2. • 0.4-5.0% of pregnant women
• Commonest non-obstetric cause of maternal
mortality in Malaysia – 10% of all maternal
deaths in 1996
• Most common disorders : rheumatic valve
disease, congenital heart disease,
cardiomyopathy
6. Blood volume
• Increases as pregnancy progresses, peaking
at 40-50% above non-pregnant level
between 32nd and 36th week, plateaus until
term.
• Clinical importance: physiological anaemia.
(RBC mass increases by only 17-40%)
8. • Cardiac output increases by 30-50% above
the pre-pregnancy level and peaks around
end of 2nd TM (20th-24th week)
• Increase is due to increase in stroke volume
initially and then an increase in heart rate
by about 20%.
(CO = SV x HR)
9. Changes in CO, SV and HR in Pregnancy
↓BP due to ↓systemic vascular resistance
11. • Fall in systemic vascular resistance
• Fall in blood pressure especially in
midpregnancy
• Increase in pulmonary blood flow, reduce
pulmonary vascular resistance, unchanged
pulmonary artery pressure
• Supine hypotension syndrome in late
pregnancy
16. • Immediate postpartum – increase in venous
return due to relief of caval compression
and auto-transfusion from the contracting
uterus.
• Within hours – heart rate and cardiac output
starts to decrease
19. Management principles
• 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND
STRATIFICATION
OF MATERNAL
AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY
AND COMPLICATIONS OF HEART
DISEASE
20. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY
21. Pre-conceptual
counselling
• Target: Heart disease patients of
childbearing age and their
husband/family.
• Assessment: Maternal and fetal risks in
the event of pregnancy
22. Issues:
• - Effect of pregnancy on the heart
• - Effect of cardiac disorder on fetal
development
• - Effect of maternal drugs on fetus
• - risk of genetic transmission to fetus
• - need for compliance
23. • Patients with heart disease should be
encouraged to complete their family early and
discouraged from too many pregnancies
• High risk patients – advise for sterilization.
E.g. Pulmonary HPT, Eisenmenger’s
syndrome, Cyanotic heart disease, Poor left
ventricular function, Marfan’s syndrome
24. • Whenever possible, correct cardiac
lesions before pregnancy, e.g.
- Congenital defects
- Mitral stenosis – symptomatic or severe MS
with MV area <1.0 cm².
- Severe aortic stenosis (valve area <1.0
cm²), impaired exercise tolerance, reduced
left ventricular function.
25. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY
26. Detection of cardiac
disease in pregnancy
• History
• Physical examination
• Investigation
Note: Symptoms and signs of heart
disease and normal pregnancy may be
similar.
27. History
• Dyspnea
• Palpitations
• Estimation of effort tolerance (NYHA
Functional Classification)
• History of rheumatic fever, cardiac
surgery and hypertension
• Drug history
28. NYHA Functional Class
• NYHA 1
no limitation. Ordinary physical activity
does not cause undue fatigue, dyspnoea
or palpitation.
• NYHA 2
slight limitation of activity. Comfortable
at rest. Ordinary physical activity results
fatigue, dyspnoea or palpitation.
•
NYHA 3
marked limitation of physical activity.
Comfortable at rest but less than ordinary
activity will lead to symptoms.
• NYHA 4
symptoms of failure are present at rest. With
any physical activity, increased discomfort is
present.
in
29. Physical examination
• Clubbing, cyanosis, features of Marfan
Syndrome
• Pulse for arrhythmia
• BP
• JVP
• Precordial examination – murmurs, RV
hypertrophy, presence of loud second heart
sound (pulmonary hypertension)
30. Investigations
• ECG
• ECHO- sometimes this is the only
reliable method in determining whether
a cardiac murmur is significant/non
significant in a pregnant patient.
32. RISK CATEGORIZATION
–
–
–
–
–
–
–
–
NYHA functional class.
Presence of cyanosis
Left and right ventricular function
Severity of pulmonary hypertension
Presence of valve/conduit stenosis
Presence of conduction defects/arrhythmias
Smoking
Multiple gestation
33. • NYHA Functional class:
- The maternal prognosis is strongly
related to NYHA functional class prior to
pregnancy.
• Maternal mortality varies from <1% in
those with NYHA 1 or 2 to around 7% in
those with NYHA 3 or 4.
36. High maternal and fetal risks
– Pulmonary hypertension (pulmonary pressure
>75% systemic pressure)
– Eisenmenger syndrome
– Uncorrected Cyanotic heart disease
– Severe aortic stenosis
– Severe mitral stenosis
– Poor LVF(LVEF<40%) irrespective of etiology
– Marfan’s syndrome (aortic root diameter >40mm)
37. Additional fetal risks
• Impaired maternal functional class,
smoking and cyanosis are associated
with poor fetal outcomes.
