Lectures 7, 8 Petrenko N.V., MD, PhD

Lectures 7, 8Petrenko N.V., MD, PhD Medical-SurgicalProblems in Pregnancy

CARDIOVASCULAR DISORDERS about 1% of pregnancies complicated by heart diseases leading cause of maternal mortality Mortality rate 50% in case pulmonary hypertension

Physiologic adaptation to pregnancy Cardiac hypertrophy • Increase blood volume on 40-50 % • Increase cardiac output 30-50% • Decreased systemic vascular resistance • The heart elevated upward and rotated forward to the left • Pulse increase about 10-15 beat/min after 14-20 weeks, palpitation • Disturbed rhythm: sinus arrhythmia, premature atrial contractions, premature ventricalar systole • BP: • I trim as prepregnancy level • II trim decrease 10-15 mm hHg • After 20 weeks turn to prepregnancy level • Increase clot factors (VII, VIII, IX, X, fibrinogen) • Cardiac output changes during labor and birth • Intravascular volume changes just after childbirth

Physiologic adaptation to pregnancy • If cardiac changes are not well tolerated cardiac failure can develop during pregnancy, labour, postpartum • If myocardial disease develops, valvular disease exists or congenital heart defect is present, cardial decompensation is anticipated

Pregnancy result in case of Cardiovascular Disorders • miscarriages • Preterm labor and birth • IUGR • Congenital heart lesions (4-16%) • Maternal mortality

Maternal cardiac disease risk group • Group I (mortality rate 1%) • Corrected tetralogy Fallot • Pulmonic/tricuspid disease • Mitral stenosis (classes I, II) • Patern ductus arteriosus • Ventricular septal defect • Atrial septal defect • Group II (mortality rate 5-15%) • Mitral stenosis with atrial fibrillation • Uncorrected tetralogy Fallot • Aortic coarctation (uncomplicated) • Marfan syndrome with normal aorta • Group III (mortality rate 20-50%) • Aortic coarctation (complicated) • Myocardial infarction • Marfan syndrome with aortic involvement • Pulmonary hypertension

Functional classification of organic heart disease(New York Heart Association, NYHA) • Class I: Asymptomatic at normal levels of activity • Class II: Symptomatic at increased activity • Class III: Symptomatic with ordinary activity • Class IV: Symptomatic at rest • Determination • 3 month • 7 or 8 month

Contraindications to pregnancy • Pulmonary hypertension • Shunt lesions associated with Eisenmenger syndrome • Complex cyanotic congenital heart disease • Aortic coarctation complicated by artic dissection • Poor ventricular function • Marfan syndrome with marked aortic dilatation

Associated Cardiovascular Disorders • I Congenital cardiac disease • Septal defects • Atrial septal defect (ASD) • Ventricular septal defect (VSD) • Patent ductus arteriosus (PDA) • Acyanotic lesions • Coarctation of aorta • Cyanotic lesions • Tetralogy of Fallot

Associated Cardiovascular Disorders cont • II Acquired cardiac disease • Mitral valve stenosis • Aortic stenosis • Ischemic heart disease • Myocardial infarction (MI) • Other cardiac diseases • (PPCM) Pulmonary hypertension • Marfan syndrome • Infective endocarditis • Eisenmenger syndrome • Valve replacement • Peripartum cardiomyopathy

Associated Cardiovascular Disorders • Increased number of successfully completed pregnancies • Postpone conception 1 year after transplantation • Vaginal birth is desired, yet there is an increased rate of cesarean birth • Breastfeeding not advised when taking cyclosporine

Congenital Cardiac Disease Septal Defects

Arial septal defect • Left-to-right shunt • Undetected because woman is asymptomatic • Uncomplicated pregnancy • Right-side heart failure or arrhythmia as a result of increased blood volume

Ventricular septal defect • Left-to-right shunt • Diagnosed and corrected during infancy and childhood, not common in pregnancy • Not complicated pregnancy • Risk for: arrhythmias, heart failure, pulmonary hypertension • Management • Rest • decrease of physical activity • anticoagulants

Patent ductus arteriosus • Left-to-right shunt • Diagnosed and corrected during infancy • Possible complications • arrhythmias, • heart failure, • pulmonary hypertension • Endocarditis • Pulmonary emboli • Management • Rest • decrease of physical activity • anticoagulants

Congenital Heart Disease Acyanotic Lesions

Coarctation of the aorta • Pregnancy safe for mother with uncomplicated coarctation • Complications • Hypertension • Congestive heart failure • Aortic rupture • Management • Rest • Antihypertensive medications (beta-blockers) • Vaginal birth with epidural anesthesia and shortening of the II stage (vacuum- or forceps assisted) • Antibiotic prophylaxis

Congenital Heart Disease Cyanotic Lesions

Tetralogy of Fallot • 1. Ventricular septal defect. • 2. overriding aorta • 3. right ventricular hypertrophy • 4. pulmonary stenosis • Right-to-left shunt • Corrected at childhood • Management • Anticoagulant • Oxygen • hemodinamic monitoring

Acquired Heart Diseases

Mitral Stenosis • The pressure gradient across the narrow valve increases secondary to the increased heart rate and blood volume • Left atrial pressure increases, back pressure into the lungs causes breathlessness, swelling in thelegs and may lead to atrial arrhythmias. • Stretching of the atrium can also occur causing palpitations and arrhythmia.

