OB-GYNE

CARDIOVASCULAR DISEASE IN Midterms

Doc Espinoza
PREGNANCY

 Relative common in women of child bearing  Nocturnal cough

age, complicate about 1-4% of pregnancies  Chest pain
 PGH 2010-2014: 2-3%of all deliveries per year  Pulmonary crackles
 Maternal mortality related heart disease has  Clinical findings:
decreased remarkably over the past 50 years o Progressive edema
(5.6% to 0.3%/100,000 live birth) o Tachycardia
 Still the second most common non obstetrical
cause of maternal mortality Diagnosis of Heart Disease
 Clinical signs:
NORMAL HEMODYNAMIC CHANGES DURING o Cyanosis
PREGNANCY o Clubbing of fingers
Hemodynamic Change Change Change o Persistent neck vein congestion
Parameter during during during o Systolic murmur grade 3/6 or greater
normal labor and postpartum o Diastolic murmur
pregnancy delivery o Cardiomegaly
o Persistent arrhythmia
Blood volume ↑ 40-50% ↑ ↓
o Persistent split-second sound
Autodiuresis
o Criteria for pulmonary hypertension
Heart rate ↑ 10-15 ↑ ↓
 Diagnostic Studies
beats/min
o Electrocardiography
Cardiac output ↑ 30-50% ↑ Add ↓ - An average 15-degree left-axis
50%
deviation and mild ST changes
Blood ↓ 10 ↑ ↓ may be seen in the inferior
pressure mmHg leads
Stroke volume ↑1st and ↑ 300-500 ↓ - Atrial and ventricular
2nd tri ml per premature contractions are
↓ 3rd tri contraction relatively frequent
Systemic ↓ ↑ ↓ o Chest X-Ray
vascular resist - Heart silhouette normally is
larger in pregnancy, however
gross cardiomegaly
CARDIAC DISEASE
o Echocardiography
 Rheumatic heart disease - Normal changes include:
 Congenital heart disease  Tricuspid and mitral
 Hypertensive heart disease regurgitation
 Coronary  Significantly increase
 Thyroid left atrial size and left
 Syphilitic ventricular diastolic
 Kyphotic cardiac disease dimension with
 Idiopathic cardiomyopathy preservation of ejection
 Corpulmonale fraction
 Constrictive pericarditis o Plasma Brain Natriuretic Peptide (BNP)
 Heart block - Useful guide in managing early
cardiac dysfunction and
Warning Signs of Heart Failure hypertensive disorders
 Paroxysmal nocturnal dyspnea
 Increasing dyspnea on exertion

Ketty CONSTANTIAM2020 Page 1

PRECONCEPTIONAL COUNSELLING benzathine penicillin G every 3 weeks is justified
 Maternal and fetal morbidity and mortality and recommended
associated with pregnancy  Dose: 1,200,000 IU IM every 3 weeks
 Risk of recurrent congenital heart disease in the
offspring Duration of Secondary Rheumatic Fever Prophylaxis
 Maternal life expectancy Category Duration after Rating
 Level of surveillance, need for treatment and last attack
anticipated hospitalization required during Rheumatic fever 10 years or until IC
pregnancy with carditis and 40 years of age
 Contraception residual heart (whichever is
 Fetal 2D Echo at 18-22 weeks disease longer)
 Risk Assessment: (persistent sometimes
o A thorough cardiovascular history and valvular disease) lifelong
examination prophylaxis
o 12 lead electrocardiogram Rheumatic fever 10 years or until IC
o Transthoracic echocardiogram with carditis but 21 years of age
o Arterial oxygen saturation no residual heart (whichever is
measurements by percutaneous disease (no longer)
oximetry valvular disease)
Rheumatic fever 5 years or until IC
THE NEW YORK HEART ASSOCIATION’S FUNCTIONAL with carditis 21 years of age
CLASSIFICATION (NYHA) (whichever is
“First published in 1928” longer)
 Class 1
o Uncompromised RHEUMATIC HEART DISEASE
o No limitation of physical activity  40-50% of all cardiac diseases in developing
 Class 2 countries
o Slightly compromised  Mitral stenosis
o Slight limitation of physical activity
Narrowed valve during
 Class 3 diastole
o Markedly compromised
o Marked limitation of physical activity
 Class 4
↑ HR shortens diastole
o Severely compromised
o Inability to perform any physical
activity without discomfort
↓ left ventricular filling
CARDIAC CONDITIONS CONTRAINDICATIONS TO
PREGNANCY
 Severe pulmonary hypertension of any etiology ↓ CO, ↑ left atrial pressure
 Severe, fixed obstructive cardiac lesions and overt cardiac failure
 NYHA Class 3-4 heart failure
 Left ventricular ejection fractions <40% o Symptoms:
 Prior peripartum cardiomyopathy - Shortness of breath with
exertion on 2nd trimester →
 Dilated unstable aorta of 40-45 mm or above
orthopnea, paroxysmal
 Severe cyanosis
nocturnal dyspnea
Secondary Rheumatic Fever Prophylaxis
MITRAL VALVE STENOSIS
 In populations in which incidence of rheumatic
 Acute deterioration is due to arrhythmia usually
fever is particularly high, the administration of
atrial fibrillation

