></ul><ul><li>Electrical cardioversion is not contraindicated in pregnancy </li></ul>
  40. 44. Paroxysmal Supra Ventricular Tachycardia (PSVT) <ul><li>Symptoms include dizziness, syncope, chest discomfort, dyspnea and palpitations. </li></ul><ul><li>Unilateral carotid sinus massage for 10 seconds. The patient should lie supine with IV fluids running and by ECG, if there is no response, try massaging the opposite side (not simultaneously). </li></ul><ul><li>The patient may attempt a valsalva's maneuver during the carotid sinus massage. If this fails, the case is managed as with atrial fibrillation. </li></ul>
  41. 45. Atrial Fibrillation (AF) <ul><li>Investigation for the precipitating causes: </li></ul><ul><li>Myocardial ischemia </li></ul><ul><li>Congestive heart failure </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Fever </li></ul><ul><li>Hypovolemia </li></ul>
  42. 46. Atrial Fibrillation (AF) <ul><li>Anxiety </li></ul><ul><li>Hyper-thyroidism </li></ul><ul><li>Symphathomimetic </li></ul><ul><li>Aminophylline. Any underlying causes or a medical disorder mandates treatment. Consultation with a cardiologist is of great value. </li></ul>
  43. 47. Atrial Fibrillation: Treatment <ul><li>If the patient of AF is hemodynamically stable cardiac conversion is usually achieved by verapamil (e.g. Isopten) administered intravenously. </li></ul><ul><li>If hemodynamically compromised or pharmacological conversion is not achieved direct current (DC) cardioconversion can be resorted to. </li></ul><ul><li>Beta-blockers can be of help when the above measures are ineffective. </li></ul><ul><li>Anticoagulation is necessary if history of TED. </li></ul>
  44. 48. Atrial flutter or fibrillation <ul><li>more likely associated with underlying </li></ul><ul><li>disease, such as thyrotoxicosis or mitral stenosis. Major </li></ul><ul><li>complications include stroke </li></ul>
  45. 50. QT-interval prolongation <ul><li>predispose individuals to a potentially fatal ventricular arrhythmia known as torsades de pointes </li></ul><ul><li>-blocker therapy decrease the risk of torsades de pointes in patients with long QT syndrome </li></ul><ul><li>many medications, including some used during </li></ul><ul><li>pregnancy such as erythromycin and clarithromycin, may predisposeto QT prolongation </li></ul>
  46. 51. Marfan Syndrome <ul><li>This autosomal dominant disease of connective tissue can result in significant complications including dissection of the aorta and aortic rupture. </li></ul><ul><li>The defect is in fibrillin which is a constituent of elastin and is a general defect. However, aortic dilatation and dissecting aneurysm are the most serious complications and are more common during pregnancy. </li></ul>
  47. 52. Marfan ‘s Syndrome: A condition, due to a defect in fibrillin (an essential component of elastic fibers), in which myxomatous degeneration is common.
  48. 53. <ul><li>Women shoulf be counseled that there is a 50% risk of their offspring inheriting this disorder. Those who choose to get pregnant should be carefully evaluated by echocardiography. </li></ul><ul><li>Those with aortic diameters less than 40 mm have a small risk of aortic dissection. </li></ul><ul><li>They should continuously receive beta-blockers (to ↓ pulse pressure) and almost complete bed rest and careful monitoring. </li></ul>Marfan Syndrome
  49. 54. <ul><li>Those with aortic diameter > 40 mm are at high risk of aortic dissection and should be counseled to have first trimester termination or surgical repair of the aorta. </li></ul>Marfan Syndrome
  50. 55. Ischemic Heart Disease <ul><li>Coronary artery disease which may lead to myocardial infarction is a rare in pregnancy. </li></ul><ul><li>Patient may have the classical risk factors including familial history, smoking, obesity, familial dyslipidemia, hypertension, diabetes mellitus and thrombophilias (as antiphospholipid.) </li></ul><ul><li>Diagnosis:↑ serum levels of the cardiac-specific contractible protein, troponin </li></ul>
  51. 56. <ul><li>Pregnancy is usually inadvisable or should be delayed until coronary bypass. </li></ul><ul><li>Treatment is as that of non-pregnancy </li></ul><ul><li>Nitroglycerine and morphine are given </li></ul><ul><li>Lidocaine: for malignant arrhythmia become indicated. </li></ul>Ischemic Heart Disease
  52. 57. <ul><li>Calcium channel blockers or beta-blockers are given if indicated. </li></ul><ul><li>Tissue plasminogen activator can be given remote from delivery. </li></ul><ul><li>If the infarct has healed sufficiently, vaginal delivery can be allowed. </li></ul>Ischemic Heart Disease
  53. 58. <ul><li>In some women interventional cardiac catheterization may become indicated. Coronary bypass surgery during pregnancy causes high risks. </li></ul><ul><li>Echocardiography, radionuclide (thalium) studies and angiography. If there is no significant ventricular dysfunction, pregnancy will likely be tolerated. </li></ul>Ischemic Heart Disease