Cardiac Disease in Pregnancy

1. Cardiac Disease in Pregnancy Woman’s Hospital School of Medicine Zhejing University He jin

2. Physiological Changes in the Cardiovascular System During Pregnancy • A thorough knowledge • is essential • In order to understand • the additional impact of cardiac disease

3. Physiological Changes • The first cardiovascular change associated with pregnancy • Peripheral vasodilation (induced by progesterone) • leading to • A decrease in systemic vascular resistance

4. Physiological Changes • Cardiac output increases • 8 weeks : 20% • 20-28 weeks :40-50% • Stroke volume increase 80ml/t • ventricular end-diastolic volume • wall muscle mass • contractility • Heart rate increase • 10 to 15 beats per minute

5. Physiological Changes • Labour leads to further increases in cardiac output • In the first stage: 15% • In the second stage: 50% • blood back into the circulation with each uterine contraction: 300-500 ml • pain and anxiety : sympathetic stimulation

6. Physiological Changes • After delivery • Cardiac output increases again immediately : 60-80% • uterine contraction • relief of cavalcompression • Within 1 h • rapid decline to pre-labour values

7. Table 1 -- Normal Hemodynamic Changes During Pregnancy

8. Types of CD during pregnancy • Congenital heart disease • Rheumatic heart disease • Pregnancy-induced hypertension heart disease • Peripartum cardiomyopathy • Other

9. Congenital heart disease • Left → right shunt • ① atrial septal defect • ② ventricular septal defect • ③ patent ductus arteriosus • No shunt ① pulmonary stenosis ② coarctation of the aorta ③ Marfan syndrome • right → Left shunt:f4、AS

10. Rheumatic heart disease • Mitral stenosis: • Increased blood volume during pregnancy • Intrapartum and early puerperium:blood volume back to the heart increased • Pulmonary circulation volume increase • Left atrial pressure increases • Pulmonary venous hypertension • Acute pulmonary edema. • Mitral incompetence:simply • Can tolerance pregnancy, delivery and puerperium.

11. Rheumatic heart disease • Aortic stenosis: severe • Pulmonary edema • Low discharge capacity heart failure • Aortic incompetence : severe • Left ventricular failure • Combined with bacterial endocarditis

12. PIH heart disease • No history of heart disease and signs over the past • Sudden onset of systemic failure are dominated by left ventricular failure • Misdiagnosed as the flu and bronchitis • Early diagnosis is important • After eliminate the cause, most can be restored

13. PIH heart disease • Myocardial ischemia, interstitial edema, hemorrhage and necrosis spots • Blood viscosity increased to promote myocardial ischemia • Combined with severe anemia • Heart failure occurs

14. Peripartum Cardiomyopathy (PPCM) • Define: dilated cardiomyopathy • Interval: between the last 3 month of pregnancy up to the first 6 months postpartum • Women : without preexisting cardiac dysfunction • Fetal death:10~30% • Maternal mortality is approximately 9% • heart failure, pulmonary infarction, arrhythmia • These women should be counseled against subsequent pregnancies

15. PPCM • The exact etiology : unknown • Possible causes • infection, immunity, multiple pregnancy, hypertension, malnutrition • viral myocarditis • automimmune phenomena • specific genetic mutations

16. PPCM • Typical signs • Fatigue • Dyspnea on exertion, orthopnea • Nonspecific chest pain • Abdominal discomfort and distension • palpitations, cough, hemoptysis, hepatomegaly, edema and other heart failure symptoms

17. PPCM • Saymptoms • Heart enlarged • Myocardial contractility reduce • Ejection function reduced • ECG: • Arrhythmias, left ventricular hypertrophy, ST segment and T wave abnormalities

18. CD main threat to pregnant women • Heart failure • Subacute infective endocarditis • Hypoxia and cyanosis • Venous thrombosis and pulmonary embolism.

19. The impact of CD in pregnant women • Gestation period: • increased blood volume, heart burden • Delivery period: • uterine contractions • blood pressure↑ • the blood flow increases • pulmonary artery pressure increased • sudden interruption of placental circulation • abdominal pressure plummeted

20. The impact of CD in pregnant women • Puerperium: • uterine contractions • retented Interstitial fluid returned to circulation • The greatest change period in systemic blood circulation and heart burden • 32 to 34 weeks • Intrapartum • 3 days postpartum • easily induced heart failure

21. The impact of CD in pregnant women • A validated cardiac risk score • Predict a maternal chance of having adverse cardiac complications Table 2 Risk factor and maternal cardiac event rates

22. Table3 Predictors of Maternal Risk for Cardiac Complications

23. The impact of CD in Fetal • Premature birth • Low birth weight • Respiratory distress • Fetal death • Neonatal death • Genetic heart disease

24. Maternal Cardiac Lesions and Risk of Cardiac Complications • Low Risk • Atrial septal defect • Ventricular septal defect • Patent ductus arteriosus • Asymptomatic aortic stenosis with low mean gradient (<50mmHg) and normal LV function (EF >50%) • Aortic regurgitation with normal LV function and NYHA functional class I or II

