Cardiovascular disease In pregnancy

Июль 26, 2022

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Cardiovascular disease In pregnancy

Содержание

2. Cardiac Diseases Rheumatic heart disease Congenital heart disease Hypertensive heart disease Coronary Thyroid Syphilitic Kyphoscoliotic cardiac
3. Physiological Consideration with Heart Disease In Pregnancy The most important changes in cardiac function occurs in
4. cont… Later in pregnancy COP is higher when women is in the lateral recumbent position than
5. cont… Heart: The heart is displaced upward and to the left with lateral rotation on its
6. conti…. Systolic murmur is heard in 90 % of cases Soft diastolic murmur transiently in 20
7. Diagnosis of Heart Disease Some clinical indicators of heart disease during Pregnancy Symptoms: Progressive dyspnea or
8. Clinical findings Cyanosis Clubbing of fingers persistent neck vein distension Systolic murmur grade 3/6 or greater
9. Diagnostic studies Electrocardiography An average 15 – degree left – axis deviation in the ECG ,
10. Echocardiography: Normal changes include : Tricuspid regurgitation , Significantly increase left atrial size and left ventricular
11. Clinical clssification The New York Heart Association’s Functional Classification [ NYHA] “ First published in 1928
12. Preconceptional counseling Maternal mortality generally varies directly with functional classification at pregnancy onset; However this relationship
13. cont… Life threatening cardiac abnormalities can be reversed by corrective surgery and subsequent pregnancy is less
14. Risks for Maternal Mortality Caused by Various Heart Disease Cardiac Disorder Mortality % Group 1 –
15. Group 2 – Moderate Risk 5 -15 % 2A : Mitral stenosis , NYHA classes 3
16. Group 3 – Major Risk 25 -50 % Pulmonary hypertension Aortic coarctation with valvar involvement Marfan
17. Management In assuring an optimal outcome , management should be a team approach involving ;obstetrician, cardiologist
18. Management Four concepts that affect management are emphasized by the American College of Obs /Gyn :-
19. Management of Class 1 & 2 General measures: _ avoid contact with persons who have respiratory
20. management cont….. sign’s of heart failure: » persistent basilar rales » nocturnal cough » a sudden
21. Management cont….. Labor and Delivery : * vaginal delivery is preferred unless there is obstetrical indication
22. * fluid balance and antibiotic prophylactic * semi recumbent position with lateral tilt * intensive medical
23. puerperium * avoid complication of pph, anemia, infection and thromboembolism * delay the procedure of tubal
24. Management of class 3&4 ؟ whether pregnancy should be undertaken ؟ consider pregnancy interruption ؟ prolonged
25. Most common lesions: _Rheumatic heart disease Incidence of rheumatic fever is decreasing in developed countries ,
26. Peripartum cardiomyopathy : this is a diagnosis of exclusion , it describe women with peripartum heart
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Слайд 2

Cardiac Diseases
Rheumatic heart disease
Congenital heart disease
Hypertensive heart disease
Coronary
Thyroid
Syphilitic
Kyphoscoliotic cardiac disease
Idiopathic

cardiomyopathy
Corpulmonale
Constrictive pericarditis
Heart block
Isolated myocarditis

Слайд 3

Physiological Consideration with Heart Disease In Pregnancy
The most important changes

in cardiac function occurs in the first 8 weeks of pregnancy with maximum changes at 28 weeks
↓ Vascular resistance
↓ Blood pressure
↑ Heart rate ↑ Stroke volume ↑ COP
↑ Blood volume 30% - 50%
Maternal weight and basal metabolic rate also affect COP

Слайд 4

cont…
Later in pregnancy COP is higher when women is

in the lateral recumbent position than when she is in the supine
During labor COP increase moderately in the first stage of labor and appreciably greater in the second stage
COP also increase in the immediate post partum period

Слайд 5

cont…
Heart:
The heart is displaced upward and to the

left with lateral rotation on its long axis
Resting pulse increase by about 10 bpm
There is some changes in the cardiac sounds include:
An exaggerated splitting of the first heart sound with increase loudness of both components, no definite changes in the aortic and pulmonary elements of the second sound, and aloud easily heard third sound

