Pregnancy With Internal Medical Diseases: Department Of Gynaecology And Obstetrics
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Pregnancy with internal medical diseases Department of gynaecology and obstetrics
Cardiovascular changes in normal pregnancy The major cardiocirulatory changes that occur during normal pregnancy include an increase in cardiac output and blood volume and a decrease in peripheral resistance 。
1.During normal pregnancy ， 6-8.5L of fluid and 500-900mmol of sodium are retained because of the action of progesterone ， renin ， aldosterone ， and prolactin 。 A dilutional anemia occurs as a dresult of the greater increase in plasma volume relative to red cell mass 。 2. .renal blood flow increases by 30% and uterine blood flow reaches 500mL/min at term 。 3. .hormonal changes include a rise in levels of estrogen and progesterone ， renin
4. Additional hemodynamic changes occur during the various stage of labor and delivery depend on the patient’s positon,the degree of sedation, 5cardiac output increase by about 20% with each uterine contraction as 300-500mL of blood is expelled form the contractiong uterus . 6 systolic blood pressure also rises with each contractin,increasing the load on the left ventricle by 10%,while the heart rate falls.pain,fear ,and anxiety contribute further to an increase in cardiac output.these chages are less marke if the patient is in the lateral decubitus position during labor or receiving epidural anesthesia.
hemodyanmic and respiratory changes of normal pregnancy
Physiologic direction and peak variable percent of change weeks
time of
time of
onset
effect
1cardiac output increased 30-50 +-10 30 2heart rate increased10-25 10-14 3blood volume increased25-50 6-10 4plasma volume increased 40-50 6-10 5red cellmass increased20-40 6-10 6blood pressure increased first trimester
2040 32-36 32 40 20
Physiologic direction and variable percent of change
time of onset
time of peak ffect weeks
7 pulmonary and increased40-30 6-10 peripheralvascular resistance 8 oxygen Consumption increased15-30 12-16 9 tidal volume increased40 6-10
20-24
40 40
7the cardiac output as plasma volume increse by 20-60%because of a shift of blood from the uterus as placenta into the vascular space as well as resorption of interstitial fluid . 8. .the hemodynamic changes of pregnancy begin to regress shortly after delivery,and pre-pregnancy levels are usually reached within 2weeks postpartum ,but may take longer.
9. The hemodynamic changes of normal pregnancy can result in symptoms and signs that mimic those of heart disease,often making it difficult to differentiate the two
Symptoms and signs of normal pregnacy mimicking heart disease
Clinical manifestations and mechanisms 1Palpitations /cardiac awareness increased heart rate;increased stroke volum,increased ectopy 2. Nasal stuffiness - vasodilatation, increased cutaneous blood flow 3. Dyspnea ， shortness of breath ， orthopnea , --increased progesterone causing hyperventilation low alveolar co2 tension upward displacement of diaphragm
4.Decreased exercise Tolerance ， easy fatigability - weight gain,lack of exercise,increased cardiac output at rest ， limiting maximum cardiac output increase with exercise 5.Dizziness;lightheadedness; Syncope ---decreased venous return due to compression of inferior vena cava by enlarged uterus and Increased venous capacitance
6epigastric or subxiphoid pain ， bloating heartburm – displacement of diaphragm,stomach,and liver by large uterus;decreased gastrointestinal motility Heat intolerance ， sweating and flushing ,--increased cutaneous blood flow and increased metabolic rate
signs 1. sinus tachycardia;ectopic beats (ventricular ,atrial )-- increased cardiac output; increased o2demand;decreased threshold for ectopic beats and arrhythmias 2. bounding pulses and capillary pulsations ---increased cardiac output, decreased total peripheral resistance;widened pulse pressure; increased cutaneous blood flow 3. prominent jugular venous Pulsations-increased cardiac output,decreased venous tone; right ventricular volume overload
4. plethoric facies increased cutaneous blood flow 5. lateral displacement of cardiac apex mechanical,high diaphragm, right and left ventricular volume overload 6. widely split s1and s2--increased cardiac output,increased heart sounds venous return,delayed right ventricular emptying
7. third heart sound--increased cardiac output,,rapid filling of ventricles 8. systolic murmur (left sternal edge or precordial) increased cardiac output,turbulent flow through pulmonary valve, increased venous return,increased mammary flow 9. continuous murmurs--venous hum,mammary soufflé,increased venous distensibility
10. varicose veins--obstruction of inferior vena cava by uterus,increased venous distensibility
clinical manifestations
mechanisms
1. capillary telangiectases--increased estrogen level and I ncreased venous distensibility 2. pulmonary rales --atelectasis due to hypoventilation of lung bases because of displacement of diaphragm 3. edema(legs,occasionally hands and face) mechanical obstruction of inferior vena by uterus,increased venous pressure in legs
ectopic beats supraventricular tachycardias --decreased threshould for ectopic beats and arrhythmias
4. ectopic beats supraventricular tachycardias decreased threshould for ectopic beats and arrhythmias
electrocardiogram
leftward or rightward axis nonspecific st-twave changes-mechanical displacement of shift,diaphragn, right ventricular volume overload ,altered sympathetic tone and altered repolarization sequence
echocardiogram/loppler ultrasound
1.increased left and right ventricular end diastolic dimensions-increased blood volume increased cardiac output 2. increased velocity of circumferential increased ejection fraction,hyperdynamic function– myocardial fiber shortening increased contractility,increased cardiac output ,increased sympathetic tone
symptoms and signs suggesting significant cardiovascular disease
1. sever or progressive dyspnea and orthopnea,especiallu at rest 。 2.paroxysmal nocturnal dyspnea,signs of pulmonary edema,cough,forthy pink sputum 3.effort syncope or chest pain 4.chronic cough ,hemoptysis 5.clubbing ,cyanosis,or persistent edema of extremities 6.increased jugular venous pressure,abnomal venous pulsations 7 accentuated or barely audible first heart sound 8.fixed of paradoxic splitting of s2 ,single s2
10 ejectionclick or late systolic click ,opening snap 11.friction rub 12.systolic murmur of grace III Or II jor gradeIV intensity or palpable thrill 13. any diastolic murmur cardiomegaly with diffuse sustained right or left ventricular heave 14electrocardiographic evidence of significant arrhythmias
etiology
cardiovasvular disease is the most important nonobstetric cause of disability and death in pregnanct women. it is not surprising that the added hemodynamic burdren of pregnancy,labor,and delivery can aggravate symptoms and precipitate complications in a woman with preexisting cardiac disease.however,even a previously healthy women may develop cardiovascular problems specifically
classification
.heart disease can be classified as congenital or acquired operated or unoperated .Acquired diseases can be infectious,autoimmune, degenerative, malignant, or idiopathic.