Ketty CONSTANTIAM2020 Page 2

  Maternal outcomes are favorable in mild MS
but not with moderate to severe stenotic lesion
(pulmonary edema, arrhythmias)
 Severity of MS – valve area of <1.5cm
 Fetal outcomes:
o Preterm delivery
o IUGR
o 30% mortality for class IV
 Management
*PBMV-Percutaneous Balloon Valvuloplasty
CONGENITAL HEART DISEASE
 Abnormality present at birth in any part of the
heart that affects its structure and function
 1/3 of all major congenital anomalies
 Asia: 9.3 per 1,000 live births
Europe: 8.2 per 1,000 live births
North America: 6.9 per live births
Most Common CHD Subtypes
1. Ventricular septal defects
2. Atrial septal defects
3. Patent ductus arteriosus
4. Pulmonary valve stenosis
5. Tetralogy of Fallot*
6. Coarctation of aorta
7. Transposition of great arteries*
8. Aortic valve stenosis
MYOCARDIAL INFARCTION
 Pregnancy raises the risk by 3 to 4 fold
 Risk factor:
o Age 40 years (30x)
o Chronic hypertension, pre eclampsia
o Diabetes
o Smoking
o Hyperlipidemia
 Diagnostics:
Ketty
o ECG
o CT scan or MRI
o Serum troponin I
PERIPARTUM CARDIOMYOPATHY
 Unknown cause
 Late in pregnancy or early in puerperium, late
as 6 months post delivery
 Symptoms:
o Shortness of breath
o Lying flat at night
 25% associated with hypertension
 Diagnostics:
o ECG
o Chest X-Ray
o 2D echo
AORTIC DISSECTION
 Systolic hypertension
 Prompt hypertensive therapy
 Diagnostic: CT scan
MODIFIED WHO CLASSIFICATION OF MATERNAL
CARDIOVASCULAR RISK PRINCIPLES
Risk Risk Pregnancy by medical condition
Class
I No detectable increased risk of maternal
mortality and no/mild increase in morbidity
II Small increased risk of maternal mortality or
moderate increase in morbidity
III Significantly increased risk of maternal
mortality or severe morbidity. Expert
counseling required. If pregnancy is detected
upon, intensive specialist cardiac and obstetric
monitoring needed throughout pregnancy,
childbirth & pueperium
IV Extremely high risk of maternal mortality or
severe morbidity; pregnancy contraindicated. If
pregnancy occurs termination should be
discussed. If pregnancy continues, care as for
class III
MODIFIED WHO CLASSIFICATION OF MATERNAL
CARDIOVASCULAR RISK APPLICATION
 Conditions in which pregnancy risk is WHO I
o Uncomplicated, small or mild
- Pulmonary stenosis
- Patent ductus arteriosus
- Mitral valve prolapse
CONSTANTIAM2020 Page 3
 o Successfully repaired simple lesions o Native severe coarctation
- Atrial or ventricular septal
defect COMMON COMPLICATIONS DURING PREGNANCY
- Patent ductus arteriosus 1. Arrhythmias
- Anomalous pulmonary venous  May manifest as premature atrial or
drainage ventricular complexes
o Atrial or ventricular ectopic beats,  Beta-blockers or digoxin (DOC)
isolated  Electrical cardioversion
 Conditions in which pregnancy risk is WHO II or - Treatment of choice for all drug
III refractory maternal
WHO II (if otherwise well & complicated) arrhythmias, safely done during
o Unrepaired atrial or ventricular septal pregnancy
defect with normal pulmonary artery  Pacemaker insertion
pressure - For bradyarrhythmias
o Repaired tetralogy of fallot 2. Congestive Heart Failure
o Most arrhythmias  Should be admitted for bed rest
 WHO II-III (depending on the individual)  Medical management:
o Mild ventricular impairment - Salt and fluid restriction
o Hypertrophic cardiomyopathy - Diuretics to limit the volume
o Native or tissue valvular heart disease load
not considered WHO I or IV - Antihypertensive therapy for
o Marfan syndrome with aortic dilatation after load reduction
o Aorta <45mm in aortic disease with
bicuspid aortic valve FETAL OUTCOME IN PATIENTS WITH CVD
o Repaired coarctation  Preterm delivery
 WHO III  IUGR
o Mechanical valve  Stillbirth
o Systemic right ventricle  Abortion
o Fontan circulation  Low birth weight
o Cyanotic heart disease (unrepaired)  Malformation
o Other complex congenital heart disease
o Aortic dilatation 40-45mm in Marfan DRUGS USED DURING PREGNANCY (CLEVELAND
syndrome CLINIC)
o Aortic dilatation 45-50mm in aortic Medication FDA Information
disease associated with bicuspid aortic Atenolol D Intrauterine growth restriction
valve and premature birth
 Conditions in which pregnancy risk is WHO IV Other Beta- C Low birthweight, hypoglycemia
(Pregnancy contraindicated) Blockers and bradycardia in the fetus
o Pulmonary arterial hypertension of any Angiotensin D High incidence of fetal death
cause Converting and fetotoxic effect, renal
o Severe systemic ventricular dysfunction Enzyme inhibitors failure, renal dysplasia
(LV ejection fraction <30%, NYHA III-IV) Amiodarone D Thyroid insufficiency
o Previous peripartum cardiomyopathy Angiotensin D High incidence of fetal death
with any residual impairment of left Receptor and fetal renal failure
ventricular function Blockers
o Severe mitral stenosis Aspirin B Low dose aspirin is safe (large
o Severe symptomatic aortic stenosis database)
o Marfan syndrome with aorta dilated Calcium Channel C Diltiazem: an increase in major
>45mm Antagonists birth defects has been
o Aortic dilatation >50mm in aortic reported
disease associated with bicuspid aortic
valve

