heart disease in pregnancy-a journal report
TRANSCRIPT
![Page 1: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/1.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 1/36
Click to edit Master subtitle style
4/21/12
Assessment anManagement of CaDisease in Pregna
CEBU INSTITUTE OFMEDICINE
![Page 2: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/2.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 2/36
4/21/12
Outline• Introduction
•
Cardiorespiratory changesa. Intrapartum hemodynamics
b. Postpartum hemodynamics
• Physical Examination in pregnant patient
•
Non invasive cardiac investigations• Bacterial endocarditis prophylaxis
• Risk of congenital heart disease in offspring
![Page 3: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/3.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 3/36
4/21/12
• General Cardiac Management Issues
a. Preconceptional counselling
b. Prenatal care
c. Predictors of poor maternal and neonatal outd. Labor and delivery
e. Post partum care
• Contraception
•
Conclusion
![Page 4: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/4.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 4/36
4/21/12
Cardiorespiratory Changes
![Page 5: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/5.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 5/364/21/12
• Heart rate, stroke volume, cardiaoutput, and blood pressure are
significantly dependent on mateposition esp. after 28th week of gestation
•
A rise in cardiac output is associwith an increased blood flow to torgans crucial in pregnancy
![Page 6: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/6.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 6/364/21/12
•
Pregnancy is associated with asignificant increase in respiratotidal volume, leading to an increin minute ventilation, but therespiratory rate remains unchan
![Page 7: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/7.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 7/364/21/12
Intrapartum Hemodynamics
•
Each uterine contraction is associatean expulsion of 300 to 500 ml of blofrom the uterus into general circulatadding to preload
•
The cardiac output in active labor isincreased by 2.5L/minute into the ra7-8L/min
• Cardiac output and stroke volume a
highest
![Page 8: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/8.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 8/36
4/21/12
•
BP and CVP are elevated inassociation with uterine contrac
![Page 9: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/9.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 9/36
4/21/12
Postpartum Hemodynamics
• Immediately after delivery there issignificant increase in cardiacoutput
![Page 10: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/10.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 10/36
4/21/12
In a group of parturient women whoepidural anaesthesia, cardiac output wreported to be approximately 40% abobaseline values at 15 minutes after vadelivery and 25% at 30 minutes postp
James CF, Banner T, Caton D. Cardiac Output in Women UndergoingSection
with Epidural or General anesthesia. AmJ Obstet Gynecol 1989;160:
![Page 11: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/11.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 11/36
4/21/12
A comparison group who received ganaesthetic also had elevations in caroutput of approximately 30% and 15%above baseline at 15 and 30 minutespostpartum
James CF, Banner T, Caton D. Cardiac Output in Women UndergoingSection
with Epidural or General anesthesia. AmJ Obstet Gynecol 1989;160:
![Page 12: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/12.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 12/36
4/21/12
• Maternal heart rate actually fall
10 beats per minute during thisdespite a mean blood loss of approximately 500 mL associatwith vaginal delivery and 1000
associated with Caesarean sect
![Page 13: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/13.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 13/36
4/21/12
•
By two weeks postpartum, cardoutput has reduced by 33%. Apostpartum diuresis peaks by thsecond to fifth postpartum day
lasts for several weeks.
![Page 14: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/14.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 14/36
4/21/12
Physical Examination in tPregnant Patient
•
More diffuse apical impulse• Palpable systolic pulsation along
left sternal border
![Page 15: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/15.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 15/36
4/21/12
Physical Examination in tPregnant Patient
• First heart sound increased in
intensity and widely split.• In the third trimester the splittin
the second heart sound widens
than normal with inspiration.
![Page 16: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/16.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 16/36
4/21/12
Physical Examination in tPregnant Patient
• In a study, 92% developed an e
systolic murmur usually heard athe left sternal border. These arusually I to II out of VI in intensit
Cutforth R, MacDonald CB. Heart sounds and murmurs in pregnancy
1966;71:741–7.
![Page 17: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/17.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 17/36
4/21/12
Physical Examination in tPregnant Patient
• Tricuspid valve inflow
murmur/Graham Steell PulmonaRegurgitation murmur
– Most common diastolic murmur in
pregnancy – Associated with physiologic dilata
the Pulmonary Artery – Resolves after delivery
h i l i i i
![Page 18: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/18.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 18/36
4/21/12
Physical Examination in tPregnant Patient
• Mitral and Aortic regurgitation
decrease during pregnancysecondary to the decrease insystemic vascular resistance
•
Prominent neck veins or inspirawheeze may normally be identi
• Pedal edema is very common
N i i C di
![Page 19: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/19.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 19/36
4/21/12
Non-invasive CardiacInvestigations
• ECG may show left-axis deviatio
and ST-T wave changes in the thtrimester.
• On Echocardiogram, the heart
appears mildly volume overloadand hyperkinetic.