evaluation of the patient with heart disease
include a careful medical history ,complete physical examinaton noninvasive laboration test in order to establish a diagnosis and to determine the severity of the disease in order to facilitate planning the patient’s management the degree of functional disability is graded according to the following new york heart association classidication
class I:no symptoms limiting ordinary physical activity classII slight limiting with mild to moderate activity but no symptoms at rest classIII marked limitation with less than ordinary activity ;dyspnea or pain in minimal activity . classIX symptoms at rest or with minimal activity and symptoms of frank congestive heart failure.
Medical history physical examination laboratory test
A electrocardiogram B echocardiogram C Doppler echocardiography D exercise tolerance test
A electrocardiogram The electrocardiogram (ECG) is useful for determining abnormalities of rhythm and the presence of conduction defects, evidence of chamber enlargement, and signs of myocardial or pericardial diaease ,ischemian,or infarction.
B echocardiogram
The transthoracic (TTE) echocardiogram (both M and 2-dimensional secto scan) is a rapid , safe and reliable tool for differntiation the physiologic murmurs resulting from the increased cardiac output of a normal pregnancy from the murmurs of congenital or acquired heart disease.the echocardiogram can provide information about abnormalities of anatomy and function of the chambers,valves, and pericardium
the echocardiogram can provide information about the patient’s volume status and differentiate cardiac from noncardiac caused of pulmonary edema that are important for diagnosis and treatment
C Doppler echocardiography
determination of bood flow and velocity ,quantitation of pressure gradients and the degree of regurgitaiton,as well as for measuring intracardiac shunts and estimation of pulmonary pressure
D exercise tolerance test
Exercise studies such as the treadmill test are normally not used during pregnancy, However,the may be useful in a woman contemplatin pregnancy or in early pregnancy
E miscellaneous
1.a throat cuture to diagnose the presence of beta-hemolytic streptococcal infection 2.and a Creative protein and antistreptolysin titer if antecedent streptococcal infection is suspected . 3.serial blood cultures are indicated if infective endocarditis is suspected . 4.chest x-ray ,cardiac catheterization ,and radioomuclide scans are generallu avorded during pregnancy, since since the radiation can be harmful to the fetus ,especially erly in gestation. however ,these tests can be performed with careful shielding og the abdomen and pelvis ,if the mother’s condition requires it.
Rheumatic heart disease
Active rheumatic carditis ,although rare during pregnancy,can be a serious and potentially fatal complication.the diagnosis is based on the jones criterial 1. evidence of a preceding group A streptococcal infection 2. the minor criteria Included fever, arthralgias ,elevated sedimentation rate,and first –degree heart block 。
mitral valve disease
mitral stenosis is the most common lesion in young women with rheumatic heart disease 1..most patients with mild to moderate stenosis who are in sinus rhythm tolerate pregnancy well ,although the risk for superimposed infective endocarditis is ever present even in hemodynamically mild disease.
.2.those with moderate to severe disease are more likely to develop complication such as pulmonary venous congestion or frank pulmonary edema,right ventricular hypertension 3. .however,sudden and unexpected deterioration can occasionalluy occur during pregnancy in patients with any degree of mitral stenosis
4.new onset of atrial fibrillation in a previously asymptomatic woman can precipitate acute pulmonary edema,which occasionally requires emergency commissurotomy. 5.The normal hemodynamic changes of pregnancy put patients with mitral stenosis is at special risk to raising left atria pressure.and the onset of atria fibrillation .
the pregnant cardiac patient is also at the risk for the development of thromboembolic complications because of the.hypercoagulable state of the blood during pregnancy as well as venous stasis in the leg
A clinical findings 1.pulmonaty venous congestion ;dyspnea on exertion,and later at rest;right ventricular failure;atrial arrhythmias,and occasionally,hemoptysis.fatigue and decrease in exercise tolerance are more often manifestations of mitral insufficiency
.the characteristic findings on physical examination include a right ventricular lift ,a loud first heart shound(s-1),accentuated pulmonic component of the second heart sound (P-2),an opening snap (os),and alow frequency diastolic rumble at the apex with presystolic accentuation
The electrocardiogram is often normal but may indicate left atrial enlargement ,right axis deviation ,or even right ventricularly useful for defining the anatomy of the valve and intravalvular structure,quantitaiton the degree of stenosis and associated regurgitation ,and identifying the presence of abnormalities in other valves and pulmonary artery pressure.
treatment
1.The goals of treatment for the patient with mitral stenosis should be to prevent or treat tachycardia and atrial fibrillation, to avoid fluid overload ,and to avoid unnecessary increases in oxygen demand such as occur with anxiety or physical activity.
