CARDIAC DISEASE IN PREGNANCY

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Slide 1 : CARDIAC DISEASE IN PREGNANCY DR. SAMEER AMBAR MD,DM Assistant Prof of Cardiology JNMC and KLES Dr. Prabhakar Kore Hospital & MRC, Belgaum drsameerambar@rediffmail.com
Slide 2 : PREGNANCY AND HEART DISEASE Cardiac disease affects 1-2% of all pregnancies. One of the leading causes of maternal mortality and morbidity Higher incidence of fetal and neonatal adverse events
Slide 3 : PREGNANCY AND HEART DISEASE Rheumatic heart disease is the most common heart disease complicating pregnancy in our country Congenital heart disease is encountered as advances in medical and surgical treatment have resulted in improved survival. CAD is expected to grow because of advanced maternal age and higher incidence of risk factors
Slide 4 : PHYSIOLOGICAL CHANGES IN PREGNANCY Cardiac output 30-50% Stroke volume 40% . Heart rate 10-20bpm . Systemic Peripheral resistance 30% Decrease in both systolic (3-5mmHg) &diastolic blood pressure (5-10mmHg) .
Slide 5 : Abrupt hemodynamic changes occur secondary to pain anxiety and uterine contractions With each uterine contraction extrusion of approximately 500ml of blood into central venous system CVS Physiology Periods of greatest risk of cardiac events 24-28 wks Early 3rd trimester Delivery Immediate postpartum
Slide 6 : CVS Physiology in Labour Rapid increase in HR and BP Cardiac output is often 50% above baseline during 2nd stage, may be even higher at the time of delivery After delivery, abrupt increase in venous return (due to autotranfusion and release of IVC compression)
Slide 7 : CVS Physiology in Labour Excessive blood loss in normal vaginal delivery / C-section can alter cardiac status Cardiovascular adaptations associated with pregnancy regress by approx. 6wks after delivery
Slide 8 : Decreased exercise capacity Tiredness Dyspnoea Palpitations Lightheadedness Presyncope Symptoms during normal pregnancy that may mimic cardiac disease
Slide 9 : Physical signs Cardiomegaly Palpable RV & PA impulse Loud S1 Exaggerated splitting of S2 Midsystolic ejection murmur at LSB Continuous murmurs ( mammary soufflé, cervical venous hum)
Slide 10 : ECG Leftward shift of QRS Axis ST - T changes Sinus tachycardia ECHO DOPPLER-Cornerstone of evaluation ­LV / RV dimensions ­LA / RA size Small pericardial effusion Functional TR / PR / MR/ AR Investigations
Slide 11 : When to suspect heart disease ? Previous history Orthopnea and PND Excessive fatigue Palpitations with sweating/syncope Chest pain
Slide 12 : When to suspect heart disease - Signs Low volume pulse Tachycardia, Irregular pulse - Atrial fibrillation Unequal pulse Signs of cardiac failure – Raised JVP, hepatomegaly, pedal edema Systolic murmurs with Thrill Diastolic murmurs
Slide 13 : Management Pre-conceptional counselling, Risk stratification Antepartum management Peripartum management
Slide 14 : Pre-conceptional counselling Obstetrician and cardiologist should work together Prevent an unwanted pregnancy and asses the risks associated with pregnancy Continuation OR Termination
Slide 15 : CHD in offspring of a parent with CHD CHD in a Parent Risk of CHD in Offspring(%) IC shunts- ASD 3 - 11 VSD 4 - 22 PDA 4 - 11 Obstruction to flow Lt sided 3 - 26 Rt sided 4 - 15 HCM 50 (AD) Marfan’s syndrome 50 (AD) Risk is 4% Vs 0.4 - 0.6% in general population
Slide 16 : Maternal mortality risk and cardiac disease Group Cardiac disease Associated mortality risk I Mitral /aortic stenosis, NYHA Class I, II Atrial septal defect* <1% Aortic/Mitral regurgitation Pulmonary/tricuspid valve disease Corrected tetralogy of Fallot Bioprosthetic valve Small –moderate VSD/PDA II Uncorrected tetralogy of Fallot 5% - 15% Marfan’s syndrome with normal aorta Mechanical prosthetic valve Severe Mitral stenosis with AF or NYHA Class III, IV Severe Aortic stenosis Previous myocardial infarction III Pulmonary hypertension—primary or secondary 25% - 50% Coarctation of aorta with valvular involvement Marfan’s syndrome with aortic involvement Peripartum cardiomyopathy
Slide 17 : Maternal Risk Stenotic lesions on the left side are not well tolerated as cardiac output is markedly reduced. Regurgitant lesions are well tolerated Congenital heart disease with L-R shunts are well tolerated due to fall in SVR R-L lesions and cyanotic lesions not tolerated Pulmonary HT carries high risk
Slide 18 : Risk Index Preconception history of adverse cardiac events Poor functional class before pregnancy(NYHA class >II) Left heart obstruction -MVOA < 1 sqcm AVA <1.5sqcm Peak LVOT grd >30mmHg LV EF <40% Estimated risk of adverse cardiac event 0 ------- 5% 1 ------- 27% >1 ------- 75% Multicentric Canadian Study . Circulation104;155,2001
Slide 19 : First Visit Detailed history The patient’s functional status as per New York Heart Association(NYHA) Cardiology consultation ECG , ECHO
Slide 20 : 5/18/2011 20 NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE CLASS I No functional limitation of activity. No symptoms of cardiac decompensation with activity. CLASS II Patients are asymptomatic at rest. Ordinary physical activity results in symptoms. CLASS III Limitation of most physical activity. Asymptomatic at rest Minimal physical activity results in symptoms. CLASS IV Severe limitation of physical activity results in symptoms. Patients may be symptomatic at rest/heart failure at any point of pregnancy.
Slide 21 : ASSESSMENT OF PREGNANT PATIENTS
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