pregnancy and heart failure prof.dr. muhammad akbar chaudhary m.r.c.p. (u.k.) f.r.c.p. (e) f.r.c.p....
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PREGNANCY AND HEART FAILURE
PROF.DR. MUHAMMAD AKBAR CHAUDHARY
M.R.C.P. (U.K.) F.R.C.P. (E)
F.R.C.P. (LONDON) F.A.C.C
Designed At A.V. Dept. F.J.M.C. By Rabia Kazmi
IF DISEASE DURING PREGNANCY IS TO BE WELL MANAGED, THE PHYSIOLOGICAL CHANGES OF PREGNANCY MUST BE KNOWN.
C. SIDNEEY BURWELL ,M.D.1958
POTENTIAL DANGERS OF PREGNANCY TO MOTHER
1. HEAMODYNAMIC BURDEN OF PREGNANCY MAY RESULT IN DISABILITY OR DEATH OF MOTHER
2. PREGNANCY MAY AGGREVATE, PRE-EXISTING MATERNAL HEART DISEASE.
3. DANGERS OF DEVELOPING BACTERIAL ENDOCARDITIS & RECURRENCE OF RHEUMATIC FEVER
4. PREGNANCY MAY CAUSE HEART DISEASES
POTENTIAL DANGERS TO FETUS
1. ABNORMAL ORGANOGENESIS OR DEATH DUE TO INADIQUATE BLOOD SUPPLY
2. 50% FETAL WASTAGE WITH SEVERE MATERNAL HEART DISEASE.
3. INCIDENCE OF CONG. HEART DISEASE IS INCREASED, WITH MOTHER HAVING CONG.H.D. (15% CHANCES) & SOMETIMES UP TO 50% (I.H.S.S. & MARFAN SYNDROME)
4. INCREASE CHANCES OF LOOSING MOTHER
CONGENITAL HEART DISEASE IN THE OFFSPRING OF A PARENT WITH CONGENITAL HEART DISEASE
Cardiacoutput(liters/min)
6
4
100
50
60
90
70
50
20-24 28-32 38-40 6-8 weeks PP
Heartrate(beats/min)
Stroke volume(cc)
Gestation
CHANGES IN C.V.S. DURING NORMAL PREGNANCY
IN NORMAL PREGNANCY Na+ AND WATER RETENSION OCCURES
PLASMA VOLUME BEGINS TO RISE AS EARLY AS 6th WEEK AFTER CONCEPTION.
PLASMA VOLUME APPROACHES MAXIMUM IN SECOND TRIMESTER AND IS 1 TIME NORMAL AT DELIVERY
TOTAL BODY WATER INCREASES TO 6-8. L.
TOTAL Na + RETENSION IS 500-900 meq.
12
IN PREGNANCYCARDIAC OUT PUT AND ITS DISTRIBUTION AT REST
CARDIOVASCULAR ASSESSMENT OF PREGNANT WOMANWHAT COULD BE NORMAL?
DYSPNOEA, CHEST PAIN, EASY FATIGABILITY, PALPITATIONS SYNCOPE MAY BE DUE TO PREGNANCY ONLY.
PERIPHERAL OEDEMA MAY OCCUR IN 80% NORMAL PREGNANT WOMAN.
VISIBLE NECK VEINS, PULMONARY RALES NOT UNCOMMON IN PREG.
CARDIOVASCULAR ASSESSMENT OF PREGNANT WOMAN
WHAT IS ABNORMAL? P.N.D, ORTHOPNOEA, SEVERE
DYSPNOEA LIMITING NORMAL ACTIVITY
HEMOPTYSIS SYNCOPE WITH EXERTION TYPICAL CHEST PAIN OF I.H.D. CYANOSIS CLUBBING SYSTOLIC MURMUR OF 3/6 AND
MORE. DIASTOLIC MURMUR.