2. digitalis, quinidine,occasionall, sodium restriction and diuretics may be necessary for treating congestive failure and atrial arrhythmias 3anemia, intercurrent infection,and thyrotoxicosis should be corrected. 3.1. cardiac surgery or balloon valvuloplasty,although rarely necessary as an adjunct to careful medical management of patients with chronic rheumatic heart diseae,occasionally becomes necessary as a life-saving maneuver in patients with sever mitral stenosis .3.2in an occasional patient ,mitral valve replacement may be nesessary as an emergency procedure during pregnancy
.4patients who have had a valve replaced with a prosthetic valve require anticoagulatin .5the teratogenic and fetotoxic effects of warfarin and the risks of bleeding for the mother and fetus during labor and delivery must be balanced against the risks of thromboembolic episodes 6patient with rheumatic valvular disease should be delivered vaginally at term unless cesarean section is indicated for obsteric reasons. 7appropriate analgesia should be given during labor ,and epidural
8.1careful hemodynamic monitoring during labor and delivery is inducated in patient with compromised circulation. 8.2postpartum oxytocics should be given cautiously and blood loss carefuly monitored .8.3redistribution of fluid from the interstitial to the intravascular space immediately postpartum can precipitate pulmonary edema in compromised
infective endocarditis
Endocarditis is an acute or subacute inflammatory process resulting from blood-borne infection (streptococcus ) ,abnomal heart valves and the endocardium in the proximity of congenital anatomic defects are preferential sites for involvement by blood-borne infection.
.infected maternal from vegetations can embolize from right-sided lesion such as the tricuspid valve to the lungs,and from left-sided lesion to the systemic circulation patients with endocardites often give a history of recent extensive dental work ,intravascular or urologic procedures,cardiac,surgery,or intravenous illicit drug abuse
Clinical findigs
The diagnosis is based on symptoms such as persisitent fever sweats,weakness,and embolic phenomena ,both to the lungs and to the periphery in an individual with risk factors for endocarditis. .physical findings include petechial hemorrhages,clubbing of the fingers and toes,splenomegaly,osler’nodes the diagnosis is confirmed by the finding of a positive blood culture or demonstration of vegetations on the valves by echocardiography.
prevention
Patients at risk for developing infective endocarditis include those with underlying congenital or acquired valvular heart disease and intravenous durg abusers
Myocarditis
Acute inflammation of the myocardium may be due to rheumatic fever , such as infecion with group B .coxsackie viruses or protozoal disease . the myocarditis may be acute or subacute,may be associated with symptoms of systemic illness,and may occur at any time.during pregnancy,
.the clinical manifestations are those of chest pain fever pulmonary rales,tachycardia,edema,and systolic murmurs and gallops on physical examination;as well as cardiomegaly,reduced ventricular function,conduction defects ,and arrythmias on electrocardiogaraphy and echocardiography. 4.specific serologic and bacteriologic tests may reveal the identity of the initiation
the clinical course is variable, .the disease may run an acute,subacute ,or chronic cours ;be self –limited with complete recovery ;or lead to progressive myocardial fibrosis and eventually to cardiomyopathy
Peripartum cardiomyopathy
Peripartum cardiomyopathy is used to describe this form of cardiac failure when the onset occurs in the last months of pregnany or within 6 months postpartum ,and no specific etiology or prior heart disease is identified
.The clinical manifestations are those of right and left ventricular failure with pulmonary congestion,hepatomegaly .low cardiac output,chest pain.hemoptysis and cough ,fatigue ,dyspnea ,decreased exercise tolerance,edema,systolic murmurs,third heart sound ,elevated jugular venous pressure,pulmonary rales,and cardiomegaly. arrhyhmias and pulmonary as well as systemic emboli are common
the electrocardiographic changes are nonspecific include arrhythmias ,low QRS voltage,left ventricular hypertrophy, on echocardiography,there is evidence of enlargement of all chambers,generalized decrease in wall motion,reduced ejection fraction ,and often mural thrombi
Treatment and prognosis
.The prognosis depends on the degree to which the cardiomegaly is reversible with standard treatment for congestive heart failure, use of anticoagulants are indicated for patients with intractable heart failure and repeated embolic episodes.
In addition to controlling precipitating or aggravating factors,the principles of management of angina pectoris and of myocardial infarction in pregnant women do not differ from those in nonpregnant patients
smoking should be forbidden and other risk factiors meticulously controlled. control of hypertension treatment of hypotension,.standard therapy to reduce oxygen demands and to improve myocardial perfusion include bed rest
women who have had a myocardial infarction before or during pregnancy should be delivery vaginally,if possible with epidura anesthesia and outlet forceps to shorten the second stage of labor.careful intrapartum hemodynamic monitoring may be indicated,
Congenital heart disease
.the common congenital cardiac anomalies can be broadly grouped under various categories such as cyanotic or acyanotic ,simple or complex,mild or severe,and compatible with a normal pregnancy or a contraindication for pregnancy.
obstructive lesions of the right or left ventricular outflow tract that result in pressure overload of the ventricle,such as pulmonary stenosis,or coarcation of the aorta left to right shunts resultingin ventricular volume overload and increased pulmonary blood flow,such as atrial septal defect,atrioventricular canal,ventricualr septal defect,endocardial cushion defect,patent ductus arteriosus,and truncus arteriosus.
Cyanotic or hypoxic congenital heart disese in which unoxygenated venous blood enters the systemic circulation,such as tetralogy of fallot,Eisenmenger’s complex,tricuspid atresia,pulmonary atresia,single ventricle ,transposition of the great arteries,and ebsterin’s anomaly,complex lesion may combine several of these features.
