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Heart Failure in Pregnancy. Ramon M. Gonzalez, MD Professor UST Medicine and Surgery. AB a 22y/o married, bank teller Visited for the 1 st time an obstetrician 5 months PTC she had a (+) pregnancy test Felt perfectly well prior to consult

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heart failure in pregnancy

Heart FailureinPregnancy

Ramon M. Gonzalez, MD

Professor

UST Medicine and Surgery

slide2

AB a 22y/o married, bank teller

  • Visited for the 1st time an obstetrician
  • 5 months PTC she had a (+) pregnancy test
  • Felt perfectly well prior to consult
  • Few days ago started to have shortness of breath on climbing 2 flights of stairs, easy fatigability on walking 2 blocks and had palpitations
slide3

Bp-100/60mmHg CR-89/min RR=21cycles/min

  • Heart- AB at 5th ICS LMCL, no thrills, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex
  • Referred by the obstetrician to a cardiologist
cardiovascular changes in pregnancy
Cardiovascular changes in pregnancy

Parameter Percentage of change

_______________________________________________

Cardiac output 40-50% Increase

Intravascular volume 45% Increase

Heart rate 15-25% Increase

Systemic vascular

resistance 20% Decrease

Stroke volume 30% Increase

Systolic BP Minimal

Diastolic BP 20% Decrease at mid-pregnancy

O2 consumption 30-40% Increase

periods of increase cardiac output
Periods of increase cardiac output
  • 28-32 weeks gestation
  • Labor and Delivery
  • Immediately postpartum
hemodynamics during labor
Hemodynamics during labor

Parameter Stage of Labor Percentage of change

____________________________________________________

Cardiac output Latent phase 10% Increase

Active phase 25% Increase

Expulsive phase 40% Increase

Immediate postpartum 70-80% Increase

Heart rate All stages Increase

CVP All stages Increase

hemodynamics during puerperium
Hemodynamics during puerperium

Parameter Postpartum Percentage of change

_______________________________________________________________

Cardiac output W/in 1hr 30% above pre-labor values

24-48 hr Just below pre-labor values

2 weeks 10% above pre-pregnant values

12-24 weeks Baseline pre-pregnancy values

Heart rate Immediate Decrease

2 weeks Pre-pregnant values

Stroke volume 48 hr Remains above pre-labor values

24 weeks 10% above pre-pregnant values

slide10

Change in New York Heart Association (NYHA) functional class between first visit and follow-up during pregnancy in patients with predominant mitral valve disease.

maternal outcome in patients with mitral stenosis
Maternal outcome in patients with mitral stenosis
  • Congestive heart failure
    • 43% vs 0% p<0.0001
  • Arrhythmias
    • 20% vs 0% p<0.0001
  • Hospitalization
    • 43% vs 2 p 0.001
  • Mortality
    • 0% vs 0% p 1.0
conclusion
Conclusion
  • Women with VHD had a high rate of clinical deterioration
  • Marked increase in morbid events during pregnancy, includingCHF, arrhythmias and need to either initiate or increase cardiovasculardrug therapy or to hospitalize patients during pregnancy.
fetal outcome in patients with mitral stenosis
Fetal outcome in patients with mitral stenosis
  • Preterm delivery
    • 35±7 vs 39±2wks p <0.0002
  • IUGR
    • 24% vs 0% p <0.001
  • Stillbirth
    • 4% vs 0% p 0.5
  • Birth weight
    • 2845g vs 3372g p 0.02
offspring risk for congenital heart defects
Offspring risk for congenital heart defects

Defect Mother affected Father affected

(%) (%)

Aortic stenosis 13–18 3

Atrialseptal defect 4–4.5 1.5

Atrioventricular canal 14 1

Coarctation of the aorta 4 2

Patent ductusarteriosus 3.5–4 2.5

Pulmonicstenosis 4–6.5 2

Tetralogy of Fallot 2.5 1.5

Ventricular septal defect 6–10 2

main aims of management
Main Aims of Management
  • To optimize the mother’s condition during pregnancy
  • To monitor for deteriorations
  • Minimize any additional load on the cardiovascular system
management of cardiac disease in pregnancy general principles of management
Management of Cardiac Disease in Pregnancy: General Principles of Management
  • Women in NYHA class I and II proceed to pregnancy without morbidity.
  • All women with heart disease should be managed by a multidisciplinary team.
  • Antenatal management is directed towards avoiding cardiac decompensation.
  • Special attention should be directed toward both prevention and early recognition of heart failure.
warning signs of heart failure
Warning signs of heart failure
  • Persistent basilar rales, frequently accompanied by a nocturnal cough
  • A sudden diminution in ability to carry out usual duties
  • Increasing dyspnea on exertion
  • Clinical findings may include hemoptysis, progressive edema and tachycardia
management of cardiac disease in pregnancy general principles of management1
Management of Cardiac Disease in Pregnancy: General Principles of Management
  • Even when pregnancy is well tolerated, infection, anemia, pain and anxiety, often result in clinical deterioration and require aggressive management.
  • A clear plan for the management of labor and delivery should be established in advance
management during pregnancy
Management during Pregnancy
  • In symptomatic patients, medical treatment should be the first line of management.
  • Cardiac drugs commonly used during pregnancy includes β blockers, hydralazine, diuretics and digoxin.
  • Advice bed rest and oxygen.
management during pregnancy1
Management during Pregnancy
  • Fetal assessment to monitor the potential problems arising from heart disease and pharmacologic treatment of the mother.
management labor and delivery
Management: Labor and Delivery
  • Vaginal delivery is the preferred mode of delivery
  • A short and pain free labor and delivery - minimize hemodynamic fluctuation
  • Hemodynamic monitoring including O2 saturation, ECG, arterial pressure, pulmonary artery and wedge pressures and cardiac output especially in class III and IV patients
management labor and delivery1
Management: Labor and Delivery
  • Epidural analgesia
    • produces good analgesia without major hemodynamic changes
    • It is administered in incremental doses
    • Slower onset of anesthesia, allows maternal CVS to compensate for occurrence of sympathetic blockade, resulting in lower risk of hypotension and decreased uteroplacental blood flow.
management labor and delivery2
Management: Labor and Delivery
  • Epidural analgesia
    • spares the lower extremity “muscle pump,” aiding in venous return and also decreases the incidence of thromboembolic events.
  • During the 2nd stage – prevent maternal effort in “pushing”
  • Shorten the 2nd stage – vacuum or forceps delivery
management labor and delivery3
Management: Labor and Delivery
  • Fetal heart rate monitoring during labor
  • Induction of labor
    • to optimize the timing of delivery in relation to anticoagulation and availability of medical staff
  • Cesarean section
    • obstetrics indication, specific cardiac lesions and deterioration of cardiac performance
management postpartum
Management: Postpartum
  • Oxytocin
    • administered by infusion and not by bolus
  • Methyergonovine and Carboprost
    • Produces severe hypertension, tachycardia and increased pulmonary vascular resistance
management postpartum1
Management: Postpartum
  • High level maternal surveillance is required until the main hemodynamic changes after delivery have resolved.
  • Postpartum hemorrhage, infection, anemia and thromboembolism are much more serious complications in those with heart disease.
management postpartum2
Management: Postpartum
  • Recent review of parturients with heart disease found that the worst cardiac compromise did not always occur at the time of delivery.