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8/4/2019 Heart Disease in Pregnancy-A Journal Report
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4/21/12
Assessment anManagement of CaDisease in Pregna
CEBU INSTITUTE OFMEDICINE
8/4/2019 Heart Disease in Pregnancy-A Journal Report
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Outline• Introduction
•
Cardiorespiratory changesa. Intrapartum hemodynamics
b. Postpartum hemodynamics
• Physical Examination in pregnant patient
•
Non invasive cardiac investigations• Bacterial endocarditis prophylaxis
• Risk of congenital heart disease in offspring
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• General Cardiac Management Issues
a. Preconceptional counselling
b. Prenatal care
c. Predictors of poor maternal and neonatal outd. Labor and delivery
e. Post partum care
• Contraception
•
Conclusion
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Cardiorespiratory Changes
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• Heart rate, stroke volume, cardiaoutput, and blood pressure are
significantly dependent on mateposition esp. after 28th week of gestation
•
A rise in cardiac output is associwith an increased blood flow to torgans crucial in pregnancy
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•
Pregnancy is associated with asignificant increase in respiratotidal volume, leading to an increin minute ventilation, but therespiratory rate remains unchan
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Intrapartum Hemodynamics
•
Each uterine contraction is associatean expulsion of 300 to 500 ml of blofrom the uterus into general circulatadding to preload
•
The cardiac output in active labor isincreased by 2.5L/minute into the ra7-8L/min
• Cardiac output and stroke volume a
highest
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•
BP and CVP are elevated inassociation with uterine contrac
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Postpartum Hemodynamics
• Immediately after delivery there issignificant increase in cardiacoutput
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In a group of parturient women whoepidural anaesthesia, cardiac output wreported to be approximately 40% abobaseline values at 15 minutes after vadelivery and 25% at 30 minutes postp
James CF, Banner T, Caton D. Cardiac Output in Women UndergoingSection
with Epidural or General anesthesia. AmJ Obstet Gynecol 1989;160:
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A comparison group who received ganaesthetic also had elevations in caroutput of approximately 30% and 15%above baseline at 15 and 30 minutespostpartum
James CF, Banner T, Caton D. Cardiac Output in Women UndergoingSection
with Epidural or General anesthesia. AmJ Obstet Gynecol 1989;160:
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• Maternal heart rate actually fall
10 beats per minute during thisdespite a mean blood loss of approximately 500 mL associatwith vaginal delivery and 1000
associated with Caesarean sect
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•
By two weeks postpartum, cardoutput has reduced by 33%. Apostpartum diuresis peaks by thsecond to fifth postpartum day
lasts for several weeks.
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Physical Examination in tPregnant Patient
•
More diffuse apical impulse• Palpable systolic pulsation along
left sternal border
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Physical Examination in tPregnant Patient
• First heart sound increased in
intensity and widely split.• In the third trimester the splittin
the second heart sound widens
than normal with inspiration.
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Physical Examination in tPregnant Patient
• In a study, 92% developed an e
systolic murmur usually heard athe left sternal border. These arusually I to II out of VI in intensit
Cutforth R, MacDonald CB. Heart sounds and murmurs in pregnancy
1966;71:741–7.
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Physical Examination in tPregnant Patient
• Tricuspid valve inflow
murmur/Graham Steell PulmonaRegurgitation murmur
– Most common diastolic murmur in
pregnancy – Associated with physiologic dilata
the Pulmonary Artery – Resolves after delivery
h i l i i i
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Physical Examination in tPregnant Patient
• Mitral and Aortic regurgitation
decrease during pregnancysecondary to the decrease insystemic vascular resistance
•
Prominent neck veins or inspirawheeze may normally be identi
• Pedal edema is very common
N i i C di
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Non-invasive CardiacInvestigations
• ECG may show left-axis deviatio
and ST-T wave changes in the thtrimester.
• On Echocardiogram, the heart
appears mildly volume overloadand hyperkinetic.
