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CARDIAC DISEASES IN

PREGNANCY
Pregnancy in patients with heart disease is becoming more
common due to its early diagnosis and better treatment.

• Incident komplikasi penyakit jantung sekitar 1 % dari seluruh


kehamilan dan sekarang penyebab utama kematian maternal
tidak langsung sekitar 20 % dari seluruh angka kematian
maternal

F. Gary Cunningham et al. (2010) Williams obstetrics, Williams Obstetrics. doi:


10.1097/00001888-193609000-00027.
NORMAL PHYSIOLOGICAL
CHANGES IN PREGNANCY

Braunwald E et al. Heart Disease. 2001. pg. 2173.


EFFECT OF MATERNAL CARDIAC
DISEASE ON PREGNANCY

Preterm delivery
Fetal Growth Restriction
Congenital heart disease (0.6%-4,5%)
Fetal death
DIAGNOSIS OF HEART
DISEASE

F. Gary Cunningham et al. (2010) Williams obstetrics, Williams Obstetrics. doi:


10.1097/00001888-193609000-00027.
F. Gary Cunningham et al. (2010) Williams obstetrics, Williams
Obstetrics. doi: 10.1097/00001888-193609000-00027.

F. Gary Cunningham et al. (2010) Williams obstetrics, Williams Obstetrics. doi:


10.1097/00001888-193609000-00027.
Chest X-Ray
Cardiomegaly,
Pulmonary vascular markings,
Enlargement of pulmonary veins.
ECG -
Cardiac chamber hypertrophy
Arrhythmia
Myocardial ischaemia and infarction
Conduction abnormalities.
Echocardiography.
Detects structural abnormality (ASD, VSD)
Valve anatomy, valves area, function
Lt. ventricular ejection fraction
Pulmonary artery pressure.
NYHA FUNCTIONAL CLASSIFICATION
• No limitation of physical activity
CLASS I • No symptom with ordinary exertion

• Slight limitation of physical activity


CLASS II • Ordinary activity causes symptoms

• Marked limitation of physical activity


CLASS III • Less than ordinary activity causes
symptom
• Asymptomatic at rest
•Inability to carry out any physical activity
CLASS IV without discomfort
•Symptoms at rest
ANTENATAL CARE

Bed rest.

Salt Restriction- 4-6 gm /day.


Treatment of precipitating factor for heart failure.

Diuretics may be required

Fetal growth monitoring.


GENERAL MANAGEMENT DURING LABOUR &
DELIVERY
Spontaneous labour at term is the rule rather than exception.

Lateral supine position

Pain relief(reduces tachycardia,myocardial work,


CO)

Restriction of IV fluid 75ml/hr

O2 inhalation & pulse oxymetry

Fetal heart monitoring


TIMING OF DELIVERY
It is individualized according to the severity of
maternal disease and any associated fetal
compromise

In cyanotic HD significant IUGR may warrant


preterm delivery

Steroids considered for <34 wks


MODE OF DELIVERY
Spontaneous vaginal delivery at term is reasanable unless mother is
decompensating or there is an obstetric indication for CS

Early delivery is not required if the maternal and fetal conditions are
stable.

Painless and effortless labor

Forceps/vacuum assisted delivery IS THE RULE


MANAGEMENT DURING PUERPERIUM

Close observation for 1st 24hrs.

Signs of pulm congestion & Edema to be


looked for.

Any Infection however during puerperium


should be seriously viewed.

Breast feeding is not contraindicated unless


there is failure.
PERIPARTUM CARE

Lactation should be encouraged


unless patient is in failure.

Lactation is a pathway for fluid


excretion and diuretic requirement
may actually fall.
CARDIAC EVENTS COMPLICATING
PREGNANCY
Heart Failure

Acute Myocardial Infarction

Eisenmenger Syndrome

Cardiomyopathy

Pulmonary Hypertension
FACTORS RESPONSIBLE FOR
PRECIPITATING HEART FAILURE

Anaemia Age > 30 years


Increased physical activity

Fluid or dietary excess Gestational age > 20


weeks
Infection

Acute rheumatic carditis Arrhythmias


MANAGEMENT OF CARDIAC FAILURE

Principles

Reduction of work load with bed rest & heparin to


prevent thromboembilism

Reduction of preload with Diuretics(furosemide is the


choice)

Reduction of afterload with vasodilators(NTG is the


choice)

Correction of precipitating factors.


