Cardiovascular disease in

Pregnancy

Case and Discussion

-Sani Shrestha

5/20/2013

Case

R.B.
34 years, F
Filipino, single
Roman catholic
Lubao, Pampanga

CC: for elective CS I

-Sani Shrestha

5/20/2013

History of present illness

The patient came for
Elective CS
(-) hypogastric pain
(-) bloody muciod vaginal
discharge
(-) watery vaginal discharge
(+) good fetal movement

Admissi
on
Hence Admission
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-Sani Shrestha

5/20/2013

PMH

MVP: 2010

Propanol 10g/day (inderal); stopped during

pregnancy and continued after 1st trimester

(-) HPN
(-) DM
(-) Allergy

-Sani Shrestha

5/20/2013

Family history

(+) Diabetes Mellitus=paternal grandmother

(+) lung CA = paternal grandfather
(-)Hypertension
(-) Asthma
(-) Allergies

-Sani Shrestha

5/20/2013

Personal socialhistory

Non-smoker
Non-alcoholic
3rd year High school
House maid (Helper)

-Sani Shrestha

5/20/2013

OB-Gyne-Menstrual History

Patient is G1P0

LMP July 26, 2012

EDC May 2, 2013
AOG 39 4/7 weeks

-Sani Shrestha

5/20/2013

M 16 years old
I monthly, regular
D 7 days
A 5 pads/day, moderately soaked
S (+)dysmenorrhea, no medications

OCP - none
1st sexual contact = 29 year old
2 sexual partners
(-) PCB
(-) Dyspareunia

-Sani Shrestha

5/20/2013

Physical examination

General: conscious, coherent, oriented

Vital signs:

BP: 130/80 mm of Hg
HR: 86
RR: 20
Temp: 36.9oC

Skin: no cyanosis
HEENT:

anicteric sclera, pinkish palpebral conjunctiva

no distended neck veins
-Sani Shrestha

5/20/2013

Lungs: symmetrical chest expansion, no

retractions, clear breath sounds
Cardiovascular: Adynamic precordium,
normal rate & regular rhythm, no murmurs
Abdomen: Abdomen was globular. (+) striae

FHT: 148s, FH: 33 cm

Genital: no lesions
IE: Cx closed

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-Sani Shrestha

5/20/2013

Musculoskeletal/extremities:

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No edema
no joint deformities.
Full range of motion

-Sani Shrestha

5/20/2013

Admitting Impression

G1P0 pregnancy uterine, 39 4/7 weeks AOG,

breech not in labor, gravidocardiac (Mitral
Valve Prolapse Mild)

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-Sani Shrestha

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Management Plan

For elective CS I

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-Sani Shrestha

5/20/2013

Final Diagnosis

G1P1 pregnancy uterine, term, transverse

presentation, delivered via LSCS 1, live birth
baby boy, BW 3.06 kg, BL 53cm, AS 7,8 NMR
39 weeks AGA, gravidocardiac (Mitral Valve
Prolapse Mild)

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-Sani Shrestha

5/20/2013

Discussion

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-Sani Shrestha

5/20/2013

Mitral Valve Prolapse

a pathological connective
tissue disorderoften
termed myxomatous
degenerationwhich may
involve the valve leaflets
themselves, the annulus, or
the chordae tendineae.
Mitral insufficiency may
develop.
Most women with MVP are
asymptomatic

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-Sani Shrestha

5/20/2013

Diagnosis:

anxiety, palpitations,
atypical chest pain, and
syncope.
For symptomatic:

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routine examination or
while undergoing
echocardiography.

-blocking drugs are given to

decrease sympathetic tone,
relieve chest pain and
palpitations, and reduce the
risk of life-threatening
arrhythmias.
-Sani Shrestha

5/20/2013

Physiological Considerations in Pregnancy

cardiac output is by as much as 50%

almost of total increase by 8 weeks

Due to augmented stroke volume (decreased

vascular resistance)

maximized by mid-pregnancy.
Later, resting pulse and stroke volume even
more because of diastolic filling from
pregnancy hypervolemia.