B t i l E d diti
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Bacterial EndocarditisProphylaxis
• Prophylaxis against bacterial
endocarditis in the pregnant pawith structural cardiac disease, congenital or acquired, is not
currently recommended.• The risk of bacteremia at the tim
vaginal delivery or Caesarean s
is low
Ri k f C it l H t Di
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Risk of Congenital Heart Disin Offspring
• A discussion of the increased ris
congenital heart disease in theioffspring is an important compoof prenatal counselling.
•
The risk is generally higher if thmother, rather than the father, affected.
Ri k f C it l H t Di
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Risk of Congenital Heart Disin Offspring
• Fetal echocardiography at 18 to
weeks’ gestation is recommenda pregnant patient with a congeheart defect.
G l C di M
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General Cardiac ManagemIssues
• Preconceptual Counselling – Genetic counselling, either before
early in pregnancy, is recommendidentify the risk for their offspring
G l C di M
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General Cardiac ManagemIssues
• Prenatal Care – Patient with cardiac disease shoul
seen early in the first trimester – Assessment by a cardiologist early
pregnancy is also indicated – Patients are seen for prenatal visit
every two weeks, or more frequennecessary.
General Cardiac Managem
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General Cardiac ManagemIssues
• Prenatal Care – A fetal echocardiogram is recomm
at 18 to 21 weeks’ gestation for pwith congenital heart disease.
General Cardiac Managem
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General Cardiac ManagemIssues
• Prenatal Care – A fetal echocardiogram is recomm
at 18 to 21 weeks’ gestation for pwith congenital heart disease.
–
Use of iron, prenatal vitamins, anddietary counselling to avoid anemwhich is a common problem inpregnancy
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Greatest risk for Cardiac event dupregnancy:
1. Prior cardiac event or arrythmia
2. NYHA functional class II or cyanosis
3. Left Heart obstruction or systemic
ventricular dysfunction
0= 5 % risk
1= 27 % risk
>1= 75 % risk
General Cardiac Managem
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General Cardiac ManagemIssues
• Labor and Delivery – Patients may await spontaneous l
and can be counselled that the raCaesarean section is not increasebecause of heart disease alone
– Careful monitoring of the mother fetus once in labor especially fluidmanagement and ECG monitoring
General Cardiac Managem
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General Cardiac ManagemIssues
• Post-Partum Care – Most crucial time for some patient
cardiac disease – Close monitoring should be maint
for at least 48 hours when cardiacoutput remains elevated
General Cardiac Managem
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General Cardiac ManagemIssues
• Post-Partum Care – Most patients are reassessed at fo
six weeks postpartum, by which tthe woman’s hemodynamic statusreturned to the nonpregnant state
General Cardiac Managem
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General Cardiac ManagemIssues
• Contraception – Sterilization of the male partner
obviously carries the least risk forwoman with cardiac disease
–
Barrier methods, when used consand properly, are usually effective
General Cardiac Managem
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General Cardiac ManagemIssues
• Contraception – Oral contraceptives can be used i
patients with cardiac disease withseveral exceptions
•
Patients with right to left shunts• Patients with cardiac disease th
associated with hypertension
General Cardiac Managem
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General Cardiac ManagemIssues
• Contraception – Progestin-only oral contraceptives
depotmedroxyprogesterone acetabe used, as the thromboembolic roral contraceptives is thought to bto the estrogen component.
– Progestin-releasing intrauterine de(IUD) can be an excellent choice
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Conclusion
• The difficult issues in a pregnan
complicated by cardiac disease best managed through a teamapproach.
•
Patients with severe symptoms close attention and may requiremedical and occasionally surgic
treatment during pregnancy
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Conclusion
• Labor, delivery, and the immed
postpartum period are associatwith significant hemodynamicchallenges and patients should
monitored throughout.• Pregnancy with cardiac disease
usually has a successful outcom
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THANK YOU