CARDIAC DISEASE IN PREGNANCY

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PLAN
Epidemiology Pathology Clinical Presentation Investigations Management New York Heart Association Classification - Antepartum - Intrapartum - Post Natal

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EPIDEMIOLOGY

diac disease complicates 1% (0.3 3.0%) of pregnancies w

t is the most important non-obstetric cause of maternal mor MMR = 5/100,000 deliveries

K.N.H MMR = 3,200/100

seases (RHD) in developing countries. This is due to high

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 About 90% of cardiac diseases in pregnancy are due to congenital heart disease in some developed countries

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PATHOLOGY
In normal pregnancy haemo dynamic changes occur from the first trimester and peak in the 3rd trimester into a high output cardiac status
HR increases by 10% (10-15 beats/min) Plasma volume increases by 40%.
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 This increase in cardiac output may cause a systolic murmur in women who are healthy. However diastolic murmurs are always indicative of heart disease.
With cardiac disease in pregnancy increased cardiac output predisposes to CCF
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 CCF is further predisposed to by - Sepsis - Anemia -Exercises (physical activity) To prevent CCF prevent sepsis and anaemia and reduce exercises.
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AETIOLOGY
Rheumatic Heart Disease (RHD) 90% involve mitral valve Mitral stenosis has highest risk for CCF When tricuspid valve is affected all other valves are usually involved

Congenital Heart Disease (CHD) VSD, ASD, PDA are commonest

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 Hypertensive Heart Disease (HHD)

Age above 35yrs Below 35yrs common causes are

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renal artery stenosis phaechromocytoma thyrotoxicosis

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 Peripartum Cardiomyopathy Rare Patient without a heart lesion develops CCF in pregnancy or post-partum Treat with digoxin and lasix
Ischaemic Heart Disease Syphylitic Heart Disease
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 Cor pulmonale Increased pulmonary vascular resistance Chronic obstructive airway diseases e.g asthma or chronic bronchitis.

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COMPLICATIONS OF CARDIAC DISEASE

Maternal -CCF - Pulmonary embolism -Anaemia Fetal - IUGR - Abortions - Preterm deliveries - IUFD
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CLINACAL PRESERNTATION
1. Failure to thrive poor growth, finger clubbing 2. C.C.F symptoms shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, wheezing. signs tachycardia,Increased JVP, Murmurs, basal creps, alae nasi flaring, tachypnoea, oedema, ascites, tender hepatomegaly
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 Tissue hypoxia pallor, cyanosis, oliguria, anuria , confusion , coma , cold periphery . Myocardial strain angina pain , palpitations, fibrillation Murmurs Infective endocarditis
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INVESTIGATIONS
ECG Echo cardiogram Urinalysis Haemogram U/E

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NEW YORK HEART ASSOCIATION CLASSIFICATION

-Based on functional state of the heart. Grade 1 -Uncompromised. -No Limitation of physical activity. Grade 2 -Slight limitation of physical activity -Dyspnoea on moderate exertion Grade 3 -Marked limitation of physical activity -Dyspnoea on mild exertion. Grade 4 -Inability to perform any physical activity -Dyspnoea at rest , current or past CCF

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ANTENATAL CARE
Combined team of cardiologist & obstetricians. Grades 1&2 as out-patients until 36 weeks of gestation. Prevent excess weight gain (diet) -Fluid retention (frusemide) - anemia (haematinics) -Sepsis (screen for UTI & isolate from URTI patients) Adequate rest 10hrs at night , 2 hrs daytime. Prop up in bed Treat pre-eclampsia aggressively Grades 3&4 give digoxin 0.25mg & Frusemide 40 mg daily RHD monthly benzathine penicillin 2.4 MU. Prosthetic valves anticoagulate. Dental Procedures be done under antibiotic cover Minor Heart surgery .e.g valvotomy is allowed. Avoid open heart surgery
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INTRAPATUM

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Prepare resuscitation tray containing ; Digoxin Frusemide Adrenaline Naloxone. Hydrocortisone Calcium gluconate Sodium bicarbonate Aminophylline Oxytocin Pethidine or morphine
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1ST STAGE
Keep propped up I.M morphine 15mg or I.M pethidine 100mg to allay anxiety & minimize pain. Oxygen by mask. Avoid I.V. fluids and if given , add I.V. frusemide If oxytocin is necessary use pump to minimize fluid infusion. Delay ARM. I.V. Broad-spectrum antibiotics Minimize number of pelvic exams. Caesarean sections for obstetric indications only.
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2nd STAGE
No valsava maneuver Vacuum extraction.

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3rd STAGE
I.V. frusemide 40mg stat Massage uterus
Avoid ergometrine I.M. oxytocin 10 units

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PEUPERIUM
Keep admitted for 10 days. Limit exercises Continue with antibiotics. Continue anticoagulation

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POST-NATAL VISIT
Advice on limited family size , 1-2 children. BTL or vasectomy Progesterone only drugs microlut , jadelle , noristerat Barrier condoms Avoid oestrogens may cause fluid retention. Avoid IUCD increases sepsis rate.

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