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Cardiac Disease in

Pregnancy

O&G Dept
CWM Hospital

Physiological changes

Four main changes that impact of a potentially


compromised CVS are
1. Volume
2. systemic vascular resistance
3. C.O
4. Hypercoagulability

Physiology

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

Physiology

Braunwald E et al. Heart


Disease. 2001. pg. 2173.

Physiology

Braunwald E et al. High Risk


pregnancy. 5th edition. pg.
143.

Reason for Risk assesment


To identify the high risk groups
To provide counseling
The risk for short term and long term
complication
Risk mother
Risk Fetus
The risk of inheritance of congenital heart
disease

Risk assessment
Lesion assessment
Global Risk (risk Index)

Mortality associated with


specific cardiac lesions
1. Low risk of maternal mortality (less than 1%).
a) Septal defects.
b) Patent ductus arteriosus.
c) Pulmonary / tricuspid lesions.
2. Moderate risk of maternal mortality (5-15%).
a) Aortic stenosis.
b) Marfans syndrome with normal aorta.
c) Uncomplicated coarctation of aorta.
3. High risk of maternal mortality (25-50%).
a) Eissenmengers syndrome.
b) Pulmonary hypertension.
c) Marfans syndrome with abnormal aortic root.
d) Peripartum cardiomyopathy.

Dr.M. Narayanswamy
Prof. & HOD,OBG
Sri Devaraj Urs Medical College, Kolar

Example of lesion specific Risk


Mitral Stenosis
Mild - 26%
Moderate- 38%
Severe67%

Silvarsides CK, Sui SC and other


Cardiac risks in pregnant women with RHD/MS, 2003

GLOBAL RISK (RISK


INDEX)

By Samuel C. Siu, MD and associates

RISK AND PREDICTORS FOR


PREGNANCY RELATED COMPLICATION IN
WOMEN WITH HEART DISEASE (1997)

Method
Retrospective cohort study
Examined 276 pregnancy in 221 women
Toronto hospital, Mt sinai hospital and
womens college hospital.
1986 to 1994

Inclusion
All pregnant women with heart disease
Congenital
Aquired
Arrhymias
Symptomatic
Sustained
Requiring treatment before pregnancy
Echo at booking or within previous 2 years

Exclusion
Patients with isolated mitral valve prolapse
23 women who underwent therapeutic
abortion

Data collection
Definition of predictors and outcome were a
consensus between cardiologist and
obstetrician
Independent review of health records by 2
coauthors

Maternal outcome
(cardiac event)

Pulmonary odema
Symptomatic tachy or brady arrythmia
Stroke or TIA
Death

Neonatal outcome

Prematurity
SGA (BWT < 10th)
RDS
Intra-ventricular hemorrhage after birth
Death

Secondary outcome
PIH
PPH

RESULTS

Basic maternal characteristics

Echo finding was also included in the


assesment
Etiology
Congenital
55%
Acquired
34%
Arrhythmia
11%

Click icon to add picture

No Maternal Death
No Eisenmenger syndrome
4 marfan syndrome ( normal aortic root)
89% of the cardiac events occurred in Antepartum period

Predictors maternal cardiac


event
1. Prior cardiac event
2.
3.
4.

5.

Hx HF, TIA or stroke


Prior arrhymia
NYHA class > II or cynosis during booking
Left heart obstruction
Aortic 1.5cm with doppler 4m/s
MVA <2 cm
LVOT > 30 mm hg
Myocardial dysfunstion EF <40%

Points system
66%

30%
3%

Sensitivity 91%
Specificity 61%

CONCLUSION

The low maternal and neonatal deaths


Greater vigilance of care
There is a strong association of a high NYHA
and cyanosis with maternal and neonatal
complication
There combination of many factors max
power
But it is recommended that this score be a
supplement, not replace the lession specific
risk factor

Weakness
Pulmonary HTN and prior cardiac surgery
wasnt associated with complication
Because there is a small number (8)
The need for a larger study
The need to assess specific lesion
All Marfan syndrome had normal aortic root
Need for a prospective study
The need to assessment medication use and
its effects