.Operative procedures for correctionor palliation are now available for almost all of these defectis and are performed even in small infants . 2.however,problems persist in most patients becaues of residual inoperable lesions and the need for anticoagulation
Patients with acyanotic congenital heart disease tolerat pregnanyc well ,whether the heart disease has been surgically corrected or not ,and have a low incidence of spontaeous abortions and premature labor.
however,patients with class II-IV severity at the onset of pregnancy have a high incidence of spontaneous abortions and stillbirths ,and interruption of pregnancy or postponement until a corrective or palliative procedure can be performed for cardiac indications may be required.in patients with congestive heart failure or large intracardiac shunts,pregnancy is not well tolerated
1. atrial septal defect Ostium secundum atrial septal defect ,one of the most common forms of congenital heart disease,is well tolerated by most wonen
.the electrocardiogram is more likely to show left axis deviation,although the incomplete right bundle branch block may be present as well the echocardiogaram and color flow doppler studies are useful to define the location of the atrial septal defect and the degree of involvement of the mitral and tricuspid valves.
2.ventricualar septal defect Isolated centicualr septal defect tend to close spontaneously before the woman reaches adulthood.women with small to moderatesized ventricular septal defects tolerate pregnancy well,a
the electrocardiogram may be normal or show left ventricular hypertrophy,while the echocardiogram and doppler studies identify the magnitude of the shunt and size of the ductus,as well as the degree of ventricular hypetrophy.
3.pulmonic valve stenosis is well tolerated if the gradient across the pulmonary valve is less than 80mmHg,since the valve continues to enlarge in relation to body mass. women with a high transvalvular gradient and right ventricular hypertrophy,,the risk of right ventricualr failure and atrial arrhythmias is increased,and assisted delivery is recommeded
4.coarctation of the aorta Coarctation of the aorta result in hypertesion of the arms with lower pressures in the legs.pregnant patients are at incresased heart failure. .endocardiits prophlyaxis is required for delivery ,even in operated cases ,and blood pressure control must be carefully maintained.
5.cyanotic congeital heart diseas In women with cyanotic congeitalheart disease,both maternal and fetal morbidituy and mortalit rates are high.the incidence od spontaneous abortions,stiilbirths ,prematurity ,and low birhweight is high
pulmonary hypertesion
The commen cause of pulmonary hypertension are as follows increased resistance to pulmonary blood flow at any of several sites in the pulmonary vascular bed.this may be due to multiple pulmonary emboli,primary pulmonary vascular disease,takayasu’s arteritis,or infestation with schistosomes or filariae increased pulmonary blood flow as in left-to – right intrtaor extracardiac shunts with the development of secondary pulmonary vasular diaease
increased resistance to pulmonary venous drainage,as in increased left ventricular end – diastolic pressure,left ventricular failure,or mitral stenosis pulmonary parenchymal disorders such as sarcoid or chronic fobrosis hypoventilation sydromes chromic hypoxia,as in high –altitude dwellwes or heavy cigarette smokers patient with large intracardiac left-to –right shunts eventually develop irreversible structual changeds and obilerative pulmonary vascular disease in response to the increased pulmonary flow.
the cardiac defect does not relieve the pulmonary hypertension and because there is a high rate of operative and postoperative mortality due to right ventricular failure. early in pregnancy because of the added hemodynamic load
patients with pulmonary hypertension should be counseled against becoming pregnant or should be advised to have an early induced aborion When pregnancy occur and is continued,patients should avoid all unnecessary exertion,especially in the third trimester
patiens should be delivered vaginally under epidural anesthesia,with close and continued hemodynamic monitoring In an intensive care unit .close observation must continous for at least 3-5days postpartum,although compoications and even death can occur as late as 3-2weeks after delivery ,as the normal postpartum hemodymamic changes occur.
General management of heart disease in pregnancy
1.established a diagnosis of heart disease ， and assess the severity and functional status with appropriate noninvasive diagnostic studies ， preferably those that do not involved ionizing radiation 。 2.establish a method of regular follow-up ， close surveillance ， and consultation with a cardiologist and other supporting personnel 。 3.reduce unnecessary cardiac work by ensuring regular rest and by avoidance of excess exertion ,heat and humidity.
4.Make certain that the patient receives an adequate diet ,avoids excessive weight gain,and complies with a regimen of moderate sodium restriction when indicated. 5.Treat intercurrent infections ,anemia ,fevers,thyrotoxicosis,and other disorders 6.Treat paroxysmal arrhythmias with appropriate drugs or DC cardioversion;prevent recuring arrhythmias with approved antiarrhythmic drugs
7.In parients with chronic atrial fibrillation,large left atrium,prosthetic valves,or recurring thromboembolism who require anticoagulant therapy,switch from oral anticoagualnts containing coumarin type drugs to subcutaneous heparin. 8.Treat chronic venous insufficiency with wellfitting elasticized support hose. 9.Theat congestive heart failure with bed rest ,digitalis ,and diuretics,and treat precipitating factors if recognized.
10Provide prophylaxi against infective endocarditis at the time of delivery 11In women with compromised caridac function,provde carefeul hemodynamic monitoring of both the mother and the fetus during labor and delivery and in the postpartum period.in patients with pulmonary hypertension,heart failure ,or major arrhythmias ,continue postpartum monitoring for 4-5days to avoid late complications 12To decrease the work of bearing down and associated pain and
anxiety ,provide epidural anesthesia for delivery and use outlet forceps to shorten the third stage of labor 13Operative valvotomy or valve replacement is rarely necessary during pregnancy and may be forestalled with the less invasive technique of balloon valvotomy ,but should be considered at any time during pregnancy (inconsultation with a cardiologist and cardiac surgeon )if raipid deterioration occurs ,if a prosthetic valve fails ,or if an emergency compocaiton develops.
