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Heart Failure in Pregnancy. Council on Women’s Health Philippine Heart Association. Introduction. About 2% of pregnancies involve maternal cardiovascular disease Increased risk to both mother and fetus

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heart failure in pregnancy

Heart Failure in Pregnancy

Council on Women’s Health

Philippine Heart Association

introduction
Introduction
  • About 2% of pregnancies involve maternal cardiovascular disease
  • Increased risk to both mother and fetus
  • Cardiac disease may sometimes be manifested for the 1st time in pregnancy because of the hemodynamic changes
  • Signs and symptoms of a normal pregnancy may mimic the presence of cardiac disease
case presentation
Case Presentation
  • AB a 22 year old married, bank teller
  • Visited for the first time an obstetrician
  • 5 months PTC she had a positive 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
pertinent pe
Pertinent PE
  • BP- 100/60 CR- 89/min RR- 21 cycles/min
  • Heart-AB at 5th ICS LMCL, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex
  • Referred by the obstetrician to a cardiologist
questions
Questions
  • Does AB have heart disease?
  • Is she experiencing heart failure symptoms?
  • What are the hemodynamic changes occurring in her?
  • What are the differential diagnoses?
  • How should you go about managing her? Medical? Surgical? Timing?
  • Can she tolerate the pregnancy?
  • What is the safest mode of delivery?
question
Question:
  • Does AB have heart disease?
question1
Question:
  • Is she experiencing heart failure symptoms?
pregnancy clinical features mimicking heart disease
Pregnancy Clinical features mimicking heart disease:
  • Dyspnea- due to hyperventilation, elevated diaphragm
  • Pedal edema
  • Cardiac impulse diffuse and shifted laterally from elevated diaphragm
  • Jugular veins may be distended and JVP raised
  • Systolic ejection murmurs in LPSB in 96% of pregnant women
question2
Question:

How should we go about evaluating AB?

  • Evaluation of Heart Failure in Pregnancy

1. Detailed Hx and PE to determine FC

2. 12 lead ECG

3. Chest Xray- Optional

4. 2D Echo Doppler

5. Plasma B Type natriuretic peptide

6. Blood works-CBC,electrolytes, renal

and thyroid function

7. TEE (seldom)

8. Fetal echocardiography

differential diagnoses of heart failure in pregnancy
Differential Diagnoses of Heart Failure in Pregnancy
  • Pneumonia
  • Pulmonary embolism
  • Amniotic fluid embolism
  • Renal failure with volume overload
  • Acute lung injury
high risk pregnancies
High risk pregnancies
  • Pulmonary hypertension
  • Dilated cardiomyopathy, EF≤40%
  • Symptomatic obstructive lesions -AS,MS,PS,CoA
  • Marfan syndrome with aortic root ≥40mm
  • Cyanotic lesions
  • Mechanical prosthetic valves
question3
Question:
  • What is the risk of AB? Can she tolerate her pregnancy?
  • Risk Scores

0 - 5% risk (low)

1 - 27% risk (interm)

>1 - 75% (high)

  • Cardiac Diseases in Pregnancy Risk Score

1. A prior cardiac event ( arrhythmia,stroke,TIA,HF)

2.Baseline NYHA FC≥II or cyanosis(saturation≤ 90%

3. Systemic ventricular systolic dysfunction

4. Left heart obstruction

- MVA ≤ 2 cm

- aortic valve area≤ 1.5 cm

- peak flow gradient ≥ 30mm Hg

management
Management
  • Medical
  • NYHA Class I or II

-Limit strenuous exercise

-Provide adequate rest

-Supplemental iron and vitamins

-Low salt diet

-Regular cardiac and obstetric evaluation

  • NYHA III and IV

-May need hospitalization for close monitoring

management1
Management
  • Percutaneous valvotomy?
  • Timing?
management2
Management
  • Surgical
  • Cardiac surgery seldom necessary and should be avoided if possible
  • Higher risk of fetal malformations and loss
  • May induce premature labor
  • Optimal time- 20-28 wk gestation
  • Extracorporeal circulation- normothermic
  • Higher pump flow rate, higher pressure with a mean of 60 mmHg
  • Advise short bypass time
management3
Management
  • Anticoagulation?
  • Warfarin
  • Unfractionated Heparin
  • Low Molecular Weight Heparin
what is w arfarin e mbryopathy
What is Warfarin Embryopathy?
  • Used in 1st trimester- teratogenic in 15-25% of cases

1. nasal cartilage hypoplasia

2. stippling of bones

3. IUGR

4. brachydactyl

sbe p rophylaxis
SBE Prophylaxis?
  • Antibiotic – a) 2 gm ampicillin IV plus 1.5 mg/Kg gentamicin IV prior to procedure, followed by one more dose of ampicillin 8 hours later
  • If with allergy from ampicillin, 1 gm vancomycin may be used.
what is the safest m ode of delivery
What is the Safest Mode of Delivery?
  • Vaginal delivery is feasible and preferable
  • CS is for an obstetric indication
  • Exception are anticoagulated patients
  • CS may be indicated in

1. Marfan syndrome,

2. severe pulmonary HPN

3. severe obstructive lesions eg AS

physiologic changes during labor and puerperium
Physiologic Changes during Labor and Puerperium
  • First stage- Cardiac output increased by 15%. Each uterine contraction releases 500 ml of blood leading to increases in CO and BP, later reflex bradycardia.
  • Second stage- Increase in intra-abdominal pressure(valsalva) causes decrease in venous return and CO
  • Third stage- Blood loss during delivery. Vaginal- 400 ml CS- 800 ml

- these lead to reduced blood volume and CO

hemodynamic c hanges after delivery
Hemodynamic Changes after Delivery
  • Abrupt increase in venous return because of autotransfusion from the uterus. Baby no longer compress the uterus.
  • Autotransfusion of blood continues 24-72 hrs after delivery. Pulmonary edema may occur.
thank you
Thank You

Thank you