Слайд 6

conti….
Systolic murmur is heard in 90 % of cases

Soft diastolic murmur transiently in 20 %
Continuous murmur arising from the breast vasculature in10 % of cases

Слайд 7

Diagnosis of Heart Disease
Some clinical indicators of heart disease during
Pregnancy

Symptoms:
Progressive dyspnea or orthopnea
Nocturnal cough
Hemoptysis
Syncope
Chest pain

Слайд 8

Clinical findings
Cyanosis
Clubbing of fingers
persistent neck vein

distension
Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent arrhythmia
Persistent split-second sound
Criteria for pulmonary hypertension

Слайд 9

Diagnostic studies
Electrocardiography
An average 15 – degree left – axis deviation

in the
ECG , and mild ST changes may be seen in the
inferior leads, Atrial and ventricular premature
contractions are relatively frequent
Chest x – ray:
Heart silhouette normally is larger in pregnancy,
however gross cardiomegaly can be excluded

Слайд 10

Echocardiography:
Normal changes include : Tricuspid regurgitation ,
Significantly increase left

atrial size and left
ventricular outflow cross sectional area.

Слайд 11

Clinical clssification
The New York Heart Association’s Functional
Classification [ NYHA]

“ First published in 1928 “
Class 1 : Uncompromised , no limitation of physical
activity
Class 2 : Slightly compromised , slight limitation of
physical activity
Class 3 : Markedly compromised , marked limitation
of physical activity
Class 4 : Severely compromised , inability to perform
any physical activity without discomfort

Слайд 12

Preconceptional counseling
Maternal mortality generally varies directly with
functional classification at

pregnancy onset;
However this relationship may change as pregnancy
progresses
Patient with pulmonary hypertension, primary or
secondary are in danger of undergoing decompensation
during pregnancy

Слайд 13

cont…
Life threatening cardiac abnormalities can be reversed
by

corrective surgery and subsequent pregnancy is
less dangerous
In other cases fetal consideration predominate, for
example the teratogenic effect of warfarin

Слайд 14

Risks for Maternal Mortality Caused by Various Heart Disease
Cardiac Disorder

Mortality %
Group 1 – Minimal Risk
Atrial septal defect 0 -1 %
Ventricular septal defect
Patent ductus arteriosus
Pulmonic or tricuspid disease
Fallot tetralogy,corrected
Bioprosthetic valve
Mitral stenosis,NYHA classes 1&2

Слайд 15

Group 2 – Moderate Risk 5 -15 %
2A :
Mitral

stenosis , NYHA classes 3 & 4
Aortic stenosis
Aortic coarctation without valvar involvement
Fallot tetralogy , uncorrected
Previous myocardial infarction
Marfan syndrome , normal aorta
2B :
Mitral stenosis with atrial fibrillation
Artificial valve

Слайд 16

Group 3 – Major Risk 25 -50 %
Pulmonary hypertension

Aortic coarctation with valvar involvement
Marfan syndrome with aortic involvement
NYHA = New York Heart Association.
From the American College of Obstetrics and Gynecologists
(1992a ) , with permission .

Слайд 17

Management
In assuring an optimal outcome , management should

be a team approach involving ;obstetrician, cardiologist
and anesthesiologist
Risk to patient of : Heart failure, subacute bacterial
endocarditis, and thromboembolic disease will be
identified and minimized

Слайд 18

Management
Four concepts that affect management are emphasized
by the American

College of Obs /Gyn :-
1) the 50% increase in blood volume and COP by the
early 3rd trimester
2) further fluctuation in volume and COP in the
peripartum period
3) a decline in systemic vascular resistance, reaching
a nadir in the 2nd trimester, and then rising to 20%
below normal by late pregnancy
4) hyprcoagulability of special importance in women
requiring anticoagulation in the non pregnant state

Слайд 19

Management of Class 1 & 2
General measures:
_ avoid contact with

persons who have respiratory
infection
_ pneumococcal and influenza vaccines are recommended
( patient with valvar heart disease)
_ cigarette smoking is prohibited
_ diet , avoidance of strenuous activity and avoidance of
anemia

