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normal physiological changes occur during pregnancy, both blood volume and cardiac output increased by 40 % cardiac output increased is result from increase in both heart rate and stroke volume greatest increase is seen within 1st trimester, peak at around 24 weeks

Effect of pregnancy on heart disease

pregnancy increased the risk of cardiovascular compromise, most noticeably in labour and the 3rd stage. cardiac failure may occur gradually throughout pregnancy as the heart fail to meet the demands on the circulation

Effect of heart disease on pregnancy

Maternal risk 1) Maternal mortality - 40-50% among women with pulmonary hypertension and eisenmengers syndrome

Fetal risk 1) Intrauterine growth restriction 2) preterm delivery 3) congenital heart disease

Detection of cardiac disease in pregnancy

Sign and symptom and a normal pregnancy may mimic those of cardiac disease Careful history and physical examination is vital Symptoms - Dypsnoea, Palpitation, Reduced effort tolerance Signs - clubbing, cyanosis, arrhytmia, heart murmur and sign of cardiac failure.

Classify severity and symptom according to NYHA

CLASS I No limitation.ordinary physical activity does not cause Undue fatique, dyspnea, or palpitation Slight limitation of physical activity, ordinary activity result in fatique palpitation dyspnea or angina Marked limitation of physical activity, comfortable at rest, less than ordinary activity will lead to symptom Inability to carry on physical activity without discomfort.symptom of congestive failure are present at rest. With any physical activity increased discomfort is experienced.


Management of heart disease in pregnancy

Pre- pregnancy management Antenatal management Management of labour and delivery

Pre pregnancy management

Detail assessment of their cardiac status and the likely effect of pregnancy on it, need cardiologist involvement Pre pregnancy counselling of women with heart disease - Risk of maternal death - possible reduction of maternal life expectancy - risk of preterm labour, IUGR, risk of fetus developing congenital heart disease

Antenatal management
Managed in a joint obstetric/cardiac clinic Monitor sign/ symptom of heart failure and any sign of deteriorating cardiac status - Breathlessness - tachycardia - reduced in effort tolerance NEW YORK HEART ASSOCIATION

Avoid risk factor for development of heart failure Respiratory infection anaemia obesity tocolytic fluid overload pain related stress The use of anticoagulant Warfarin is teratogenic if used in first trimester Replacing warfarin with heparin in 1st pregnancy

Management of labour and delivery

Avoid induction of labour if possible If not, can be augmented according to cardiac regime to avoid fluid overload

use prophylactic antibiotic for those with structural anomalies of the heart, prosthetic heart valves. Standard Regime 1 Ampicillin (IV or IM 2gm) + Gentamycin (IV or IM 1.5mg/kg not to exceed 80 mg) amoxycillin 1.5 g orally 6 hours after initial dose (single dose0 Standard Regime 2 Ampicillin (IV or IM 2GM) + Gentamicin (IV or IM 1.5mg/kg, not to exceed 80 mgamoxycillin 2gm IV or IM 8 hours after initial dose (single dose)

Patients is allergic to penicillin - Antibiotic to be given 1 hour before procedure Vancomycin (IV 1gm over 1 hour) + Gentamicin (IV or IM 1.5mg/kg not to exceed 80 mg) repeat 8 hours for both antibiotic, same dosage.

Mother should remain propped up position and give oxygen supplementation careful haemodynamically monitoring - Cardiac monitoring - Pulse oximeter - Vital sign (BP, HR, temp every hour) - strict i/o charting (ensure fluid balance) Analgesia - Epidural can be offered depend on nature of the heart disease and degree of heart failure.

Keep shorten second stage Via instrumental delivery Use syntocinon Precaution Avoid usage of pethidine ( can cause tachycardia) Avoid lithotomy position (can cause sudden increased in venous return) - avoid ergometrine (can cause vasoconstriction, hypertension,heart failure) After delivery , observe closely for 24 hours in HDU