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-Sani Shrestha

5/20/2013

Diagnosis of Heart Disease

in normal pregnancy,

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functional systolic heart murmurs are common;

respiratory effort is accentuated = suggests
dyspnea;
edema in the lower extremities after
midpregnancy; and
fatigue and exercise intolerance

-Sani Shrestha

5/20/2013

Clinical Indicators of Heart Disease during Pregnancy

Symptoms

Clinical Findings

Cyanosis

Progressive dyspnea or
orthopnea
Nocturnal cough

Clubbing of fingers

Hemoptysis

Persistent neck vein distension

Syncope

Chest pain

Systolic murmur grade 3/6 or

greater
Diastolic murmur

Cardiomegaly

Persistent arrhythmia

Persistent split second sound

Criteria for pulmonary

hypertension

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-Sani Shrestha

5/20/2013

Clinical Classification of Heart Disease

classification of the New York Heart Association

(NYHA)
based on past and present disability
uninfluenced by physical signs.

Class I.

Class II.

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Uncompromisedno limitation of physical activity:

These women do not have symptoms of cardiac insufficiency
or experience anginal pain.
Slight limitation of physical activity:
These women are comfortable at rest, but if ordinary
physical activity is undertaken,
discomfort in the form of excessive fatigue, palpitation,
dyspnea, or anginal pain results.
-Sani Shrestha

5/20/2013

Class III.

Marked limitation of physical activity:

These women are comfortable at rest, but less
than ordinary activity causes excessive fatigue,
palpitation, dyspnea, or anginal pain.

Class IV.

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Severely compromisedinability to perform any

physical activity without discomfort:
Symptoms of cardiac insufficiency or angina may
develop even at rest.
If any physical activity is undertaken, discomfort is
increased.
-Sani Shrestha

5/20/2013

Predictors of cardiac complications

Prior heart failure, TIA, arrhythmia, or stroke.

Baseline NYHA class III or IV or cyanosis.
Left-sided obstruction defined as

mitral valve area < 2 cm2,

aortic valve area < 1.5 cm2, or
peak left ventricular outflow tract gradient > 30 mm Hg by
echocardiography.

Ejection fraction < 40 %

With one of these factors and even more so with two or more
factors, risk of following increases:

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pulmonary edema,
sustained arrhythmia,
stroke,
cardiac arrest, or
cardiac death
-Sani Shrestha

5/20/2013

Maternal Cardiac Lesions and Risk of Cardiac

Complications During Pregnancy
Low Risk
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Asymptomatic AS with low mean gradient (<50 mm Hg)
and normal LV
function (EF > 50%)
AR with normal LV function and NYHA Class I or II
MVP (isolated or with mild or moderate MR and normal LV
function)
MR with normal LV function and NYHA Class I or II
Mild or moderate MS (MVA > 1.5 cm2, mean gradient < 5
mm Hg) without severe pulmonary hypertension
Mild or moderate PS
Repaired acyanotic congenital heart disease without
residual cardiac dysfunction
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-Sani Shrestha

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Maternal Cardiac Lesions and Risk of

Cardiac Complications During Pregnancy
Intermediate Risk

Large left to right shunt

Coarctation of the aorta
Marfan syndrome with a normal aortic root
Moderate or severe MS
Mild or moderate AS
Severe PS

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-Sani Shrestha

5/20/2013

Maternal Cardiac Lesions and Risk of Cardiac

Complications During Pregnancy
High Risk
Eisenmenger's syndrome
Severe pulmonary hypertension
Complex cyanotic heart disease (TOF, Ebstein's anomaly,
TA, TGA, tricuspid atresia)
Marfan syndrome with aortic root or valve involvement
Severe AS with or without symptoms
Aortic or mitral valve disease, or both (stenosis or
regurgitation), with moderate or severe LV dysfunction (EF
< 40%)
NYHA Class III or IV symptoms associated with any valvular
disease or with cardiomyopathy of any cause
History of prior peripartum cardiomyopathy

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-Sani Shrestha

5/20/2013

Management of NYHA Class I and II Disease

NYHA class I and most in class II proceed

through pregnancy without morbidity.
Special attention for heart failure.
The first warning sign is likely to be

symptoms of serious heart failure.

persistent basilar rales,

accompanied by a nocturnal cough.
A sudden diminution in doing usual duties
Increasing dyspnea or coughs

Clinical findings may include hemoptysis,

progressive edema, and tachycardia.