38. Level of care
• HIGH RISK patients are ideally managed in
tertiary centre with a multidisciplinary team
approach.
• MODERATE RISK can be managed in
hospitals where specialists are available.
• LOW RISK can be managed in the clinic by
their primary care doctors.
39. Specialist referral
• Known heart disease or previous cardiac
surgery who have not been assessed or risk
categorised prior to pregnancy
• Moderate to high risk
• Worsening symptoms due to heart disease
• Suspected heart disease, to confirm or refute
diagnosis
40. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY
41. General principles of Mx
•
•
•
•
Assess maternal and fetal health.
Assess NYHA functional class.
Confirm clinical diagnosis.
Establish baseline hemodynamics
(LVEF, PAP by ECHO)
• Consider termination in high risk cases
42. • Identify factors that can precipitate
complications e.g. Anemia, infection,
hypertension - treat accordingly.
• Complications of heart disease should be
identified and treated.
–
–
–
–
Heart failure
Worsening left to right shunt
Thromboembolism
Arrhythmias
44. Valvular heart disease
• Mitral stenosis:
• -Mild to moderate (MV area >1 cm²)
tolerates pregnancy well with use of
diuretics and beta-blockers
• -Severe MS (MV area <1 cm² and/or
PHT) should be considered for mitral
vulvotomy during 2nd TM
45. • Mitral Regurgitation and Aortic Regurgitation –
generally well tolerated
• Mild to moderate Aortic stenosis – well tolerated
• Severe Aortic stenosis – if clinical deterioration is
evident – terminate pregnancy
• Pulmonary stenosis – rarely problematic
• Prosthetic heart valves –most tolerate pregnancy
well. Requires full anti-coagulation.
46. Congenital heart disease
• Risk of CHD to offspring is increased (3.416.1%)
• Low birth weight, prematurity and fetal
wastage increased in cyanotic mothers.
• Acyanotic CHD (ASD, VSD, PDA) – well
tolerated in pregnancy
• Cyanotic CHD – associated with Pulmonary
HPT.
47. Pulmonary Hypertension
• Present when the pulmonary artery systolic and
mean pressures are >30mmHg and >20mmHg.
• High maternal mortality – 40-50%, usually at the time
of delivery or early postpartum
• Mx:
- consider termination if early,
- anticoagulation, continuous O2 therapy, hydration if
near fetal viability
49. Anticoagulation agents
Warfarin
- excellent anticoagulation
- generally avoided in first trimester
(risk of embryopathy esp. in doses >5mg dly
- avoided after 37 weeks
(risk of fetal bleeding in labour)
Heparin
- does not cross placenta
- in first trimester and after 37 weeks
- prob. of thrombocytopenia and osteopenia
Low Molecular Weight Heparin (LMWH)
- advantages over unfractionated
heparin (UFH)
51. • 1. PRE-CONCEPTUAL CONSELLING
• 2. ASSESSMENT AND STRATIFICATION
OF MATERNAL AND FETAL RISKS
• 3. MANAGEMENT OF PREGNANCY AND
COMPLICATIONS OF HEART DISEASE
• 4. DETERMINING TIMING, MODE AND
PLACE OF DELIVERY
52. Labour & Delivery
• When, where, how – individualised
• Monitoring during labour and
postpartum
• Pain relief during labour
• Antibiotic prophylaxis
54. Pre-pregnancy
• All women with heart disease should be
counselled on maternal and fetal risks
should they become pregnant
• Wherever indicated, significant cardiac
lesions should be corrected prior to
pregnancy
55. During pregnancy
• Pregnant patients with heart disease
should be risk stratified
• Low risk – Managed by primary care
doctors
• Moderate risk – Hospital with
Specialists
• High risk – Tertiary care centre
56. • Complications should be looked for and
treated
• Patients requiring anticoagulants should
be counseled on the available options
57. Labour and delivery
• Moderate and high risk – Labour and delivery
best managed by multidisciplinary team
• Timing and mode of delivery should be
individualised
• Adequate analgesia during labour is
important
• Antibiotic prophylaxis during labour in patients
susceptible to endocarditis
58. CONCLUSION
• Cardiovascular diseases are major
maternal mortality and morbidity
causes of
• An understanding of the physiology of the
cardiovascular adaptation in pregnancy and its
pathophysiology in disease states is crucial to
efficient management of these diseases in
pregnancy
• The importance of prevention of
pregnancy
cannot be overemphasized
in certain cardiac
diseases