Mitral Stenosis • Maternal mortality rate in classes III and IV • 5 %without arterial fibrillation • 15% with arterial fibrillation • There is marked increase in the following issues regarding the fetus • Rate of prematurity • Fetal growth retardation • Low neonatal birth weight

Mitral Stenosis • Therapeutic approach is: • to reduce the heart rate • and decrease left atrial pressure • Restrict physical activity • Restrict salt intake • diuretics • Beta blockers • Digoxin (if patient is in a. fib) • Calcium channel blockers • if medical therapy is ineffective surgery may be necessary after 20 weeks • Balloon valvuloplasty • Surgery (repair/replacement)

Mitral Stenosis • Vaginal delivery can be permitted in most patients • Hemodynamic monitoring is recommended (Swan) and should be continued several hours following delivery

Aortic Stenosis • AS lead to obstruction to left ventricular ejection • Mild AS is usually tolerated • Moderate to severe AS is likely to be associated with symptomatic deterioration during pregnancy • Women with valve area <1.0 should consider valve replacement prior to pregnancy

Aortic Stenosis • Symptoms often develop in the 2nd and 3rd trimester • Exertional dyspnea • Chest pain • Syncope • Fetal effects included • Intrauterine growth retardation • Premature delivery • Reduced birth weight • Increase in cardiac defects

Ischemic Heart Disease • MI is rare in childbearing woman • Risk factors increase • Age • Smoking • Stress • Cocaine use • Hyperbilirubinemia • DM • Family history of IHD • Hypertension • Oral contraceptives

Ischemic Heart Disease • Mangement • Oxygen • Aspirin • Beta-blockers • Nitrates • Heparin • Side-lying position • Vaginal birth is preferable with avoiding of maternal pushing (vacuum- or forceps-assisted) • Diuretic postpartum

Other Heart Diseases

Primary Pulmonary Hypertension • Constriction of the arteriolar vessels in the lung, leads to increase in the pulmonary artery pressure right ventricular hypertension, hypertrophy, dilatation, right ventricular failure with tricuspid regurgitation • Associated with high maternal mortality estimated to be 50%, half of them occurs a few hours to several days post partum usually related to sudden death or progressive RV failure, although the exact cause of death is not clear • Deterioration usually occurs in the second/third trimester

Primary Pulmonary Hypertension • Symptoms may include • Fatigue • Dyspnea • Chest pain • Edema and ascites • Syncope • Diagnostic test • Chest radiogram • ECG • EchoCG • Dopler studies

Primary Pulmonary Hypertension • Fetal effects include • High incidence of prematurity • Fetal growth retardation • Fetal loss • Pregnancy should be discouraged in all patients with primary pulmonary HTN

Primary Pulmonary Hypertension • For patients who chose to continue pregnancy • Nifedipin or prostacycline (for pulmonary vasodilatation) • Anticoagulant • Continuous hemodynamic monitoring during labor and delivery • Antiembolic strocking • Side-lying position • Oxygen therapy • Epidural analgesia

Marfan Syndrome • Autosomal dominant genetic disorder characterized • weakness of the connective tissue, • resulting in joint deformities, • ocular lens dislocation, • weakness of aortic wall and root • Mitral valve prolapse (90%) • Aortic insufficiency (25%) risk of aortic dissection and rupturing • Pregnancy in patients with Marfan poses 2 problems • Cardiovascular complications of the mother • Risk of having a child who inherits Marfan’s syndrome • Cardiovascular problems • Dilation of the ascending aorta, may lead to development of aortic regurgitation and heart failure • Proximal and distal dissections of the aorta with possible involvement of the coronaries

Marfan’s Syndrome • Obstetrical complications • Cervical incompetence • Abnormal placental location (previa) • Postpartum hemorrhage • Preconception counseling • Patients with more than mild dilation of the aorta, or history of aortic dissection should be advised against pregnancy • Progressive dilation of the aorta during gestation may occur even with a normal-sized aorta • Preconception echo evaluation allows for evaluation of the aortic root, CT, MRI. • Periodic echocardiographic follow-up is recommended