25. Maternal Cardiac Lesions and Risk of Cardiac Complications • Low Risk • Mitral valve prolapse • (isolated or with mild to moderate mitral regurgitation and normal LV function) • Mitral regurgitation with normal LV function and NYHA class I or II • Mild to moderate mitral stenosis • (mitral valve area >1.5cm2, mean gradient <5mmHg) without severe pulmonary hypertension) • Mild/moderate pulmonary stenosis • Repaired acyanotic congenital heart disease without residual cardiac dysfunction

26. Maternal Cardiac Lesions and Risk of Cardiac Complications • Intermediate Risk • Large left-to-right shunt • Coarctation of the aorta • Marfan syndrome with a normal aortic root • Moderate to severe mitral stenosis • Mild to moderate aortic stenosis • Severe pulmonary stenosis

27. Maternal Cardiac Lesions and Risk of Cardiac Complications • High Risk • Eisenmenger's syndrome • Severe pulmonary hypertension • Complex cyanotic heart disease • (tetralogy of Fallot, Ebstein's anomaly, truncus arteriosis, transposition of the great arteries, tricuspid atresia) • Marfan syndrome with aortic root or valve involvement

28. Maternal Cardiac Lesions and Risk of Cardiac Complications • High Risk • Uncorrected severe aortic stenosis with or without symptoms • Uncorrected severe mitral stenosis with NYHA functional class II-IV symptoms • Aortic and/or mitral valve disease (stenosis or regurgitation) with moderate to severe LV dysfunction (EF <40%) • NYHA class III-IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology • History of prior peripartum cardiomyopathy

29. Diagnosis • History: • Palpitations, difficulty breathingor heart failure • Organic heart disease • Rheumatic fever

30. Diagnosis • Signs and symptoms abnormal: • Exertional dyspnea, Paroxysmal nocturnal dyspnea , orthopnea, hemoptysis, recurrent exertional chest pain • Cyanosis, clubbing, jugular vein engorgement continuing. • Cardiac auscultation • a diastolic murmur of grade Ⅲ or rough systolic murmur over the whole • a pericardial friction rub, diastolic gallop, alternating pulse

31. Early signs of heart failure • Chest tightness, palpitations, shortness of breath after mild activity • Resting heart rate> 110 beats / min • Respiration> 20 times / min • Paroxysmal nocturnal dyspnea • The end of the lung wet rales persisted

32. Diagnosis:auxiliary examination • Noninvasive testing of the heart may include: • ECG: severe arrhythmias • atrial fibrillation, atrial flutter, Ⅲ degree atrioventricular block, ST segment and T wave abnormalities and changes • Chest radiograph • the heart was significantly expanded • Echocardiogram • expansion of the heart chamber • myocardial hypertrophy • valvular motion abnormalities • cardiac structural abnormalities

33. Management • Before pregnancy: • detailed examination to determine whether she is suitable to pregnant • access to counselling • specialized • multidisciplinary • preconception • In order to empower them to make choices about pregnancy

34. Not suitable for pregnancy ！ • Cardiac function grade Ⅲ ~ Ⅳ • Those who previously had heart failure • A pulmonary hypertension, severe stenosis the main A, Ⅲ atrioventricular block, atrial fibrillation, atrial flutter,diastolic gallop; • Cyanotic heart disease • Active rheumatic or bacterial endocarditis

35. The main aims of management • To optimize the mother's condition during the pregnancy • considering ß-blockers • Thromboprophylaxis • pulmonary arterial vasodilators • To monitor for deterioration • Minimize any additional load on the cardiovascular system

36. Pregnant women with CD • Should be assessed clinically as soon as possible • A multidisciplinary team and appropriate investigations undertaken • The core members of the team should include: • Suitably experienced obstetricians • Cardiologists • Anaesthetists • Midwives • Neonatologists • Intensivists

37. Management of gestation period • Regular prenatal care • Early prevention of heart failure • adequate rest • appropriate weight limit • treatment the motivation of heart failure : infection, anemia,PIH • The treatment of heart failure • as same as those who are not pregnant

38. Mode of Delivery • Vaginal delivery: • cardiac function Ⅰ ~ Ⅱ grade • not a fetal macrosomia • cervical conditions are good • Cesarean section: • Marfan syndrome : expansion of the aortic root> 45 mm • use warfarin during delivery • sudden hemodynamic deterioration • severe pulmonary hypertension and severe aortic stenosis

39. Management in intrapratum • First stage of labor • Semi-recumbent position, oxygen masks, attention Bp, R, P, heart rate, • cedilanid : 0.4mg +5% GS20ml iv slow (when necessary) • antibiotics : during labor to 1 week after postpartum

40. Vaginal delivery • Low-dose regional analgesia:usually recommended • providing effective pain relief • reduce the further increases in • cardiac output • myocardial oxygen demand • Be careful not to inhibit the neonatal breathing

41. Management in intrapratum • Second stage of labor: • episiotomy, facilitate instrumental delivery to shorten the stage • Third stage of labor: • Ergot disabled to prevent venous pressure increased • injection of morphine or pethidine immediately postpartum • abdominal pressure sandbags • control the liquid velocity

42. Management in puerperium • Monitoring heart rate, blood oxygen, blood pressure during delivery 24 hours • She could not breast-feeding • more than grade Ⅲ cardiac function • Prophylactic antibiotics • High-level maternal surveillance

43. Thanks four your listening