Fetal echocardiography after 20weeks of gestation is a useful technique for detecting fetal cardiac abnormalities,especially in women with congenital heart diaease or prior offsping with anomalies .the finding of an abnormality can be helpful in planning perinatal manegment of the fetus
Cardiovascular changes in normal pregnancy The major cardiocirulatory changes that occur during normal pregnancy include an increase in cardiac output and blood volume and a decrease in peripheral resistance 。
1.During normal pregnancy ， 6-8.5L of fluid and 500-900mmol of sodium are retained because of the action of progesterone ， renin ， aldosterone ， and prolactin 。 A dilutional anemia occurs as a dresult of the greater increase in plasma volume relative to red cell mass 。 2. .renal blood flow increases by 30% and uterine blood flow reaches 500mL/min at term 。 3. .hormonal changes include a rise in levels of estrogen and progesterone ， renin
4. Additional hemodynamic changes occur during the various stage of labor and delivery depend on the patient’s positon,the degree of sedation, 5cardiac output increase by about 20% with each uterine contraction as 300-500mL of blood is expelled form the contractiong uterus . 6 systolic blood pressure also rises with each contractin,increasing the load on the left ventricle by 10%,while the heart rate falls.pain,fear ,and anxiety contribute further to an increase in cardiac output.these chages are less marke if the patient is in the lateral decubitus position during labor or receiving epidural anesthesia.
hemodyanmic and respiratory changes of normal pregnancy
Physiologic direction and peak variable percent of change weeks
time of
time of
onset
effect
1cardiac output increased 30-50 +-10 30 2heart rate increased10-25 10-14 3blood volume increased25-50 6-10 4plasma volume increased 40-50 6-10 5red cellmass increased20-40 6-10 6blood pressure increased first trimester
2040 32-36 32 40 20
Physiologic direction and variable percent of change
time of onset
time of peak ffect weeks
7 pulmonary and increased40-30 6-10 peripheralvascular resistance 8 oxygen Consumption increased15-30 12-16 9 tidal volume increased40 6-10
20-24
40 40
7the cardiac output as plasma volume increse by 20-60%because of a shift of blood from the uterus as placenta into the vascular space as well as resorption of interstitial fluid . 8. .the hemodynamic changes of pregnancy begin to regress shortly after delivery,and pre-pregnancy levels are usually reached within 2weeks postpartum ,but may take longer.
9. The hemodynamic changes of normal pregnancy can result in symptoms and signs that mimic those of heart disease,often making it difficult to differentiate the two
Symptoms and signs of normal pregnacy mimicking heart disease
Clinical manifestations and mechanisms 1Palpitations /cardiac awareness increased heart rate;increased stroke volum,increased ectopy 2. Nasal stuffiness - vasodilatation, increased cutaneous blood flow 3. Dyspnea ， shortness of breath ， orthopnea , --increased progesterone causing hyperventilation low alveolar co2 tension upward displacement of diaphragm
4.Decreased exercise Tolerance ， easy fatigability - weight gain,lack of exercise,increased cardiac output at rest ， limiting maximum cardiac output increase with exercise 5.Dizziness;lightheadedness; Syncope ---decreased venous return due to compression of inferior vena cava by enlarged uterus and Increased venous capacitance
6epigastric or subxiphoid pain ， bloating heartburm – displacement of diaphragm,stomach,and liver by large uterus;decreased gastrointestinal motility Heat intolerance ， sweating and flushing ,--increased cutaneous blood flow and increased metabolic rate
signs 1. sinus tachycardia;ectopic beats (ventricular ,atrial )-- increased cardiac output; increased o2demand;decreased threshold for ectopic beats and arrhythmias 2. bounding pulses and capillary pulsations ---increased cardiac output, decreased total peripheral resistance;widened pulse pressure; increased cutaneous blood flow 3. prominent jugular venous Pulsations-increased cardiac output,decreased venous tone; right ventricular volume overload
4. plethoric facies increased cutaneous blood flow 5. lateral displacement of cardiac apex mechanical,high diaphragm, right and left ventricular volume overload 6. widely split s1and s2--increased cardiac output,increased heart sounds venous return,delayed right ventricular emptying
7. third heart sound--increased cardiac output,,rapid filling of ventricles 8. systolic murmur (left sternal edge or precordial) increased cardiac output,turbulent flow through pulmonary valve, increased venous return,increased mammary flow 9. continuous murmurs--venous hum,mammary soufflé,increased venous distensibility
10. varicose veins--obstruction of inferior vena cava by uterus,increased venous distensibility
clinical manifestations
mechanisms
1. capillary telangiectases--increased estrogen level and I ncreased venous distensibility 2. pulmonary rales --atelectasis due to hypoventilation of lung bases because of displacement of diaphragm 3. edema(legs,occasionally hands and face) mechanical obstruction of inferior vena by uterus,increased venous pressure in legs
ectopic beats supraventricular tachycardias --decreased threshould for ectopic beats and arrhythmias
4. ectopic beats supraventricular tachycardias decreased threshould for ectopic beats and arrhythmias
electrocardiogram
leftward or rightward axis nonspecific st-twave changes-mechanical displacement of shift,diaphragn, right ventricular volume overload ,altered sympathetic tone and altered repolarization sequence
echocardiogram/loppler ultrasound
1.increased left and right ventricular end diastolic dimensions-increased blood volume increased cardiac output 2. increased velocity of circumferential increased ejection fraction,hyperdynamic function– myocardial fiber shortening increased contractility,increased cardiac output ,increased sympathetic tone
symptoms and signs suggesting significant cardiovascular disease
1. sever or progressive dyspnea and orthopnea,especiallu at rest 。 2.paroxysmal nocturnal dyspnea,signs of pulmonary edema,cough,forthy pink sputum 3.effort syncope or chest pain 4.chronic cough ,hemoptysis 5.clubbing ,cyanosis,or persistent edema of extremities 6.increased jugular venous pressure,abnomal venous pulsations 7 accentuated or barely audible first heart sound 8.fixed of paradoxic splitting of s2 ,single s2
10 ejectionclick or late systolic click ,opening snap 11.friction rub 12.systolic murmur of grace III Or II jor gradeIV intensity or palpable thrill 13. any diastolic murmur cardiomegaly with diffuse sustained right or left ventricular heave 14electrocardiographic evidence of significant arrhythmias
etiology
cardiovasvular disease is the most important nonobstetric cause of disability and death in pregnanct women. it is not surprising that the added hemodynamic burdren of pregnancy,labor,and delivery can aggravate symptoms and precipitate complications in a woman with preexisting cardiac disease.however,even a previously healthy women may develop cardiovascular problems specifically
classification
.heart disease can be classified as congenital or acquired operated or unoperated .Acquired diseases can be infectious,autoimmune, degenerative, malignant, or idiopathic.