Ketty CONSTANTIAM2020 Page 4

Clopidogrel B The benefits in some high risk
pregnancies may outweigh the
potential fetal risks
Digoxin C No reports of congenital
defects, monitor serum levels
Loop Diuretics C Hypovolemia can lead to
reduced uterine perfusion
Low molecular C Factor X should be measured
weight heparin & weekly, levels may fluctuate
unfractionated during pregnancy
heparin
Nitrates B Careful titration is advised to
avoid maternal hypertension
Spironolactone D Potential anti androgens
effects on the developing male
fetus
Statins X Animal studies demonstrated
increased skeletal
abnormalities, fetal and
neonatal mortality
Thiazide Diuretics B Hypovolemia can lead to
reduced uterine perfusion
Other Interventions during Pregnancy
 Interventional treatment
o Necessary in certain emergency
situations, ultrasound guidance and
abdominal shielding should be done to
reduce radiation exposure to the fetus
 Cardiac surgery
o Should be done if all other treatment
modalities have failed
o Best avoided in first trimester to
decrease fetal risks and to delay surgery
till after 28 weeks
o Delivery may be contemplated before
the surgery
FETAL SURVEILLANCE
 Biophysical profile
 Congenital anomaly
 Doppler velocimetry
MAIN AIMS OF MANAGEMENT
 To optimize the mother’s condition during
pregnancy
 To monitor for deteriorations
 Minimize any additional load on the
cardiovascular system
Ketty CONSTANTIAM2020
MANAGEMENT: Labor and Delivery
 Labor in the lateral decubitus position
 Decrease aortocaval compression by the gravid
uterus
 Timing and Mode of Delivery:
o Vaginal Delivery
- Use of prostaglandins or
mechanical methods for
cervical ripening
- Adequate pain relief with
epidural anesthesia
- Assisted vaginal delivery
(vacuum or forceps extraction)
o Cesarean delivery
- Oral anticoagulation in preterm
labor
- Acute intractable heart failure
- Aortic root diameter >45mm
- Acute or chronic aortic
dissection
o Routine endocarditis prophylaxis is NOT
recommended
 Antibiotic Prophylaxis
o Ampicillin 2g IM or IV and Gentamicin
1.5mg/kg IV, not exceed 120mg given at
initiation of labor or within 30 minutes
of CS
o Followed by Ampicillin 1g IM/IV or
Amoxicillin 1g PO 6 hours later
o If allergic to Ampicillin, Vancomycin 1g
IV over 1-2 hours period
Recommended Antibiotic Prophylaxis
o Prosthetic cardiac valve or prosthetic
material used for valve repair
o Previous infective endocarditis
o Congenital heart disease
- Unrepaired cyanotic CHD,
including palliative shunts and
conduits
- Complete repaired congenital
heart defect with prosthetic
material or device, whether
placed by surgery or by
catheter intervention, during
the first 6 months after the
procedure
- Repaired CHD with residual
defects at the site or adjacent
to the site of a prosthetic patch
or device
Page 5
 o Cardiac transplant recipients who
develop cardiac valvulopathy

Prophylaxis NOT INDICATED

o Atrial septal defects
o Ventricular septal defects
o Patent ductus arteriosus
o Mitral valve prolapse
o Previous Kawasaki disease
o Hypertrophic cardiomyopathy
o Previous coronary artery bypass graft
surgery
o Cardiac pacemakers (intravascular and
epicardial) implanted defibrillators
o Bicuspid aortic valves
o Coarctation of aorta
o Calcified aortic stenosis
o Pulmonic stenosis

 Postpartum Care
o Controlled intravenous infusion of
oxytocin
o Prophylactic diuretics and ACE
inhibitors
o Elastic support stockings and early
ambulation
o Lactation is possible

 Contraception
o Barrier methods and levonorgestrel
containing IUD (SAFEST AND MOST
EFFECTIVE)
o Progestogen only pill
o Low dose COC
o Etonogestrel-containing implant
o Vasectomy

Ketty CONSTANTIAM2020 Page 6