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-Sani Shrestha

5/20/2013

Labor and Delivery

Vaginal delivery is preferred

unless obstetrical indications for CS

During labor, the mother with significant heart

disease should be kept in a semirecumbent
position with lateral tilt.
Vital signs are taken frequently between
contractions.
Increases in PR >100 bpm or RR > 24 / min,

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particularly when associated with dyspnea,

may suggest impending ventricular failure.

-Sani Shrestha

5/20/2013

Puerperium

Postpartum hemorrhage, anemia, infection,

and thromboembolism are much more serious
complications in those with heart disease.
These factors often act in concert to
precipitate postpartum heart failure

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-Sani Shrestha

5/20/2013

Management of Class III and IV Disease

If feasible, women with some types of severe

cardiac disease should consider pregnancy
interruption.
If the pregnancy is continued, prolonged
hospitalization or bed rest is often necessary.
Epidural analgesia for labor and delivery is
usually recommended.
Vaginal delivery is preferred in most cases,
and labor induction can usually be done safely
Cesarean delivery is usually limited to
obstetrical indications

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-Sani Shrestha

5/20/2013

Valvular Heart Disease

Rheumatic fever remains the chief cause of

serious mitral valvular disease
1.
2.
3.
4.
5.

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Mitral Stenosis
Mitral Insufficiency
Aortic Stenosis
Aortic Insufficiency
Pulmonic Stenosis

-Sani Shrestha

5/20/2013

Mitral Stenosis

Rheumatic endocarditis = of
mitral stenosis
The normal mitral valve surface
area = 4.0 cm2.
stenosis = < 2.5 cm2,
symptoms develop
The most prominent complaint
is dyspnea

due to pulmonary venous

hypertension and edema.

Fatigue, palpitations, cough,

and hemoptysis are also
common.
32

-Sani Shrestha

5/20/2013

significant stenosis
tachycardia =
ventricular diastolic filling time and
the mitral gradient
left atrial and pulmonary venous and capillary
pressures

Pulmonary
edema
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-Sani Shrestha

5/20/2013

Management

If symptoms of pulmonary congestion develop

dietary sodium is restricted, and diuretic therapy

is started

If new-onset atrial fibrillation develops,

intravenous verapamil, 5 to 10 mg, is given,
or electrocardioversion is performed.
For chronic fibrillation, digoxin, a -blocker, or
a calcium-channel blocker is given to slow
ventricular response.
Therapeutic anticoagulation with heparin is
indicated with persistent fibrillation.

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-Sani Shrestha

5/20/2013

Mitral Insufficiency

Chronic mitral regurgitation

Acute mitral insufficiency

rheumatic fever,
mitral valve prolapse, or
left ventricular dilatation
rupture of a chorda tendineae,
infarction of papillary muscle, or
leaflet perforation from infective
endocarditis.

mitral regurgitation is well tolerated

Heart failure only rarely develops
Intrapartum prophylaxis against
bacterial endocarditis may be
indicated
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-Sani Shrestha

5/20/2013

Aortic Stenosis

normal 2- to 3-cm2 aortic orifice

reducesresistance to ejection
If valve area is of normal size = severe
obstruction to flow and a progressive
pressure overload on the left ventricle
Concentric left ventricular hypertrophy
follows, and if severe, end-diastolic
pressures become elevated, ejection fraction
declines, and cardiac output is reduced
Characteristic clinical manifestations
develop late and include chest pain,
syncope, heart failure, and sudden death
from arrhythmias.
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-Sani Shrestha

5/20/2013

valve replacement is indicated

for symptomatic patients.
increased complications =
valve area < 1.5 cm2.
Management of the
symptomatic woman includes
strict limitation of activity and
prompt treatment of infections.
If symptoms persist despite
bed rest:

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valve replacement or valvotomy

using cardiopulmonary bypass
-Sani Shrestha

5/20/2013

Aortic Insufficiency

Common causes

rheumatic fever, connective-tissue

abnormalities, and congenital lesions.