B t i l E d diti
![Page 20: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/20.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 20/36
4/21/12
Bacterial EndocarditisProphylaxis
• Prophylaxis against bacterial
endocarditis in the pregnant pawith structural cardiac disease, congenital or acquired, is not
currently recommended.• The risk of bacteremia at the tim
vaginal delivery or Caesarean s
is low
Ri k f C it l H t Di
![Page 21: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/21.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 21/36
4/21/12
Risk of Congenital Heart Disin Offspring
• A discussion of the increased ris
congenital heart disease in theioffspring is an important compoof prenatal counselling.
•
The risk is generally higher if thmother, rather than the father, affected.
Ri k f C it l H t Di
![Page 22: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/22.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 22/36
4/21/12
Risk of Congenital Heart Disin Offspring
• Fetal echocardiography at 18 to
weeks’ gestation is recommenda pregnant patient with a congeheart defect.
G l C di M
![Page 23: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/23.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 23/36
4/21/12
General Cardiac ManagemIssues
• Preconceptual Counselling – Genetic counselling, either before
early in pregnancy, is recommendidentify the risk for their offspring
G l C di M
![Page 24: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/24.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 24/36
4/21/12
General Cardiac ManagemIssues
• Prenatal Care – Patient with cardiac disease shoul
seen early in the first trimester – Assessment by a cardiologist early
pregnancy is also indicated – Patients are seen for prenatal visit
every two weeks, or more frequennecessary.
General Cardiac Managem
![Page 25: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/25.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 25/36
4/21/12
General Cardiac ManagemIssues
• Prenatal Care – A fetal echocardiogram is recomm
at 18 to 21 weeks’ gestation for pwith congenital heart disease.
General Cardiac Managem
![Page 26: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/26.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 26/36
4/21/12
General Cardiac ManagemIssues
• Prenatal Care – A fetal echocardiogram is recomm
at 18 to 21 weeks’ gestation for pwith congenital heart disease.
–
Use of iron, prenatal vitamins, anddietary counselling to avoid anemwhich is a common problem inpregnancy
![Page 27: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/27.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 27/36
4/21/12
Greatest risk for Cardiac event dupregnancy:
1. Prior cardiac event or arrythmia
2. NYHA functional class II or cyanosis
3. Left Heart obstruction or systemic
ventricular dysfunction
0= 5 % risk
1= 27 % risk
>1= 75 % risk
General Cardiac Managem
![Page 28: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/28.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 28/36
4/21/12
General Cardiac ManagemIssues
• Labor and Delivery – Patients may await spontaneous l
and can be counselled that the raCaesarean section is not increasebecause of heart disease alone
– Careful monitoring of the mother fetus once in labor especially fluidmanagement and ECG monitoring
General Cardiac Managem
![Page 29: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/29.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 29/36
4/21/12
General Cardiac ManagemIssues
• Post-Partum Care – Most crucial time for some patient
cardiac disease – Close monitoring should be maint
for at least 48 hours when cardiacoutput remains elevated
General Cardiac Managem
![Page 30: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/30.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 30/36
4/21/12
General Cardiac ManagemIssues
• Post-Partum Care – Most patients are reassessed at fo
six weeks postpartum, by which tthe woman’s hemodynamic statusreturned to the nonpregnant state
General Cardiac Managem
![Page 31: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/31.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 31/36
4/21/12
General Cardiac ManagemIssues
• Contraception – Sterilization of the male partner
obviously carries the least risk forwoman with cardiac disease
–
Barrier methods, when used consand properly, are usually effective
General Cardiac Managem
![Page 32: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/32.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 32/36
4/21/12
General Cardiac ManagemIssues
• Contraception – Oral contraceptives can be used i
patients with cardiac disease withseveral exceptions
•
Patients with right to left shunts• Patients with cardiac disease th
associated with hypertension
General Cardiac Managem
![Page 33: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/33.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 33/36
4/21/12
General Cardiac ManagemIssues
• Contraception – Progestin-only oral contraceptives
depotmedroxyprogesterone acetabe used, as the thromboembolic roral contraceptives is thought to bto the estrogen component.
– Progestin-releasing intrauterine de(IUD) can be an excellent choice
![Page 34: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/34.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 34/36
4/21/12
Conclusion
• The difficult issues in a pregnan
complicated by cardiac disease best managed through a teamapproach.
•
Patients with severe symptoms close attention and may requiremedical and occasionally surgic
treatment during pregnancy
![Page 35: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/35.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 35/36
4/21/12
Conclusion
• Labor, delivery, and the immed
postpartum period are associatwith significant hemodynamicchallenges and patients should
monitored throughout.• Pregnancy with cardiac disease
usually has a successful outcom
![Page 36: Heart Disease in Pregnancy-A Journal Report](https://reader035.vdocuments.us/reader035/viewer/2022070606/577d258f1a28ab4e1e9f1a5c/html5/thumbnails/36.jpg)
8/4/2019 Heart Disease in Pregnancy-A Journal Report
http://slidepdf.com/reader/full/heart-disease-in-pregnancy-a-journal-report 36/36
4/21/12
THANK YOU