Heart disease with pregnancy

1. Heart disease with pregnancy Prof Uma Singh

2. Incidence of heart disease • Varies between 0.1 – 4.0 %, average 1% • Mortality due to heart disease has decreased • Devpd countries – maternal mortality due to heart disease has increased • Pregnancy with heart disease has increased • Devpd countries – rheumatic is decreasing • Congenital heart disease with pregnancy is also increasing

3. Hemodynamic changes in normal pregnancy

4. Critical periods • Changes start from as – 6weeks • Max changes around –30 weeks • Intra partum period • Just after delivery • Second week of puerperium

5. Pregnancy changes mimic cardiac disease • Symptoms – breathlessness, weakness, oedema, syncope • Tachycardia • Splitting of 1st hear sound • Murmur – systolic , breast bruit • Displacement of apex beat – upwards to left

6. Symptoms of heart disease • Progressive dyspnea or orthopnea • Nocturnal cough • Syncope • Chest pain • Hemoptysis

7. Clinical findings of heart disease • Cyanosis • Clubbing of fingers • Persistent neck vein distention • Systolic murmur grade 3/6 or greater • Diastolic murmur • Cardiomegaly • Persistent arrythmia • Persistent split second sound • Pulmonary hypertension

8. Investigations • ECG – cardiac arrhythmias, hypertrophy • Echocardiography – cardiac status and structural anomalies • X-ray chest – cardiomegaly, vascular prominence • Cardiac catheterization - rarely

9. NYHA (New York Heart Association) Functional grading of heart disease Grade I: No limitation of physical activity- asymptomatic with normal activity Grade II: Mild limitation of physical activity -Symptoms with normal physical activity Grade III: Marked limitation of physical activity -Symptoms with less than normal activity, comfortable at rest Grade IV: Severe limitation of physical activity- symptoms at rest

10. Classification of Heart Disease according to etiology Congenital – non cynotic( ASD, VSD, Pulmstenosis, coarctation of aorta), cyanotic (Fallotstetralogy, Eisenmenger’s syndrome) Rheumatic heart disease – MS, MR, AS, AR Cardiomyopathy Ischaemic heart disease Others – conduction defects, syphilitic, thyrotoxic, hypertensive,

11. Classification of Heart Disease during pregnancy according to risk Low risk ( 0 – 1%) – ASD, VSD, PDA, MS-1,2, corrected FT Medium risk ( 5 – 15 %) – MS-3,4, MS with atrial fibrillation, AS, uncorrected FT High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement

12. Poor prognostic indicators • h/o heart failure, ischaemic attack, stroke • Arrhythmias, • Base line NYHA class 3 and 4 • MV area below 2cm sq, AV area below 1.5 • Ejection fraction less than 40%

13. Additional risk factors • Anaemia • Infections • Hypertension • Physical labour • Weight gain • Multiple pregnancy • Caffein , alcohol intake • Pain • Drugs – tocolytic

14. Effect of pregnancy on heart disease • Worsening of cardiac status • CCF, bacterial endocarditis, pulmonary edema, pulmonary embolism, rupture of aneurism • No long term effect on basic defect

15. Effect of heart disease on pregnancy • Abortion • Preterm labour • IUGR • Congenital heart disease in baby – 5% • Intrauterine fetal demise

16. Management Requires- High index of suspicion Timely diagnosis Effective management Team Approach- Obstetrician Cardiologist Anesthetist Neonatologist CTV surgeon Nursing Staff

17. PreconceptionalCounseling No pregnancy unless must esp in high risk types Maternal mortality varies directly with functional classification at pregnancy onset Optimal Medical/Surgical treatment pre-pregnancy Counselling- Maternal & Fetal risks Prognosis Social and cost considerations Hospital delivery- Preferable at tertiary care centre

18. Medical termination of pregnancy Termination advised in early pregnancy in high risk group only – ( Primary pulmonary Ht, Eisenmenger syndrome, Coarctation of aorta, Marfan syndrome with dilated aortic root) Only in 1st trim, better before 8 weeks Suction evacuation preferred MTP also carries risk for life

19. Antenatal care Clear counseling of risk and prognosis ANC every 2 weeks upto 30 weeks then weekly On each visit-note-pulse rate, BP, cough dyspnea, weight, anaemia, auscultate lung bases, re-evaluate functional grade Ensure treatment compliance Exclude fetal congenital anomaly by level-III USG and fetal ECHO at 20 weeks in maternal congenital heart disease Fetal monitoring