may develop with bacterial endocarditis

or aortic dissection.
In chronic disease, left ventricular
hypertrophy and dilatation develop
together with slow-onset fatigue,
dyspnea, and edema,
well tolerated during pregnancy.
If symptoms of heart failure develop,
diuretics are given and bed rest is
encouraged.
bacterial endocarditis prophylaxis may
be required
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-Sani Shrestha

5/20/2013

Pulmonic Stenosis

The clinical diagnosis =

auscultating a systolic
ejection murmur over the
pulmonary area
Increased hemodynamic
burdens of pregnancy can
precipitate right-sided heart
failure or atrial arrhythmias in
women with severe stenosis
surgical correction before or
during pregnancy if
symptoms progress.
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-Sani Shrestha

5/20/2013

Congenital Heart Disease

Septal Defects

Atrial Septal Defects

Ventricular Septal Defects
Atrioventricular Septal Defect

Persistent Ductus Arteriosus

Cyanotic Heart Disease

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-Sani Shrestha

5/20/2013

Atrial Septal Defects

Pregnancy is well tolerated unless

pulmonary hypertension
If congestive heart failure or an
arrhythmia develops, treatment is
given.
Bacterial endocarditis prophylaxis has
been recommended in certain
circumstances with unrepaired defects
The potential to shunt blood right to
left makes possible a paradoxical
embolism
Compression stockings and
prophylactic heparin in the pregnant
woman with a septal defect
recommended
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-Sani Shrestha

5/20/2013

Ventricular Septal Defects

the defect <1.25 cm2,

the defect > the aortic

valve orifice

pulmonary hypertension and

heart failure do not develop.

symptoms rapidly develop.

Pregnancy is well tolerated

with small to moderate leftto-right shunts.

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-Sani Shrestha

5/20/2013

When pulmonary
arterial pressures reach
systemic levels,
however, there is
reversal or bidirectional
flowEisenmenger
syndrome
the maternal mortality
rate is 30 - 50 %

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-Sani Shrestha

5/20/2013

Atrioventricular Septal Defect

ovoid-shaped AV
junction.
Compared with simple
septal defects,
complications are more
frequent during
pregnancy.

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-Sani Shrestha

5/20/2013

Persistent Ductus Arteriosus

Physiological consequences of
this lesion are related to its size
With an unrepaired PDA

Develops pulmonary
hypertension, heart failure, or
cyanosis

A sudden blood pressure

decrease at deliverysuch as
with conduction analgesia or
hemorrhagemay lead to fatal
collapse.
Hypotension should be avoided
whenever possible and treated
vigorously if it develops.
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-Sani Shrestha

5/20/2013

Cyanotic Heart Disease

When congenital heart lesions

are associated with right-to-left
shunting of blood past the
pulmonary capillary bed,
cyanosis develops.
The classical and most
commonly encountered lesion in
pregnancy is the Fallot
tetralogy.

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a large ventricular septal defect

pulmonary stenosis
right ventricular hypertrophy, and
an overriding aorta that receives
blood from both the right and left
ventricles.
-Sani Shrestha

5/20/2013

Eisenmenger Syndrome

secondary pulmonary
hypertension that develops
from any cardiac lesion.

atrial / ventricular septal defects

persistent ductus arteriosus.

develops when pulmonary

vascular resistance > systemic
resistance, with concomitant
right-to-left shunting.
Women with Eisenmenger
syndrome tolerate hypotension
poorly, and the cause of death
usually is right ventricular
failure with cardiogenic shock.

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-Sani Shrestha

5/20/2013

Peripartum Cardiomyopathy

National Heart, Lung, and Blood Institute and the

Office of Rare Diseases established the following
diagnostic criteria:
a)
b)
c)
d)

Development of cardiac failure in the last month of

pregnancy or within 5 months after delivery,
Absence of an identifiable cause for the cardiac failure,
Absence of recognizable heart disease prior to the last
month of pregnancy, and
Left ventricular systolic dysfunction demonstrated by
classic echocardiographic criteria such as depressed
shortening fraction or ejection fraction

Relationship between terbulatine tocolytic therapy

and Peripartum cardiomyopathy.
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-Sani Shrestha