evaluation of the patient with heart disease
include a careful medical history ,complete physical examinaton noninvasive laboration test in order to establish a diagnosis and to determine the severity of the disease in order to facilitate planning the patient’s management the degree of functional disability is graded according to the following new york heart association classidication
class I:no symptoms limiting ordinary physical activity classII slight limiting with mild to moderate activity but no symptoms at rest classIII marked limitation with less than ordinary activity ;dyspnea or pain in minimal activity . classIX symptoms at rest or with minimal activity and symptoms of frank congestive heart failure.
Medical history physical examination laboratory test
A electrocardiogram B echocardiogram C Doppler echocardiography D exercise tolerance test
A electrocardiogram The electrocardiogram (ECG) is useful for determining abnormalities of rhythm and the presence of conduction defects, evidence of chamber enlargement, and signs of myocardial or pericardial diaease ,ischemian,or infarction.
B echocardiogram
The transthoracic (TTE) echocardiogram (both M and 2-dimensional secto scan) is a rapid , safe and reliable tool for differntiation the physiologic murmurs resulting from the increased cardiac output of a normal pregnancy from the murmurs of congenital or acquired heart disease.the echocardiogram can provide information about abnormalities of anatomy and function of the chambers,valves, and pericardium
the echocardiogram can provide information about the patient’s volume status and differentiate cardiac from noncardiac caused of pulmonary edema that are important for diagnosis and treatment
C Doppler echocardiography
determination of bood flow and velocity ,quantitation of pressure gradients and the degree of regurgitaiton,as well as for measuring intracardiac shunts and estimation of pulmonary pressure
D exercise tolerance test
Exercise studies such as the treadmill test are normally not used during pregnancy, However,the may be useful in a woman contemplatin pregnancy or in early pregnancy
E miscellaneous
1.a throat cuture to diagnose the presence of beta-hemolytic streptococcal infection 2.and a Creative protein and antistreptolysin titer if antecedent streptococcal infection is suspected . 3.serial blood cultures are indicated if infective endocarditis is suspected . 4.chest x-ray ,cardiac catheterization ,and radioomuclide scans are generallu avorded during pregnancy, since since the radiation can be harmful to the fetus ,especially erly in gestation. however ,these tests can be performed with careful shielding og the abdomen and pelvis ,if the mother’s condition requires it.
Rheumatic heart disease
Active rheumatic carditis ,although rare during pregnancy,can be a serious and potentially fatal complication.the diagnosis is based on the jones criterial 1. evidence of a preceding group A streptococcal infection 2. the minor criteria Included fever, arthralgias ,elevated sedimentation rate,and first –degree heart block 。
mitral valve disease
mitral stenosis is the most common lesion in young women with rheumatic heart disease 1..most patients with mild to moderate stenosis who are in sinus rhythm tolerate pregnancy well ,although the risk for superimposed infective endocarditis is ever present even in hemodynamically mild disease.
.2.those with moderate to severe disease are more likely to develop complication such as pulmonary venous congestion or frank pulmonary edema,right ventricular hypertension 3. .however,sudden and unexpected deterioration can occasionalluy occur during pregnancy in patients with any degree of mitral stenosis
4.new onset of atrial fibrillation in a previously asymptomatic woman can precipitate acute pulmonary edema,which occasionally requires emergency commissurotomy. 5.The normal hemodynamic changes of pregnancy put patients with mitral stenosis is at special risk to raising left atria pressure.and the onset of atria fibrillation .
the pregnant cardiac patient is also at the risk for the development of thromboembolic complications because of the.hypercoagulable state of the blood during pregnancy as well as venous stasis in the leg
A clinical findings 1.pulmonaty venous congestion ;dyspnea on exertion,and later at rest;right ventricular failure;atrial arrhythmias,and occasionally,hemoptysis.fatigue and decrease in exercise tolerance are more often manifestations of mitral insufficiency
.the characteristic findings on physical examination include a right ventricular lift ,a loud first heart shound(s-1),accentuated pulmonic component of the second heart sound (P-2),an opening snap (os),and alow frequency diastolic rumble at the apex with presystolic accentuation
The electrocardiogram is often normal but may indicate left atrial enlargement ,right axis deviation ,or even right ventricularly useful for defining the anatomy of the valve and intravalvular structure,quantitaiton the degree of stenosis and associated regurgitation ,and identifying the presence of abnormalities in other valves and pulmonary artery pressure.
treatment
1.The goals of treatment for the patient with mitral stenosis should be to prevent or treat tachycardia and atrial fibrillation, to avoid fluid overload ,and to avoid unnecessary increases in oxygen demand such as occur with anxiety or physical activity.
