HEART DISEASE IN PREGNANCY

! ! ! The commonest cause of heart disease in pregnancy: ! - Rheumatic Heart Disease 55% ! - Congenital Heart Disease 40%

Normal Physiological Changes in CVS during Pregnancy

Parameter
Blood volume Cardiac output Stroke volume Heart rate Systolic blood pressure Diastolic blood pressure Pulse pressure Systemic vascular resistance

1st Trimester

2nd Trimester to

3rd Trimester to , or to

Normal changes in heart sounds during pregnancy

Increase loudness of both S1 and S2 Increase splitting of mitral and tricuspid component of S1 No constant change in S2 Loud S3 by 20 weeks gestation <5% develop S4 >95% develop a systolic murmur that disappears after delivery 20% have transient diastolic murmur 10% develop continuous murmur d/t increased mammary blood ow

During labour, anxiety, pain and uterine contraction will lead to more cardiac output....

Management Principles: 1. Pre-conceptual counseling 2. Assessment and stratication of maternal and fetal risks 3. Management of the pregnancy and complications of heart disease 4. Determining the timing, mode and place of delivery 5. Antibiotic prophylaxis during procedure/labour SYMPTOMS: Pre conceptual counseling Severe, progressive, dyspnoea Progressive orthopnoea PND Syncope with exertion Chest pain related to effort/ emotion

Risk assessment: 1. NYHA Functional Class 2. Presence of cyanosis 3. Left ventricular and right ventricular function 4. Severity of pulmonary hypertension 5. Presence of valve/conduit stenosis (left heart obstruction) 6. Presence of conduction defects 7. Presence of arrythmias 8. Smoking 9. Multiple gestation

- The effect of the haemodynamic changes on the patient - The effect of the cardiac disorder on fetal development - The effect of maternal drugs on the fetus - The risk of genetic transmission to the fetus Patients with heart disease should be encouraged to complete their family early and be discouraged from having too many pregnancies. High-risk patients should be advised on permanent contraceptive measures. Not impossible to diagnose heart disease in pregnancy Pregnant women must be examined at least once by a doctor during ANC PMH & PSH Screen for cardiac signs and symptoms

NYHA Functional Class CLASS I:

SIGNS TO LOOK FOR: Clubbing Central cyanosis Displaced apex beat Murmurs (esp Diastolic, systolic murmur) Signs of Left heart failure gallop rhythm basal crepitation pleural effusion Signs of Right heart failure congested neck veins enlarged tender liver Ascites oedema

CLASS II

CLASS III:

CLASS IV:

INTRAPARTUM MANAGEMENT
Standard Regimen

ANTIBIOTIC PROPHYLAXIS REGIME

Ampicillin Gentamicin Amoxicillin IV or IM Ampicillin 2.0 gm + IV or IM Gentamycin 1.5 mg/kg (not to exceed 80 mg) 30 mins before procedure, followed by: Amoxicillin 1.5 gm orally 6 hours after initial dose or repeat parenteral regime 8 hours after initial dose

1. Left lateral position 2. Oxygen therapy 3. Closely vital signs monitoring: 1. Arterial saturation with pulse oximeter 2. Blood Pressure 3. CVP (occasionally) 4. Continuous ECG monitoring for mother (to detect arrythmias) 5. Fetal monitoring (CTG) 6. Fluid therapy to be carefully monitored to avoid pulmonary oedema 7. Pain and anxiety relief vital to reduce tachycardia 8. Second stage must be shortened 9. Antibiotic prophylaxis against endocarditis at onset of labour or induction of labour POSTPARTUM 1. Increase in venous return: due to the relief of caval compression and auto transfusion from the contracting uterus 2. Systolic BP rises in rst 24 hours of delivery 3. Stroke volume rises by 10% in the rst 48 hours of delivery and then reduces over next 2-4 weeks 4. Careful haemodynamic monitoring is important in these patients for about 48-72 hours. 5. Remain in hospital for atleast a week 6. Encouraged patient to breast feed

Penicillin Allergic Patient Vancomycin Gentamicin IV Vancomycin 1.0 gm over 1 hour+ IV or IM Gentamycin 1.5 mg/kg (not to exceed 80 mg) 1 hour before procedure and repeat 8 hours later Alternative Low Risk Regime Amoxicillin 3gm orally 1 hour before procedure, then 1.5gm 6 hours later

ANTICOAGULATION IN PREGNANCY: Indications: 1. Mechanical heart valves 2. DVT and Thromboembolism - risk of DVT is 5x 3. Atrial Fibrillation associated with structural heart disease 4. Misc cond: Peripartum Cardiomyopathy, Primary Pulmonary HPT, Eisenmengers Syndrome, Complex CHD Drugs given: 1. Warfarin a. Assoc with warfarin embryopathy 4-10% b. Fetal complications seen in dose >5mg daily 2. Unfractionated heparin a. Does not cross placenta b. Requires monitoring with APTT c. Complications: abcess, hematomas, thrombocytopenia, osteoporosis 3. LMWH : Fewer complications of thrombocytopenia and osteoporosis