Marfan’s Syndrome • Management • Vigorous physical activity should be avoided • Beta blockers (reduces the rate of aortic dilation) • If substantial dilation/dissection should occur, depending on the stage of pregnancy • therapeutic abortion, • early delivery or • surgical intervention should be considered

Infective endocarditis • Inflammation of endocardium • Cause: microorganisms • Clinical manifestation: • incompetence of heart valves • Congestive heart failure • Cerebral emboli • Treatment • Antibiotics

Eisenmenger Syndrome • Right-to-left or bidirectional shunting at atrial or ventricular level and combined with elevated pulmonary vascular resistance • High risk of maternal (30-50%) and fetal (50%) morbidity and mortality • Pregnancy is contraindicated (contraception or termination of pregnancy) • Death usually (75%) occurs between the first few days and weeks after delivery, but the cause is unclear

Eisenmenger Syndrome • Patients should be monitored closely for any signs of deterioration • Early elective hospitalization is recommended • Activity is strictly limited • Hemodynamic monitoring is required • Anticoagulant??? • Prophylaxis of hypovolemia • Oxygen • Epidural analgesia

Hypertrophic Cardiomyopathy • Most cases have favorable outcomes • Symptoms may worsen, especially in patients who were already symptomatic • Increased SOB • Fatigue • Chest pain • Syncope • The risk of the fetus of inheriting the disease is as high as 50%

Valve replacement • Risk of thromboembolism • Anticoagulant??? • + hypercoagulability • - maternal, fetal hemorrhage • - risk of fetal abnomalities • Porcine heterograft valves • + do not require of anticoagulants • - premature valve failure • Heparin (beside coumadin) • Before conception or as soon as possible • 2-3 times a day, activated partial thromboplastin time 1.5-2.0 • Dicontinued at the time of active labour • Reactivate within 6 h of VB or 12-24 h after CS • Low-molecular weight heparin

Peripartum Cardiomyopathy • A form of dilated CMP with LV systolic dysfunction that results in the signs and symptoms of heart failure • Criteria • Development in last month of pregnancy or the first 5 months after delivery • Absence of heart disease prior to last month of pregnancy • Absence of identifiable cause of heart failure • LV systolic dysfunction • Etiology is unknown • Theories • Genetic predisposition • Autoimmunity • Viral infection

Peripartum Cardiomyopathy • Associated risk factors: • Age - over 35 • twin pregnancy • gestational hypertension • Multiparity • African-american race • use of tocolytic therapy • Motality rate 25-50%

Peripartum Cardiomyopathy • Clinical findings • Left ventricular failure • Dyspnea • Fatigue • Edema • Enlarged heart • S3, murmurs of MR and TR • Tachycardia • ST-T wave abnormalities • arrhythmias

Peripartum Cardiomyopathy • clinical course varies • 50-60% of patients demonstrate complete recovery within the first 6 months • The rest of the patients demonstrate either further clinical deterioration, leading to cardiac transplant or premature death, or persistent LV dysfunction and chronic heart failure • No agreement on recommendation for future pregnancies • Pregnancy contraindicated • Persistent cardiomegaly • Cardiac dysfunction

Peripartum Cardiomyopathy • Management • Acute heart failure treatment with O2, diuretics, digoxin and vasodilators (hydralazine is safe) • Because of the increased incidence of thromboembolic events, anticoagulation therapy is recommended

Care management • Preconceptual councelling • Peripartum risk • Pregnancy • Decisions after evaluation risk • If possible – multidisciplinary approch (cardiologist, perinsatologist, anesthesiologist, ginecologist)

Assessment • Interview • Personal medical history • Heart disease (congenital, streptococcal infections, rheumatic fever, valvular disease, endocarditis, angina, MI) • Factors increase stress of the heart (anemia, infection, edema) • Review cardiovascular and pulmonary system • Chest pain, edema on face, hand, feet, hypertension, heart murmur, palpitation,dyspnea, diaphoesis, pallor, syncope • Cough, hemoptysis, shortness of breath, • Medication • Emotional status (depression, anxiety, fear of morbidity and mortality for herself and featus)

Assessment • Examination • Vital sign • Oxygen saturation level • Pattern of edema • Discomphort of pregnancy • Weight gain • Sign of potential cardiac decompensation

Sign of potential cardiac decompensation • Subjective symptoms • Increasing fatigue or difficulty of breathing or both with usual activities • Feeling of smothering • Frequent cough • Palpitations; feeling that her heart is racing • Swelling of face, feet, legs, fingers • Objective signs • Irregular weak, rapid pulse (more 100b/m) • Progressive generalised edema • Cracles at the base of lungsafter 2 inspirations and exhalations • Orthopnea; increasing dyspnea • Rapid respirations (more 25 b/m) • Moist, frequent cough • Increasing fatique • Cyanosis of lips and nail beds

Lectures 7, 8 Petrenko N.V., MD, PhD