20. Special Advice • Rest, Avoid undue excitement/strain • Diet/ Iron and vitamins • Hygiene, dental care to prevent any infection • Dietary salt restriction (4-6g/d) • Avoid smoking, drugs – betamimetics • Early diag and tmt of PIH, infections • Therapeutic/prophylactic cardiac interventions as applicable- • Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence of rheumatic fever • Diuretics, Beta Blockers, Digitalis, Anticoagulants • Surgical treatment as applicable - balloon mitral valvotomy

21. Indications for admission Elective admission- NYHA 1 – 2 weeks before EDD NYHA 2 – 28 to 30 weeks NYHA-III/IV- Irrespective of POG as soon as patient comes To Change from oral anticoagulants to heparin-early pregnancy, 36 weeks in patients on anticoagulant Emergency admission- Deterioration of functional grade Symptoms and signs of complications- Fever/ persistent cough/ basal crepts/ tachyarrhythias (P/R >100 min)/ JVP>2cm/Anaemia/ Infections/ PET/Abnormal weight gain /other medical disorders

22. Labor and Management Institutional delivery Induction of Labor Only for obstetric indications Oxytocin preferred- Higher concentration with restricted fluid Intracervical foley instillation esp in congenital heart disease PGE2 Gel may be employed- Vasodilatation - use with caution

23. Management in first stage of labor Confined to bed- propped up or semi recumbent Intermittent oxygen inhalation 5-6 l/min Sedation and analgesia- (Epidural, pethidine, tramadol) Cautious use of I.V. fluids (not >75ml/hr except in aortic stenosis and VSD) Stop anticoagulants Digitalise if in CHF,P.R.>110/ min, R/R >24/min

24. Management in first stage of labor Diuretics in pulmonary congestion Deriphyllin if bronchospasm Prevention of infective endocarditis Cardiac monitoring and pulse oximetry ±pulmonary artery catheterisation- continuous haemodynamic monitoring Evaluation by Anaesthetist and cardiologist

25. SABE Prophylaxis

26. Management of second stage of labor Delivery in propped up position Avoid forceful bearing down Adequate pain relief-epidural/pudendal block avoid spinal/Saddle block Cut short second stage of labor- episiotomy, vacuum, forceps – not always must Strict Cardiovascular monitoring

27. Third stage of labor- • AMTSL-10 U oxytocin IMI • Avoid bolus syntocinon/Ergometrine • Propped Up, oxygen inhalation • Furosemide I.V. 40 mg • Pethidine/morphine (15mg) • Watch for signs of CHF & Pul. Edema • Treat PPH energetically

28. First Hour After Delivery Propped up/sitting position, oxygen Watch for signs of pulm edema Sedation Antibiotics

29. Indications for LSCS- • Mainly obstetrical • Coarctation of aorta • Marfan syndrome with dilated root of aorta • Prefer epidural anaesthesia • Narcotic conduction analgesia/GA in Pulmonary hypertension and pts having intracardiac shunts

30. Advice at time of discharge: Continue medical treatment Avoid infection Reassesment after 6 weeks or earlier if some complication occurs Iron supplementation Cardiological consultation for definitive management of heart disease

31. Contraceptive advice at time of discharge: Contraception- Barrier, Progesterone – good option- DMPA, Norplant IUCD-Less preferred COC - contraindicated Sterilization- vasectomy-best Tubal ligation-Interval, puerperial can be done

32. MCQs Text book of Obstetrics, Dr J B Sharma, 1st edition Page 529 to 536

33. 1. Pregnancy is contra indicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy • Eisenmengers syndrome

34. 2. Pregnancy is contra indicated with • Mitral stenosis • Aortic stenosis • Fallots tetralogy • Eisenmengers syndrome

35. 2. Third stage of labour in a case of heart disease should be managed by • Ergometrine • Oxytocin • Misoprostol • Carboprost

36. Third stage of labour in a case of heart disease should be managed by • Ergometrine • Oxytocin • Misoprostol • Carboprost

37. 3. In pregnancy with heart disease risk of cardiac failure increases at • 10-12 weeks • 20-22 weeks • 30-32 weeks • 40-42 weeks

38. 3. In pregnancy with heart disease risk of cardiac failure increases at • 10-12 weeks • 20-22 weeks • 30-32 weeks • 40-42 weeks

39. 4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is • NYHA Class 1 • NYHA Class 2 • NYHA Class3 • NYHA Class 4

40. 4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is • NYHA Class 1 • NYHA Class 2 • NYHA Class3 • NYHA Class 4

41. 5. Which of the following contraceptive is contraindicated in a woman with heart disease? • OCP • POP • Lng IUS • Diaphragm

42. 5. Which of the following contraceptive is contraindicated in a woman with heart disease? • OCP • POP • Lng IUS • Diaphragm

43. 6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

44. 6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36weeks c) 40 weeks d) at onset of labour

45. 7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4

46. 7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class4