By Samuel C. Siu, MD and associates

PROSPECTIVE
MULTICENTER STUDY OF
PREGNANCY OUTCOMES
IN WOMEN WITH HEART

Difference in Method

Prospective study
Enrolled 562
Had more pulmonary HTN ( n= 25)
Marfan syndrome ( n= 10)
There was still no Eisenmenger syndrome

RESULTS

Cardiac events
Primary
(80) 13%

Total number
cardiac events
(99) 17%

Pulmonary
edema
(38)
Arrhythmia
(40)
Stroke or TIA
(4)
cardiacDeath
(2)

Secondary
(37) 6%

Worsening of
the Fx classes
(26)
Need for
intervention
(13)

Neonatal events
Premature birth
(105)
Total number
Neonatal
events
(122)

Small for
gestational age
(22)

RDS + IVH =
(17)

Fetal
(8)

Death
NND
(7)

Obstetric events
PIH
(24)
obstetric
events

Noncardiac
deaths
(2)
PPH
(19)

PET
(12)

Click icon to add picture

Click icon to add picture

1. Prior hx of arrythmia or cardiac event


2. NYHA class > 2 or cynosis at booking
3. Left heart obstruction
1. MVA < 2cm sq
2. AVA < 1.5 cm sq
3. LVOT > 30mm hg
4. EF < 40%

Click icon to add picture

75%
27%
5%

CASE 1

Case 1
26 yr old Fijian primp
know case of RHD and abnormal rhythm at
form3
Was on digoxin now no meds
Defaulted clinic 2 years before
Presented with
SOB at rest & Palpitation
26 weeks of gestation (unbooked)

Case 1
On Examination
P 160 Bp 150/70 Sat- 97% ( oxygen 3L)
No Cynosis
JVP normal
Lung
Bilateral crepitation
Heart
Systolic murmur

Case 1
Abdominal
20cm fundal height
Extremities
No oedema
Investigation
ECG Show fast AF
Chest xray Enlarged heart
Enlarged LV
Enlarged LA

Case 1
Echo
was done but the result was missing from
the folder
Severe MS (<1cm)
Assesment
CCF
AF
VHD ( severe MS )

Risk assesment
1. Prior cardiac event
Prior arrhymia
2. NYHA class > II
3. Left heart obstruction
MVA <2 cm
Total points is 3 = 75%

Outcome
This patient manage to reach
35 weeks by scan
39 weeks by dates
She had a CS for obstetric reasons
The wasnt any notes availible intra op
But GA was used
She when into a coma post op
GCS of 6

CT Scan
Report: impression
Generalised ischeamic encephalopathy
Small infarct basal ganglia
Due to
? Prolonged hypotension

Post mortem
Heart
Mitral valve admit tip of finger
Impression
Heart failure as a complication of VHD in
high risk pregnancy

CASE 2

Mrs AK

23 yr old Fijian
G1P0

29/7/11 Cardiac Clinic


Intermittent
episodes of SOB
last yr.
Now Asx,
OE: HR 80bpm
Lying flat
comfortably
No cyanosis.
Chest: Clear

CVS: JVP 3cm


Apex 5th ICS MCL
Loud S1
Soft Ejection
systolic murmur at
Mitral area
ECG: 80bpm NSR
CXR: NAD

2/8/11 Echocardiogram

AoR 2.79cm
LA 3.74cm
IVSd 1cm
LVPWd 0.67cm
LVs 3.44cm
MVA 1.9cm2
EF 60%

Summary:
Mod MS with Mild MR

Mitral Valve
abnormal with
thickened cusps of
both leaflets.
No pulmonary HTN

Currently: 36/40
Last Seen @ 33/40
Completely Asx
Physically nil sign of failure

Impression:
NYHA 1
Mod MS and Mild MR
MVA 1.9cm

Risk Index

No Hx of Cardiac event
NHYA 1 and nil cynosis
MVA 1.9
EF 60%

Total points is 1 =
27% cardiac event
4% Neonatal or fetal death

Longterm Plan
1. Benzathine IM every 3/52
2. Weekly Reviews
3. IOL @ 38/40

Making a assesment

Risk index
Specific lesion
If there is a discordance
Take the higher Risk assesment