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Seminar III Obstetric & Gynecology

Seminar III Obstetric & Gynecology. Prepared & Presented by: Ibrahim Tawhari . Scenario: . Hx .: A 30-year-old multigravida at the 20 weeks’ gestation. Has a mild SOB with activity. She has no symptoms at rest. Had a childhood history of rheumatic fever. P/E: Diastolic murmur.

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Seminar III Obstetric & Gynecology

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  1. Seminar IIIObstetric & Gynecology Prepared & Presented by: Ibrahim Tawhari.

  2. Scenario: • Hx.: • A 30-year-old multigravida at the 20 weeks’ gestation. • Has a mild SOB with activity. • She has no symptoms at rest. • Had a childhood history of rheumatic fever. • P/E: • Diastolic murmur. • Investigations: • Echocardiography: Mitral stenosis.

  3. Cardiac Diseases in Pregnancy Prepared & presented by: Ibrahim Tawhari.

  4. Outlines:

  5. Normal Hemodynamic Changes in Pregnancy: • Plasma volume • Cardiac Output • Heart rate • Left Ventricular Work index 50% 20% 20%

  6. Normal Hemodynamic Changes in Pregnancy: • Systemic Vascular Resistance SVR • Pulmonary Vascular Resistance PVR • BP 20% 35%

  7. Normal Hemodynamic Changes in Pregnancy: • Murmur!!?? • A systolic ejection murmur along the left sternal border is normal in pregnancy owing to increased COP. • “Hyperdynamic Circulation” • Diastolic murmurs are never normal in pregnancy and must be investigated.

  8. Outlines:

  9. Outlines:

  10. Classification of Cardiac Diseases: Structural Classification Functional Classification

  11. Structural Classification:

  12. Structural Classification:

  13. Structural Classification:

  14. Classification of Cardiac Diseases: Structural Classification Functional Classification

  15. New York Heart Association Classification NYHA:

  16. New York Heart Association Classification NYHA: Class I and Class II are low risk patients. They have a good prognosis and do not need invasive monitoring in labour. Class III and Class IV are High risk patients. They have a poor prognosis need invasive monitoring in labour.

  17. Outlines:

  18. Signs & Symptoms of Heart Diseases: • Symptoms: • Severe progressive dyspnea. • Orthopnea. • Paroxysmal Nocturnal Dyspnea PND. • Hemoptysis. • Chest pain. • Syncope.

  19. Signs & Symptoms of Heart Diseases: • Signs: • Severe systolic murmur  3/6 “ with palpable thrill”. • Diastolic murmur. • Parasternal heave. “ cardiomegaly “. • Cyanosis & clubbing. • Signs of pulmonary HTN. • Persistent jugular venous distension.

  20. Outlines:

  21. Overview ….. Special Conditions:

  22. Rules: Valvular Stenosis are NOT well-tolerated in pregnancy… Valvular insufficiency as well as ASD & VSD are well-tolerated in pregnancy…

  23. Rheumatic Heart Diseases

  24. Rheumatic Heart Diseases: • They are the most common etiology. • Mitral Stenosis: • The most common acquired heart disease in pregnancy. • Dx.: Echocardiography. • Complications: • Slow diastolic follow. • Diastolic Murmur. • Left Atrial Enlargement: • Atrial fibrillation  emboli. • Subacute bacterial endocarditis SBE.

  25. Rheumatic Heart Diseases: • Complications: • Pulmonary edema develops early.

  26. Rheumatic Heart Diseases: • Mitral Insufficiency (Regurgitation): • Well tolerated in pregnancy… • In the past, rheumatic fever was the commonest etiology. • However, nowadays, the commonest cause is congenital mitral valve Prolapse. • Usually, not complicated by SBE. (No need for prophylaxis).

  27. Rheumatic Heart Diseases: • Aortic Stenosis: • If severe: • Mortality is high. • The pregnancy should be terminated. • Correction: surgical • Surgical correction is ideal to be done before pregnancy. • If it is necessary to be done during pregnancy, it is done in the 2nd trimester. • 2 types: • Closed surgery: can also be done in 1st trimester. • Open: is NEVER done during pregnancy.

