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Medical Disease in Pregnancy

Medical Disease in Pregnancy. Cardiovascular Disease. Cullen Archer, MD Department of Obstetrics and Gynecology. Physiologic change in Pregnancy. Cardiac output increases 30-35% during pregnancy HR rises steadily throughout pregnancy Although elevated in pregnancy, SV falls near term

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Medical Disease in Pregnancy

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  1. Medical Disease in Pregnancy Cardiovascular Disease Cullen Archer, MD Department of Obstetrics and Gynecology

  2. Physiologic change in Pregnancy • Cardiac output increases 30-35% during pregnancy • HR rises steadily throughout pregnancy • Although elevated in pregnancy, SV falls near term • Architecture of heart is remodeled to allow increased contractility

  3. Physiologic change in Pregnancy • Blood volume increases by 40% • Afterload is decreased by early vasodilation • Colloid osmotic pressure is decreased by 18% near term • Promotes Na/H2O retention • Increases plasma volume

  4. Peripartum Physiology • Baseline cardiac output increases 13% by 8 cm. dilatation • Largely due to increased SV • Uterine contractions return ~ 500cc of blood to the systemic circulation • Increases preload and augments cardiac output by 34% above pre-labor baseline

  5. Postpartum physiology • Within hours of delivery, marked diuresis begins • Fluid is mobilized from the expanded extravascular space • Intravascular space contracts • By 2 weeks postpartum, cardiac output falls 26% and is only 10% above values measured at 24 weeks

  6. Atrial Septal Defects • Usually asymptomatic • Large ASDs can be associated with pulmonary HTN and L to R shunting

  7. Ventricular Septal Defects • Large unrestrictive VSDs permit equalization of right and left pressures • Eisenmenger’s syndrome

  8. Congenital Aortic Stenosis • Outflow obstruction • Antepartum • Peripartum

  9. Pulmonic valve stenosis • Usually tolerated well • Severely stenotic valves • Cautious use of IVF • Shorten second stage • Preconception counseling

  10. Coarctation • Usually post-ductal obstruction • Symptoms related to hypertension proximal to obstruction and hypoperfusion distal to obstruction • In pregnancy, risks are associated with dissection and rupture • MMR 3-4%

  11. Uncorrected TOF • Exacerbation of shunt • Morbidity and mortality are associated with pregnancy related decline in SVR and peripartum blood loss • MMR 4-15%

  12. Eisenmenger’s syndrome • Exacerbation of shunt • Progressive hypoxemia • Avoid sudden drops in SVR • MMR 30-70% • Advise against pregnancy or offer termination

  13. Mitral Stenosis • Leading cause of cardiac maternal mortality • Elevated LA pressure  pulmonary edema and pulmonary HTN

  14. Mitral Regurgitation • Usually a result of rheumatic fever • Decreased peripheral vascular resistance should decrease the amount of MR and assist a poorly functioning ventricle • Severe MR with ventricular dysfunction increases MMR as high as 5-10%

  15. Aortic Regurgitation • Rarely complicates pregnancy unless LV systolic function is significantly depressed

  16. Peripartum cardiomyopathy • Incidence 1/15,000 to 1/1300 live births • Etiology unknown • 50% have return to normal function • Suspect when women present with CHF after 36 weeks

  17. Primary pulmonary hypertension • Pregnancy contraindicated with severe disease • TTE vs. cardiac cath • Treatments • Peripartum considerations

  18. Preeclampsia • Hypertensive disorder of pregnancy • Newly onset after 20 weeks gestation • Proteinuria • Risk factors

  19. HELLP Syndrome • Definition • Complications

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