2. digitalis, quinidine,occasionall, sodium restriction and diuretics may be necessary for treating congestive failure and atrial arrhythmias 3anemia, intercurrent infection,and thyrotoxicosis should be corrected. 3.1. cardiac surgery or balloon valvuloplasty,although rarely necessary as an adjunct to careful medical management of patients with chronic rheumatic heart diseae,occasionally becomes necessary as a life-saving maneuver in patients with sever mitral stenosis .3.2in an occasional patient ,mitral valve replacement may be nesessary as an emergency procedure during pregnancy
.4patients who have had a valve replaced with a prosthetic valve require anticoagulatin .5the teratogenic and fetotoxic effects of warfarin and the risks of bleeding for the mother and fetus during labor and delivery must be balanced against the risks of thromboembolic episodes 6patient with rheumatic valvular disease should be delivered vaginally at term unless cesarean section is indicated for obsteric reasons. 7appropriate analgesia should be given during labor ,and epidural
8.1careful hemodynamic monitoring during labor and delivery is inducated in patient with compromised circulation. 8.2postpartum oxytocics should be given cautiously and blood loss carefuly monitored .8.3redistribution of fluid from the interstitial to the intravascular space immediately postpartum can precipitate pulmonary edema in compromised
infective endocarditis
Endocarditis is an acute or subacute inflammatory process resulting from blood-borne infection (streptococcus ) ,abnomal heart valves and the endocardium in the proximity of congenital anatomic defects are preferential sites for involvement by blood-borne infection.
.infected maternal from vegetations can embolize from right-sided lesion such as the tricuspid valve to the lungs,and from left-sided lesion to the systemic circulation patients with endocardites often give a history of recent extensive dental work ,intravascular or urologic procedures,cardiac,surgery,or intravenous illicit drug abuse
Clinical findigs
The diagnosis is based on symptoms such as persisitent fever sweats,weakness,and embolic phenomena ,both to the lungs and to the periphery in an individual with risk factors for endocarditis. .physical findings include petechial hemorrhages,clubbing of the fingers and toes,splenomegaly,osler’nodes the diagnosis is confirmed by the finding of a positive blood culture or demonstration of vegetations on the valves by echocardiography.
prevention
Patients at risk for developing infective endocarditis include those with underlying congenital or acquired valvular heart disease and intravenous durg abusers
Myocarditis
Acute inflammation of the myocardium may be due to rheumatic fever , such as infecion with group B .coxsackie viruses or protozoal disease . the myocarditis may be acute or subacute,may be associated with symptoms of systemic illness,and may occur at any time.during pregnancy,
.the clinical manifestations are those of chest pain fever pulmonary rales,tachycardia,edema,and systolic murmurs and gallops on physical examination;as well as cardiomegaly,reduced ventricular function,conduction defects ,and arrythmias on electrocardiogaraphy and echocardiography. 4.specific serologic and bacteriologic tests may reveal the identity of the initiation
the clinical course is variable, .the disease may run an acute,subacute ,or chronic cours ;be self –limited with complete recovery ;or lead to progressive myocardial fibrosis and eventually to cardiomyopathy
Peripartum cardiomyopathy
Peripartum cardiomyopathy is used to describe this form of cardiac failure when the onset occurs in the last months of pregnany or within 6 months postpartum ,and no specific etiology or prior heart disease is identified
.The clinical manifestations are those of right and left ventricular failure with pulmonary congestion,hepatomegaly .low cardiac output,chest pain.hemoptysis and cough ,fatigue ,dyspnea ,decreased exercise tolerance,edema,systolic murmurs,third heart sound ,elevated jugular venous pressure,pulmonary rales,and cardiomegaly. arrhyhmias and pulmonary as well as systemic emboli are common
the electrocardiographic changes are nonspecific include arrhythmias ,low QRS voltage,left ventricular hypertrophy, on echocardiography,there is evidence of enlargement of all chambers,generalized decrease in wall motion,reduced ejection fraction ,and often mural thrombi
Treatment and prognosis
.The prognosis depends on the degree to which the cardiomegaly is reversible with standard treatment for congestive heart failure, use of anticoagulants are indicated for patients with intractable heart failure and repeated embolic episodes.
In addition to controlling precipitating or aggravating factors,the principles of management of angina pectoris and of myocardial infarction in pregnant women do not differ from those in nonpregnant patients
smoking should be forbidden and other risk factiors meticulously controlled. control of hypertension treatment of hypotension,.standard therapy to reduce oxygen demands and to improve myocardial perfusion include bed rest
women who have had a myocardial infarction before or during pregnancy should be delivery vaginally,if possible with epidura anesthesia and outlet forceps to shorten the second stage of labor.careful intrapartum hemodynamic monitoring may be indicated,
Congenital heart disease
.the common congenital cardiac anomalies can be broadly grouped under various categories such as cyanotic or acyanotic ,simple or complex,mild or severe,and compatible with a normal pregnancy or a contraindication for pregnancy.
obstructive lesions of the right or left ventricular outflow tract that result in pressure overload of the ventricle,such as pulmonary stenosis,or coarcation of the aorta left to right shunts resultingin ventricular volume overload and increased pulmonary blood flow,such as atrial septal defect,atrioventricular canal,ventricualr septal defect,endocardial cushion defect,patent ductus arteriosus,and truncus arteriosus.
Cyanotic or hypoxic congenital heart disese in which unoxygenated venous blood enters the systemic circulation,such as tetralogy of fallot,Eisenmenger’s complex,tricuspid atresia,pulmonary atresia,single ventricle ,transposition of the great arteries,and ebsterin’s anomaly,complex lesion may combine several of these features.