  28. Congenital Heart Diseases

  29. Congenital Heart Diseases: • Acyanotic: • VSD and ASD are the most common congenital heart diseases. • They are well-tolerated in pregnancy. • Cyanotic: • Tetralogy of Fallot is the most common. • Should be repaired surgically.

  30. Congenital Heart Diseases:

  31. Congenital Heart Diseases: • Eisenmenger’s Syndrome:

  32. Congenital Heart Diseases: • Eisenmenger’s Syndrome: • Characterized by pulmonary HTN and bidirectional shunt. • If the pulmonary pressure exceeds the systemic pressure, the shunt reverses  Mortality is high. • During pregnancy, decrease in systemic vascular resistance SVR places the patient at risk of mortality. • The mortality rate of Eisenmenger’s syndrome during pregnancy is about 50%

  33. Congenital Heart Diseases: • Eisenmenger’s Syndrome: • Management:  Avoid Hypotension….

  34. Marfan’s Syndrome

  35. Congenital Heart Diseases: • Marfan’s Syndrome: • An autosomal dominant CT disease. • Defect on fibrillin gene on chromosome 15. • Fibrillin is an important components in the media layer of blood vessels wall.

  36. Congenital Heart Diseases: • Marfan’s Syndrome:

  37. Congenital Heart Diseases: • Marfan’s Syndrome: • If the aortic root is diameter is  40mm, the maternal mortality rate is high (about 50%).

  38. PeripartumCardiomyopathy

  39. PeripartumCardiomyopathy:

  40. PeripartumCardiomyopathy: • Occurs in last few weeks of pregnancy and first few months post partum. • Enlargement and weakness of ventricles:  Biventricular Failure • Idiopathic. • Occurs more in multipara. • Maternal mortality is high 75%. • High risk for recurrence.

  41. Maternal Mortality Risk: • Low Maternal Mortality:  1% • VSD, ASD, PDA • Minimal Mitral Stenosis. • Corrected Tetralogy of Fallot. • Porcine Heart Valve.

  42. Maternal Mortality Risk: • Intermediate Maternal Mortality: 5-15% • Mitral stenosis with atrial fibrillation. • Uncorrected Tetralogy of Fallot. • Marfan’s syndrome (aortic root  40mm). • Artificial (Metalic) heart valve.

  43. Maternal Mortality Risk: • High Maternal Mortality: 25-50% • Pulmonary HTN. • Eisenmenger’s syndrome. • Marfan’s syndrome (aortic root 40mm). • AoricCoarctation. • Peripartumcardiomyopathy.

  44. Outlines:

  45. Management: Remember…. - Two major issues should be considered during management: Tachycardia Intravascular volume • They are normal physiologic changes of pregnancy. • But, they increase stress on diseased heart.

  46. Management: Remember…. so, management always seeks: Tachycardia Intravascular volume Control Control • The aim of management is to: • Control the vascular volume • Control tachycardia.

  47. Management: Antepartum Management Intrapartum Management Postpartum Management

  48. Antepartum Management: • Low salt intake. • Diuretics if needed. • Avoid strenuous activities. • Control anemia. • Digitalis or -blockers if indicated. • Done after the 20th week of gestation if the mother has congenital heart diseases. Control intravascular volume: Control tachycardia: Feta echocardiogram:

  49. IntrapartumManagement: Vaginal delivery is the aim unless there is obstetrical indication.

  50. Intrapartum Management: • During labour, bleeding is going on  prevent hypotension. • Monitor intravenous fluid volume. • Use areterial line and pulmonary artery catheter, specially with classes NYHA III and IV. • Provide reassurance. • Use sedatives and epidural analgesia (not anesthesia) to control pain. • Avoid second stage pushing (bearing down). • Forceps to shorten the 2nd stage. Control intravascular volume: Control tachycardia: ** ** Epidural anesthesia are not used because they cause peripheral pooling of blood.

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