5/20/2013

Treatment

Salt restriction and use of diuretics

Hydralazine is Drug of Choice for prepartum,

in addition to nitrate or amplodipine,

ACE-inhibitors are mainstay in post-partum

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-Sani Shrestha

5/20/2013

Hypertrophic Cardiomyopathy

cardiac hypertrophy, myocyte disarray, and

interstitial fibrosis
caused by mutations in any one of more than
a dozen genes that encode proteins of the
cardiac sarcomere.
autosomal dominant
abnormality is in the myocardial muscle
characterized by left ventricular myocardial
hypertrophy with a pressure gradient to left
ventricular outflow

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-Sani Shrestha

5/20/2013

Diagnosis:

Most are asymptomatic,

echocardiographic identification of a
hypertrophied and nondilated left ventricle in the
absence of other cardiovascular conditions.
but dyspnea, anginal or atypical chest pain,
syncope, and arrhythmias may develop.

Complex arrhythmias may progress to sudden

death,
Symptoms are usually worsened by exercise.

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-Sani Shrestha

5/20/2013

Infective Endocarditis

involves cardiac endothelium

produces vegetations that usually deposit on a
valve.
involve a native or a prosthetic valve, and it may
be associated with intravenous drug abuse.
Organisms that cause indolent endocarditis are
most commonly viridans-group streptococci or
Enterococcus species.
the most common causative organisms are
streptococciespecially viridansfollowed by
Staphylococcus aureus and Enterococcus species
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-Sani Shrestha

5/20/2013

Diagnosis

Fever is virtually universal,

a murmur ultimately is heard in 80-85 % of cases
Anorexia, fatigue, and other constitutional
symptoms are common
Other findings are anemia, proteinuria, and
manifestations of embolic lesions, including
petechiae, focal neurological manifestations,
chest or abdominal pain, and ischemia in an
extremity.
Diagnosis is made using the Duke criteria,

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positive blood cultures for typical organisms

evidence of endocardial involvement
-Sani Shrestha

5/20/2013

Management

primarily medical with appropriate timing of

surgical intervention if necessary.
Most viridans streptococci are sensitive to penicillin
G given intravenously with gentamicin for 2 weeks.
Complicated infections are treated longer, and
women allergic to penicillin = IV ceftriaxone or
vancomycin for 4 weeks.
Prosthetic valve infections are treated for 6 to 8
weeks.
Right-sided infections caused by methicillinresistant S. aureus (MRSA) are treated with
vancomycin
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-Sani Shrestha

5/20/2013

Myocardial Infarction

Uncommon
More common during the 3rd
and or peripartum
Presents with ischemic chest
pain, abnormal ECG and
elevated cardiac enzymes
Management : early
coronary angiography
In postpartum period,
spontaneous coronary artery
dissection is most common
cause of MI
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-Sani Shrestha

5/20/2013

Risk factors:

Treatment:

Increase maternal age

Smoking
DM type II
Coronary stenting or emergency coronary artery
bypass grafting

IM or IV Ergometrine after delivery associated

with MI due to coronary artery spasm.

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-Sani Shrestha

5/20/2013

Antepartum Management

Limitation of physical activity is helpful in

severely affected women with

ventricular dysfunction,
left heart obstruction
class III or IV symptoms

Beta-blockers rather than digoxin for

controlling heart rate for patients with
functionally significant MS

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-Sani Shrestha

5/20/2013

CS is indicated only in

Aortic dissection
Marfan syndrome with dilated aortic root
Taking warfarin within 2 weeks of labor

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-Sani Shrestha

5/20/2013

Postpartum Management

Patients at intermediate or high risk may

require monitoring for at least 72 hours
postpartum
Patients with Eisenmenger syndrom are risk of
death for up to 7 days postpartum, thus
longer observation required.

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-Sani Shrestha

5/20/2013

References
Williams Obstetrics 23rd Edition
Textbook of Obstetrics 3rd Edition
Pregnancy and Heart Disease:
Cleveland Clinic;
http://www.clevelandclinicmeded.c
om/medicalpubs/diseasemanagem
ent/cardiology/pregnancy-andheart-disease/

THANK YOU!
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-Sani Shrestha

5/20/2013