Clinical signs  shock, hypoperfusion, pulm edema
Most likely problem ?

Acute pulmonary edema and or CCF

FIRST LINE ACTIONS


Oxygen & intubation
NTG sublingual
Furosemide iv 0.5-1.0 mg/kg

SECOND LINE ACTIONS


NTG if SBP >100mm Hg
Dopamine if SBP 70-100 with signs & symptoms of shock
Dobutamine if SBP>100 with no signs & symptoms of shock
Haarrison’s;17th edn/1704
ACUTE MYOCARDIAL INFARCTION

Pregnancy is associated with a higher myocardial oxygen


consumption and reduced supply.

incidence of AMI is 1 in 35,700 deliveries, with a maternal


mortality rate of 7.3%.

Delivery within 2 weeks of acute myocardial infarction was


associated with up to 50% maternal mortality.

Etiology: coronary spasm-43%,atherosclerosis-47%,coronary


artery dissection-10%
EISENMENGER’S SYNDROME

Severe PAH resulting in RtLt shunt at ASD/ VSD


High risk for maternal morbidity and mortality(50%)

Poor fetal outcome(prematurity,IUD,IUGR,perinatal death)

To be advised against pregnancy, termination indicated

Death due to RV failure with cardiogenic shock


EISENMENGER’S SYNDROME

If a patient decide to proceed to term :

- Close follow-up

- Restriction of physical activity

- Hospitalization for any sign of premature uterine activity

- Early elective hospitalization recommended

- High concentration O2 may be helpful

- Vaginal delivery mostly tolerated( + forceps & vacuum extraction)

- Cesarean section
CARDIOMYOPATHIES

The 2010 ESC Working Group: PPCM is an idiopathic cardiomyopathy


Peripartum cardiomyopathy
with the following characteristics:= PPCM, also called pregnancy-
associated
● Developmentcardiomyopathy
of heart failure (HF) toward the end of pregnancy or
within five months following delivery
● Absence of another identifiable cause for the HF
● Left ventricular (LV) systolic dysfunction with an LV ejection
fraction(LVEF) of less than 45 percent. The LV may or may not be
dilated
DIAGNOSIS

Usually 20-35 years

Symptoms: Dyspnea, Cough, Orthopnea, Paroxysmal nocturnal dyspnea,


Pedal edema

Signs: Elevated jugular venous pressure, Displaced apical impulse, Third


heart sound, Murmur of mitral regurgitation

Chest X-Ray enlarged heart, pulm vascular redistribution,


ECHOenlargement of all cardiac chambers mainly LV, LVEF & CO
decreased, PCWP increases
Vigorous treatment of acute heart failure.
 Oxygen, diuretics, digoxin and vasodilators

Anticoagulant therapy is used because of high incidence of


thrombo embolic events in PPCM

Vaginal delivery Preferred.

Recurrence in subsequent Pregnancies is 21% with


normal LV function & 44% in persistent LV
dysfunction
PRIMARY PULMONARY HYPERTENSION

Maternal Mortality 50%

Fetal outcome very poor

Termination of Pregnancy indicated.

Bed rest from 20wks. of GA


PULMONARY HYPERTENSION

Commonest cause is Eisenmenger’s syndrome.

Maternal mortality 50%, perinatal 28%, 80% death


during 1st postpartum month

Highest incidence during labor and puerperium.

Mode of delivery: caesarean section probably


preferable.
CONCLUSION

Pregnancy causes significant haemodynamic changes and


imposes an additional burden on the cardiac patient,
especially around the time of labour and in the immediate
puerperium.

To achieve a successful pregnancy outcome, a clear


understanding of these haemodynamic adaptations as well as
meticulous maternal and foetal surveillance for risk factors
and complications throughout the pregnancy is essential.
Referral to a higher centre especially in presence
of moderate to severe disease.

The concerted efforts of a team consisting of the


obstetrician, cardiologist, anaesthesist,
cardiothoracic surgeon, neonatologist, and
paediatric cardiologist are mandatory to ensure
optimal results.