Dr. Ramesh Chaudhary1st yr. Resident

JIVANYOG NURSING HOME, VISNAGARJIVANYOG NURSING HOME, VISNAGAR

IncidanceLess than 1 percent in hospital delivaries Commonest is rheumatic type f/b congenital hrt

disRatio is 3;1 in developing countries to o 1;1 in

developed countriesRh lesios are –ms(most common ),mr, as,ar Congenital types are –septal defects ,PDA,PULMO

STENOSIS,FELLOTS TETROLOGY

OTHER COARCTATION OF AORTA ,HYPERTENSIVE,SYPHILITIC AND CORONARY CARDIAC DS

Cardiac output; 4.5 to 6.251 30% increaseStroke volume 65 to 75 ml increasesPulse70 to 85Bp mild diastolic reduction in bpVenous pressure 10 to 20 cm of h2o 100 %

riseperipheral resistance markedly diminishedBlood viscosity 4.7 t0 3.8 -decres

Normal hrt –enough resrved power that can cope up with extra load

Damaged hrt has less reserved power to withstand against extra load

So ,chance of failure ,which usually occure at 30 wks ,during labour or at soon after labour

additional factors responsible for deterioration are advancing age ,arrythmia,left vent hypertrophy,h/o hrt failure,and apperance of risk factors like infection,anaemia,pre-eclampsia,excessive wt gain,multiple pregnancyand inadeqate supervision

Preterm delivary,prematurity and IUGR which is common in cynoticc hrt dis

Maternal depend on -nature of lesion , -functional capacity of hrt -quality of medical supervision during pregnancy- apperance of risk factor a mentioned aboveMortality on maternal side is least in rheumatic type

about less than one percent but increses upto 50% in cynotic hrt dis and max death occures after birth of baby

Other causes of death than cardiac failure are pulmo oedema,embolism ,active rhumatic carditis ,SABE,and rapture of cerebral aneurism in coarctation of aorta

FETAL PROGNOSIS;good but incresed chances of prematurity ,iugr ,and chance of abortion ,and chance of congenital malformation increses if either of parents suffering from congenital hrt dis

Symptoms Progressive nocturnal dyspnoea and

orthopnoea,nocturnal cough ,hemoptysis,syncope and chest pain

Criteria to find out organic hrt lesion Diastolic murmur,systojic murmur with

thrill,cardiac enlargement,presence of arrythmia

Othrs are cluubing ,cynosis, NVE and split s2Studies done for diagnosisECG,X-RAY AND ECHO

Grd-1 no limitation of physical activityGrd 2 mild compromised ordinary

physical activity causes discomfortGrd 3 mark compromised less than ordinary

physical activity cause discomfortGrd 4 severerly compromised discomfort

at rest

Grp 1 minimal risk –0 to 1 % mortality ASD ,VSD,PDA ,PS and TS Corrected Fallot’s Tetralogy Prosthetic Valves MS—related with NYHA class 1 and 2.

Group 2: moderate risk.5-15% mortality. MS, related with NYHA 3 and 4. AS Coarcrtation of Aorta without Valvae involvment. Uncorrected Fallot’s tetralogy Previous MI. Marfan’s with normal Aorta

Group 3: major risk—25-50% mortality. PHT, Aortic coarctation with valvular involvement Marfans’ with aortic involvment.

In cases of congenital heart ds. With PHT.Artificial valvesAF.Warfarin in nonpregnant------ as soon as

prgnacy is diagnoised, 5000 IU heparin SC BD up to 12 wks---shift on Warfarin up to 36 wks ---after that shift on heparin till 7 days postpartum .

DECISION OF ADMISSION:Grade 1 NYHA –2 wks prior to EDD.Grade 2 –at 28 wks in specially unfavourable

surrondings.Grade 3 and 4—as soon as prgnancy is

diagnosed.

Emergency Admission:Deterioration of functional grading .Appearance of pregnancy complications like

pre-eclampsia, anemia and abnormal wt. gain.

INTRAPARTUM MANAGEMENT:No place for induction.Induction only for obst. Indications.

FIRST STAGE:FIRST STAGE:Bed rest.Lt lateral position—to reduce aortocaval pressure by

gravid uterus.In majority –epidural labour analgesia.O2 inhalation.Restricted IV fluid ---less than 75ml/hr to prevent

pulmonary edema.Prophylactic antibiotics to prevent purperial

endocarditis.Monitor PR, RR, ---if PR> 110/min ---rapid

digitalization by 0.5 mg digoxin IM /Slowly IV.

