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Heart Failure in Pregnancy

Heart Failure in Pregnancy. Council on Women’s Health Philippine Heart Association. Introduction. About 2% of pregnancies involve maternal cardiovascular disease Increased risk to both mother and fetus

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Heart Failure in Pregnancy

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  1. Heart Failure in Pregnancy Council on Women’s Health Philippine Heart Association

  2. Introduction • About 2% of pregnancies involve maternal cardiovascular disease • Increased risk to both mother and fetus • Cardiac disease may sometimes be manifested for the 1st time in pregnancy because of the hemodynamic changes • Signs and symptoms of a normal pregnancy may mimic the presence of cardiac disease

  3. Case Presentation • AB a 22 year old married, bank teller • Visited for the first time an obstetrician • 5 months PTC she had a positive pregnancy test • Felt perfectly well prior to consult • Few days ago started to have shortness of breath on climbing 2 flights of stairs, easy fatigability on walking 2 blocks and had palpitations

  4. Pertinent PE • BP- 100/60 CR- 89/min RR- 21 cycles/min • Heart-AB at 5th ICS LMCL, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex • Referred by the obstetrician to a cardiologist

  5. Questions • Does AB have heart disease? • Is she experiencing heart failure symptoms? • What are the hemodynamic changes occurring in her? • What are the differential diagnoses? • How should you go about managing her? Medical? Surgical? Timing? • Can she tolerate the pregnancy? • What is the safest mode of delivery?

  6. Question: • Does AB have heart disease?

  7. Question: • Is she experiencing heart failure symptoms?

  8. Pregnancy Clinical features mimicking heart disease: • Dyspnea- due to hyperventilation, elevated diaphragm • Pedal edema • Cardiac impulse diffuse and shifted laterally from elevated diaphragm • Jugular veins may be distended and JVP raised • Systolic ejection murmurs in LPSB in 96% of pregnant women

  9. Question: How should we go about evaluating AB? • Evaluation of Heart Failure in Pregnancy 1. Detailed Hx and PE to determine FC 2. 12 lead ECG 3. Chest Xray- Optional 4. 2D Echo Doppler 5. Plasma B Type natriuretic peptide 6. Blood works-CBC,electrolytes, renal and thyroid function 7. TEE (seldom) 8. Fetal echocardiography

  10. Differential Diagnoses of Heart Failure in Pregnancy • Pneumonia • Pulmonary embolism • Amniotic fluid embolism • Renal failure with volume overload • Acute lung injury

  11. High risk pregnancies • Pulmonary hypertension • Dilated cardiomyopathy, EF≤40% • Symptomatic obstructive lesions -AS,MS,PS,CoA • Marfan syndrome with aortic root ≥40mm • Cyanotic lesions • Mechanical prosthetic valves

  12. Question: • What is the risk of AB? Can she tolerate her pregnancy? • Risk Scores 0 - 5% risk (low) 1 - 27% risk (interm) >1 - 75% (high) • Cardiac Diseases in Pregnancy Risk Score 1. A prior cardiac event ( arrhythmia,stroke,TIA,HF) 2.Baseline NYHA FC≥II or cyanosis(saturation≤ 90% 3. Systemic ventricular systolic dysfunction 4. Left heart obstruction - MVA ≤ 2 cm - aortic valve area≤ 1.5 cm - peak flow gradient ≥ 30mm Hg

  13. Management • Medical • NYHA Class I or II -Limit strenuous exercise -Provide adequate rest -Supplemental iron and vitamins -Low salt diet -Regular cardiac and obstetric evaluation • NYHA III and IV -May need hospitalization for close monitoring

  14. Management • Percutaneous valvotomy? • Timing?

  15. Management • Surgical • Cardiac surgery seldom necessary and should be avoided if possible • Higher risk of fetal malformations and loss • May induce premature labor • Optimal time- 20-28 wk gestation • Extracorporeal circulation- normothermic • Higher pump flow rate, higher pressure with a mean of 60 mmHg • Advise short bypass time

  16. Management • Anticoagulation? • Warfarin • Unfractionated Heparin • Low Molecular Weight Heparin

  17. What is Warfarin Embryopathy? • Used in 1st trimester- teratogenic in 15-25% of cases 1. nasal cartilage hypoplasia 2. stippling of bones 3. IUGR 4. brachydactyl

  18. SBE Prophylaxis? • Antibiotic – a) 2 gm ampicillin IV plus 1.5 mg/Kg gentamicin IV prior to procedure, followed by one more dose of ampicillin 8 hours later • If with allergy from ampicillin, 1 gm vancomycin may be used.

  19. What is the Safest Mode of Delivery? • Vaginal delivery is feasible and preferable • CS is for an obstetric indication • Exception are anticoagulated patients • CS may be indicated in 1. Marfan syndrome, 2. severe pulmonary HPN 3. severe obstructive lesions eg AS

  20. Physiologic Changes during Labor and Puerperium • First stage- Cardiac output increased by 15%. Each uterine contraction releases 500 ml of blood leading to increases in CO and BP, later reflex bradycardia. • Second stage- Increase in intra-abdominal pressure(valsalva) causes decrease in venous return and CO • Third stage- Blood loss during delivery. Vaginal- 400 ml CS- 800 ml - these lead to reduced blood volume and CO

  21. Hemodynamic Changes after Delivery • Abrupt increase in venous return because of autotransfusion from the uterus. Baby no longer compress the uterus. • Autotransfusion of blood continues 24-72 hrs after delivery. Pulmonary edema may occur.

  22. Thank You Thank you

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