Heart Disease In Preg

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CARDIAC DISEASE IN PREGNANCY – Dr. Kudoyi PLAN • • • •

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Epidemiology Pathology Clinical Presentation Investigations

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Management – New York Heart Association Classification o Antepartum o Intrapartum o Post Natal

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EPIDEMIOLOGY • Cardiac disease complicates 1% (0.3 – 3.0%) of pregnancies worldwide • It is the most important non-obstetric cause of maternal mortality • Worldwide MMR = 5/100,000 deliveries; K.N.H MMR = 3,200/100,000 deliveries • 95% of cardiac disease in pregnancy are due to Rheumatic heart diseases (RHD) in developing countries. This is due to high prevalence of untreated beta haemolytic streptoccocal throat infections. • About 90% of cardiac diseases in pregnancy are due to congenital heart disease in some developed countries PATHOLOGY • In normal pregnancy hemodynamic changes occur from the first trimester and peak in the 3rd trimester into a high output cardiac status • HR increases by 10% (10-15 beats/min) Plasma volume increases by 40%. • This increase in cardiac output may cause a systolic murmur in women who are healthy. However diastolic murmurs are always indicative of heart disease. • With cardiac disease in pregnancy increased cardiac output predisposes to CCF • CCF is further predisposed to by o Sepsis o Anemia o Exercises (physical activity) • To prevent CCF prevent sepsis and anaemia and reduce exercises. AETIOLOGY 1. Rheumatic Heart Disease (RHD) • 90% involve mitral valve • Mitral stenosis has highest risk for CCF • When tricuspid valve is affected all other valves are usually involved 2.

Congenital Heart Disease (CHD) • VSD, ASD, PDA are commonest

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Hypertensive Heart Disease (HHD) • Age above 35yrs • Below 35yrs common causes are i. renal artery stenosis ii. phaechromocytoma iii. thyrotoxicosis

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Peripartum Cardiomyopathy • Rare

Patient without a heart lesion develops CCF in pregnancy or post-partum • Treat with digoxin and lasix Ischaemic Heart Disease

6. Syphylitic Heart Disease Cor pulmonale • Increased pulmonary vascular resistance • Chronic obstructive airway diseases e.g asthma or chronic bronchitis.

COMPLICATIONS OF CARDIAC DISEASE 1. Maternal – • CCF • Pulmonary embolism • Anaemia 2.

Fetal • • • •

IUGR Abortions Preterm deliveries IUFD

CLINICAL PRESENTATION 1. Failure to thrive – poor growth, finger clubbing 2. C.C.F • symptoms – shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, wheezing. • signs – tachycardia,Increased JVP, Murmurs, basal creps, alae nasi flaring, tachypnoea, oedema, ascites, tender hepatomegaly 3. Tissue hypoxia – pallor, cyanosis, oliguria, anuria , confusion , coma , cold periphery . 4. Myocardial strain – angina pain , palpitations, fibrillation 5. Murmurs 6. Infective endocarditis INVESTIGATIONS 1. ECG 2. Echo – cardiogram 3. Urinalysis 4. Haemogram 5. U/E NEW YORK HEART ASSOCIATION CLASSIFICATION Based on functional state of the heart. 1. 2. 3. 4.

Grade 1 -Uncompromised. -No Limitation of physical activity. Grade 2 -Slight limitation of physical activity -Dyspnoea on moderate exertion Grade 3 -Marked limitation of physical activity -Dyspnoea on mild exertion. Grade 4 -Inability to perform any physical activity -Dyspnoea at rest , current or past CCF

MANAGEMENT ANTENATAL CARE 1. Combined team of cardiologist & obstetricians. 2. Grades 1&2 as out-patients until 36 weeks of gestation. 3. Prevent • excess weight gain (diet)

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Fluid retention (frusemide)

Anemia (haematinics) Sepsis (screen for UTI & isolate from URTI patients) 4. Adequate rest – 10hrs at night , 2 hrs daytime. 5. Prop up in bed 6. Treat pre-eclampsia aggressively 7. Grades 3&4 – give digoxin 0.25mg & Frusemide 40 mg daily 8. RHD – monthly benzathine penicillin 2.4 MU. 9. Prosthetic valves – anticoagulate. 10. Dental Procedures be done under antibiotic cover 11. Minor Heart surgery .e.g valvotomy is allowed. 12. Avoid open heart surgery •

INTRAPATUM Prepare resuscitation tray containing ; 1. Digoxin 2. Frusemide 3. Adrenaline 4. Naloxone. 5. Hydrocortisone 6. Calcium gluconate 7. Sodium bicarbonate 8. Aminophylline 9. Oxytocin 10. Pethidine or morphine 1ST STAGE 1. Keep propped up 2. I.M morphine 15mg or I.M pethidine 100mg to allay anxiety & minimize pain. 3. Oxygen by mask. 4. Avoid I.V. fluids and if given , add I.V. frusemide 5. If oxytocin is necessary use pump to minimize fluid infusion. 6. Delay ARM. 7. I.V. Broad-spectrum antibiotics 8. Minimize number of pelvic exams. 9. Caesarean sections for obstetric indications only. 2nd STAGE 1. No valsava maneuver 2. Vacuum extraction. 3rd 1. 2. 3. 4.

STAGE I.V. frusemide 40mg stat Massage uterus Avoid ergometrine I.M. oxytocin 10 units

PEUPERIUM 1. Keep admitted for 10 days. 2. Limit exercises 3. Continue with antibiotics. 4. Continue anticoagulation POST-NATAL VISIT 1. Advice on limited family size , 1-2 children. 2. BTL or vasectomy 3. Progesterone only drugs – microlut , jadelle , noristerat 4. Barrier – condoms 5. Avoid oestrogens – may cause fluid retention. 6. Avoid IUCD – increases sepsis rate.

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