Слайд 20

management cont…..
sign’s of heart failure:
» persistent basilar rales

» nocturnal cough
» a sudden diminution in ability to carry
out usual duties
» increasing dyspnea on exertion
» attacks of smothering with cough
» hemoptysis, progressive edema and
tachycardia

Слайд 21

Management cont…..
Labor and Delivery :
* vaginal delivery is preferred

unless there is obstetrical
indication
* relief of pain with intravenous analgesics ,
continuous epidural analgesia is recommended for
most situation , but it’s contraindicated in patient with:
[ Intracardiac shunt , pulmonary hypertension , Aortic stenosis ] ,
to avoid the risk of maternal hypotension

Слайд 22

* fluid balance and antibiotic prophylactic
* semi recumbent position

with lateral tilt
* intensive medical management for any sign’s of
impending ventricular failure
[ pulse > 100 , RR > 24 , dyspnea ]
* expedite vaginal delivery
* close monitoring for the 3rd stage of labor

Слайд 23

puerperium
* avoid complication of pph, anemia, infection
and

thromboembolism
* delay the procedure of tubal sterilization until
it is obvious that the mother is a febrile, not
anemic and can ambulate without evidence
of distress
* option of contraceptive advise

Слайд 24

Management of class 3&4
؟ whether pregnancy should be undertaken
؟

consider pregnancy interruption
؟ prolonged hospitalization or bed rest
؟ vaginal delivery is preferred
؟ caesarian section delivery should be with the availability of experience anesthetic support in a facility with
experience with complicated cardiac disease

Слайд 25

Most common lesions:
_Rheumatic heart disease
Incidence of rheumatic fever

is decreasing in developed
countries , It still remain the chief cause of serious mitral
valve disease in women,(3/4thof cases of mitral stenosis)
_Congenital Heart Disease:
many congenital heart lesions appear to be inherited as
polygenic characteristic , 10% of women with congenital
heart disease would give birth to similarly affected infants ,
50 % were concordant for the same anomaly

Слайд 26

Peripartum cardiomyopathy :
this is a diagnosis of exclusion , it

describe women
with peripartum heart failure with no apparent etiology,
symptoms of cardiac decompensation appear during
the last weeks of pregnancy or 1 to 6 months postpartum
obstetrical complications such as : preeclampsia, anemia
from blood loss , and infection either contribute or
precipitate heart failure

Cardiovascular disease In pregnancy

Содержание

Cardiac DiseasesRheumatic heart diseaseCongenital heart diseaseHypertensive heart diseaseCoronaryThyroid SyphiliticKyphoscoliotic cardiac diseaseIdiopathic

Physiological Consideration with Heart Disease In Pregnancy The most important changes

cont… Later in pregnancy COP is higher when women is

cont… Heart: The heart is displaced upward and to the

conti…. Systolic murmur is heard in 90 % of cases

Diagnosis of Heart DiseaseSome clinical indicators of heart disease during Pregnancy

Clinical findings Cyanosis Clubbing of fingers persistent neck vein

Diagnostic studiesElectrocardiography An average 15 – degree left – axis deviation

Echocardiography: Normal changes include : Tricuspid regurgitation , Significantly increase left

Clinical clssification The New York Heart Association’s Functional Classification [ NYHA]

Preconceptional counseling Maternal mortality generally varies directly with functional classification at

cont… Life threatening cardiac abnormalities can be reversed by

Risks for Maternal Mortality Caused by Various Heart Disease Cardiac Disorder

Group 2 – Moderate Risk 5 -15 % 2A : Mitral

Group 3 – Major Risk 25 -50 % Pulmonary hypertension

Management In assuring an optimal outcome , management should

Management Four concepts that affect management are emphasized by the American

Management of Class 1 & 2General measures: _ avoid contact with

management cont….. sign’s of heart failure: » persistent basilar rales

Management cont….. Labor and Delivery : * vaginal delivery is preferred

* fluid balance and antibiotic prophylactic * semi recumbent position

puerperium * avoid complication of pph, anemia, infection and

Management of class 3&4 ؟ whether pregnancy should be undertaken ؟

Most common lesions: _Rheumatic heart disease Incidence of rheumatic fever

Peripartum cardiomyopathy : this is a diagnosis of exclusion , it

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