.Operative procedures for correctionor palliation are now available for almost all of these defectis and are performed even in small infants . 2.however,problems persist in most patients becaues of residual inoperable lesions and the need for anticoagulation
Patients with acyanotic congenital heart disease tolerat pregnanyc well ,whether the heart disease has been surgically corrected or not ,and have a low incidence of spontaeous abortions and premature labor.
however,patients with class II-IV severity at the onset of pregnancy have a high incidence of spontaneous abortions and stillbirths ,and interruption of pregnancy or postponement until a corrective or palliative procedure can be performed for cardiac indications may be required.in patients with congestive heart failure or large intracardiac shunts,pregnancy is not well tolerated
1. atrial septal defect Ostium secundum atrial septal defect ,one of the most common forms of congenital heart disease,is well tolerated by most wonen
.the electrocardiogram is more likely to show left axis deviation,although the incomplete right bundle branch block may be present as well the echocardiogaram and color flow doppler studies are useful to define the location of the atrial septal defect and the degree of involvement of the mitral and tricuspid valves.
2.ventricualar septal defect Isolated centicualr septal defect tend to close spontaneously before the woman reaches adulthood.women with small to moderatesized ventricular septal defects tolerate pregnancy well,a
the electrocardiogram may be normal or show left ventricular hypertrophy,while the echocardiogram and doppler studies identify the magnitude of the shunt and size of the ductus,as well as the degree of ventricular hypetrophy.
3.pulmonic valve stenosis is well tolerated if the gradient across the pulmonary valve is less than 80mmHg,since the valve continues to enlarge in relation to body mass. women with a high transvalvular gradient and right ventricular hypertrophy,,the risk of right ventricualr failure and atrial arrhythmias is increased,and assisted delivery is recommeded
4.coarctation of the aorta Coarctation of the aorta result in hypertesion of the arms with lower pressures in the legs.pregnant patients are at incresased heart failure. .endocardiits prophlyaxis is required for delivery ,even in operated cases ,and blood pressure control must be carefully maintained.
5.cyanotic congeital heart diseas In women with cyanotic congeitalheart disease,both maternal and fetal morbidituy and mortalit rates are high.the incidence od spontaneous abortions,stiilbirths ,prematurity ,and low birhweight is high
pulmonary hypertesion
The commen cause of pulmonary hypertension are as follows increased resistance to pulmonary blood flow at any of several sites in the pulmonary vascular bed.this may be due to multiple pulmonary emboli,primary pulmonary vascular disease,takayasu’s arteritis,or infestation with schistosomes or filariae increased pulmonary blood flow as in left-to – right intrtaor extracardiac shunts with the development of secondary pulmonary vasular diaease
increased resistance to pulmonary venous drainage,as in increased left ventricular end – diastolic pressure,left ventricular failure,or mitral stenosis pulmonary parenchymal disorders such as sarcoid or chronic fobrosis hypoventilation sydromes chromic hypoxia,as in high –altitude dwellwes or heavy cigarette smokers patient with large intracardiac left-to –right shunts eventually develop irreversible structual changeds and obilerative pulmonary vascular disease in response to the increased pulmonary flow.
the cardiac defect does not relieve the pulmonary hypertension and because there is a high rate of operative and postoperative mortality due to right ventricular failure. early in pregnancy because of the added hemodynamic load
patients with pulmonary hypertension should be counseled against becoming pregnant or should be advised to have an early induced aborion When pregnancy occur and is continued,patients should avoid all unnecessary exertion,especially in the third trimester
patiens should be delivered vaginally under epidural anesthesia,with close and continued hemodynamic monitoring In an intensive care unit .close observation must continous for at least 3-5days postpartum,although compoications and even death can occur as late as 3-2weeks after delivery ,as the normal postpartum hemodymamic changes occur.
General management of heart disease in pregnancy
1.established a diagnosis of heart disease ， and assess the severity and functional status with appropriate noninvasive diagnostic studies ， preferably those that do not involved ionizing radiation 。 2.establish a method of regular follow-up ， close surveillance ， and consultation with a cardiologist and other supporting personnel 。 3.reduce unnecessary cardiac work by ensuring regular rest and by avoidance of excess exertion ,heat and humidity.
4.Make certain that the patient receives an adequate diet ,avoids excessive weight gain,and complies with a regimen of moderate sodium restriction when indicated. 5.Treat intercurrent infections ,anemia ,fevers,thyrotoxicosis,and other disorders 6.Treat paroxysmal arrhythmias with appropriate drugs or DC cardioversion;prevent recuring arrhythmias with approved antiarrhythmic drugs
7.In parients with chronic atrial fibrillation,large left atrium,prosthetic valves,or recurring thromboembolism who require anticoagulant therapy,switch from oral anticoagualnts containing coumarin type drugs to subcutaneous heparin. 8.Treat chronic venous insufficiency with wellfitting elasticized support hose. 9.Theat congestive heart failure with bed rest ,digitalis ,and diuretics,and treat precipitating factors if recognized.
10Provide prophylaxi against infective endocarditis at the time of delivery 11In women with compromised caridac function,provde carefeul hemodynamic monitoring of both the mother and the fetus during labor and delivery and in the postpartum period.in patients with pulmonary hypertension,heart failure ,or major arrhythmias ,continue postpartum monitoring for 4-5days to avoid late complications 12To decrease the work of bearing down and associated pain and
anxiety ,provide epidural anesthesia for delivery and use outlet forceps to shorten the third stage of labor 13Operative valvotomy or valve replacement is rarely necessary during pregnancy and may be forestalled with the less invasive technique of balloon valvotomy ,but should be considered at any time during pregnancy (inconsultation with a cardiologist and cardiac surgeon )if raipid deterioration occurs ,if a prosthetic valve fails ,or if an emergency compocaiton develops.
Fetal echocardiography after 20weeks of gestation is a useful technique for detecting fetal cardiac abnormalities,especially in women with congenital heart diaease or prior offsping with anomalies .the finding of an abnormality can be helpful in planning perinatal manegment of the fetus
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