SECOND STAGE:SECOND STAGE:If tendency to delay –cut short second stage –by

vaccum /forceps.NO ERGOMETRINConcentrated oxytocin infusion.THIRD STAGE:THIRD STAGE:CONVENTIONAL MANAGEMENT:Slight to moderate blood loss is benificial IV frusemide may be accompanied.INDICATIONS FOR CS:Only for obst. Indications.Elective CS:--Elective CS:--coarctation of aorta , mycotic

cerebral aneurysmEpidural analgesia.

Pain relief:Continuous Epidural analgesia is recomended

in most cases.Contraindicated –intracardiac shunts, PHT,

and aortic stenosis because it may cause reversal of shunt by causing hypotension and reduction of output in AS which is dependant on preload—in such condition Narcotic analgesia or GA preferred.,

Commonest RHD.Commonest RHD.Normal area of valve—3 to 6 cm2, symptoms Normal area of valve—3 to 6 cm2, symptoms

appears below 2.5 cm2 area.appears below 2.5 cm2 area.With NYHA grade 1 and 2 –mortality less than With NYHA grade 1 and 2 –mortality less than

1%.1%.Grade 3 and 4—5 to 15%Grade 3 and 4—5 to 15%Epidural analgesia preferred and restrict IV fluid.Epidural analgesia preferred and restrict IV fluid.Valvotomy: in case of unresponsive cardiac Valvotomy: in case of unresponsive cardiac

failure with pregnancy beyound 12 wks.failure with pregnancy beyound 12 wks.Best time for surgery—14 to 18 wks.Best time for surgery—14 to 18 wks.Anticoagulant therpy and antibiotics to prevent Anticoagulant therpy and antibiotics to prevent

SABE and thromboembolism.SABE and thromboembolism.

Commonly congenital , less commonly rheumatic.

Maternal mortality---significant 15-20% and perinatal loss 30%.

Long term bedrest .Epidural analgesia—contraindicate d and no

fluid restricted and to be given more than 125 ml/hr.

ASD: most common , tolerate pregnancy and labour well CCf unresponsive to medical treatment—required surgery.

Shunt reversal is major risk which develops in hypovolemia and hemorrhagic conditions and hypotension.

Peripartum prophylactic antibiotics

PDA: Tolerate pregnancy well. PHT—cause of maternal death. Surgical correction can be performed provided there is no PHT. Epidural to be avoided. Fetal loss up to 7%. And 4% chance of same lesion in child.

VSD: Defect < 1.25 cm2—generally. Moderate Lt to RT shunt and moderate PHT –women tolerates well Risk of reversal leads to circulatory collapse and cynosis. Epidural analgesia and hypotension to be avoided. Fetal loss up to 20% and 8% chance to get same malformation in fetus.

Fallot’s tetralogy;4 lesions are –VSD, PS, RVH and overriding of

aorta.Uncorrected pts are at high risk but usually

corrected stages pts are found.Complications like –SABE, brain abscess and

cerebral embolism are common.Maternal mortality –5 to 10% Perinatal –30 to 40%.IUGR common.Systemic hypotension is dangerous –even leads

to death.

EISENMENGERATION’S SYNDROME:It is presence of ASD VSD and PDA with PHT

with Rt to LT flow from shunts.Maternal mortality –50% and perinatal loss is

very high .Usually termination –should be considered

and Suction and Evacuation is preferred method.

OTHER CONGENITAL HEART DS: Coarctatiton aorta: Major risk of dissection, BE, and rupture of Intracranial aneurysm. Maternal mortality—3 to 8% and fetal loss up to 25% and elective CS

preferred to minimize dissection associated with labour. BP is to be maintained throughout pregnancy and prophylactic antibiotics. Primary PHT: Characterized by thickening of muscular layer of arteriols Maternal mortality—40% and fetal outcome bad. Vasodilators like hydralazines is to be given even in absence systemic HT. Marfan’s Syndrome: Autosomal dominant. 50% chance of transmission to offspring Dilatation of aorta >40 mm ---contraindicated for pregnancy. Beta blocker ---to reduce hemodynamic load on ascending aorta even in

absence of systemic HT. If there is any dilatation of aorta during prgnancy---elective CS.

CARDIOMYOPATHY:Manifestations appear usually in last month of

pregnancy to 5 mths after delivery.Etiology –not known.Usually multiprous, young 25 to 35 yrs of age and in

second and third postpartum month.Sx;; dyspnoea, nocturnal cough, weakness and

palpitaions.Examinations;; Tachycardia, arrythmia, peripheral

edema, and creopts .X-ray---enlaged heart,ECHo-=--dilated chambers particularly lt. ventricalTreatment: bed rest ,

digitalis ,diuretics ,anticoagulants Vaginal delivery favorable Unfavourable cases ---cesaren section.