CARDIAC LESION RELEVANT HEMODYNAMIC CHANGE IN PREGNANCY
RESULT TIME OF GREATEST RISK
DEMONSTRATED RISK
MANAGEMENT
CARDIOMYOPATHY, RHEUMATIC FEVER
MYOCARDITIS;
BLOOD VOLUME CARDIAC OUT PUT
PULMONARY CAPILLARY PRESSURECARDIAC OUT PUT
>12 WEEKS UNCOMMON;MATERNAL MORBIDITY
TREAT PULMONARY CONGESTIONAVOID PREGNANCY IF LEFT VENTRICULAR FAILURE IS PRESENT
A. MYOCARDIAL DISEASES
EFFECT OF PREGNANCY ON VARIOUS HEART DISEASES
EFFECTS OF PREGNANCY ON VARIOUS HEART DISEASESB. VALVE ABNORMALITIES
MITRAL STENOSIS
MITRAL REGURGITATION (INCLUDE MITRAL PROLAPSE WHEN COMPLICATED BY IMPORTANT MITRAL REGURGITATION )
AORTIC STENOSIS
AORTIC REGURGITATION
PULMONARY STENOSIS
CARDIAC OUT PUT HEART RATE BLOOD VOLUME PULMONARY VASCULAR RESISTANCE
OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY BLOOD VOLUME
OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY
BLOOD VOLUME
OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY
PULMONARY CAPILLARY PRESSURE
VENOUS RETURN LA FILLING LA FILLING PULMONARY CAPILLARY PRESSURE
VENOUS RETURN LV FILLING CARDIAC OUT PUT
PULMONARY CAPILLARY PRESSURE
VENOUS RETURN LV FILLING CARDIAC OUT PUT
12 WEEKS (WHEN HEMODYNAMIC CHANGES BECOME SIGNIFICANT)
LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY) & POSTPARTUM >12 WEEKS
LATE IN PREGNANCY WHEN SUPINE (LABOR, DELIVERY, SURGERY)& POST PARTUM PREGNANCY
>12 WEEKS
LATE IN PREGNANCYWHEN SUPINE (LABOR, DELIVERY, SURGERY) & POSTPARTUM
MATERNAL MORBIDITY & MORTALITY FROM PULMONARY CONGESTION & PULMONARY EDEMA FETAL GROWTH & FETAL LOSS POSSIBLE EXPLANATION OF SOME MATERNAL DEATHS
UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL
MATERNAL MORTALITY UNCOMMON BECAUSE AORTIC STENOSIS IS RARE
UNCOMMON:PREGNANCY IS USUALLY UNEVENTFUL
UNCOMMON:PREGNANCY IS USUALLY UNEVENTFUL
LIMIT DEMANDS FOR CARDIAC OUTPUT, BASED ON SYMPTOMS AVOID TACHYCARDIA TREAT TRACHYARRYTHMIA
MAINTAIN VENOUS RETURN, ESPECIALLY IF SYMPTOMS OF CARDIAC OUTPUT OCCURRX OF PULMONARY CONGESTION IF OCCURS (RESTRICT SODIUM, DIURETICS)
MAINTAIN VENOUS RETURN STRICT LIMITATION OF ACTIVITY, AND IF SYMPTOMS PRESIST,PROCEED TO VALVE SURGERY OR INTERRUPTION OF PREGNANCY RX OF PULMONARY CONGESTION IF IT OCCURS (RESTRICT SODIUM INTAKE ,DIURETICS )MAINTAIN VENOUS RETURN
EFFECTS OF PREGNANCY IN VARIOUS HEART DISEASE
C. CONGENITAL HEART DISEASES-GARDLAC LESION RELEVENT
HEMODYNAMIC CHANGE IN PREGNANCY
RESULT TIME OF GREATEST RISK
DEMONSTRATED RISK
MANAGEMENT
SHUNTS;LEFT TO RIGHT (ESTALDEFECT,PATENT DUCTUS)
RIGHT TO LEFT (EISENMENGR’S SYNDROME, TETRALOGY OF FALLOT)
CARDIAC OUT
PUT BLOOD VOLUME PULMONARY VASCULAR RESISTANCE PERIPHERAL VASCULAR RESISTANCE OBSTRUCTION OF INFERIOR VENA CAVA
PULMONARY CAPILLARY PRESSURE
SHUNTING AND VENOUS RETURN PULMONARY BLOOD FLOW
>12 WEEKS
LATE IN PREGNANCY WHEN SUPINE (LABOUR, DELIVERY, SURGERY) AND POST PARTUM
UNCOMMON:PREGNANCY IS USUALLY UNEVENTFUL
MATERNAL MORTALITY DUE TO SUDDEN DEATH FETAL GROWTH & FETAL LOSS
RX OF PULMONARY CONGESION IF IT OCCURES (RESTRICT SODIUM INTAKE , DIURETICS )
AVOID PREGNANCY MAINTAIN VENOUS RETURN
COARCTATION OF THE AORTA
OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS
BLOOD VOLUME PULSE PRESSURE STEROID HARMONES? TENDANCY TO HYPERTENSION
VENOUS RETURN LV FILLING CARDIAC OUT PUT
DISTENSION OF AORTIC ROOT
LATE IN PREGNANCYWHEN SUPINE(LABOUR, DELIVERY, SURGERY) & POSTPARTUM >12 WEEKS
UNCOMMON: PREGNANCY IS USUALLY UNEVENTFUL
AORTIC RUPTURE DISSECTION OF AORTARUPTURE OF INTRACRANIAL ANEURYSM
MAINTAIN VENOUS RETURN
DELAY PREGNANCY UNTILL RX, OPTIMAL TREAT HYPERTENSION & MINIMIZE PULSE PRESSURE
EFFECTS OF PEGNANCY IN VARIOUS HEART DISEASE
D. OTHER PROBLEMS
ANY CAUSE OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS BLOOD LOSS AT DELIVERY
VENOUS RETURN LV FILLING CARDIAC OUTPUT
LATE IN PREGNANCY WHEN SUPINE (LABOUR DILIVERY, SURGERY) AND POSTPARTUM
MATERNAL MORTALITY DUE TO SUDDEN DEATH
AVOID PREGNANCYMAINTAIN VENOUS RETURN TRY TO LOWER PULMONARY VASCULAR RESISTANCE
IDIOPATHIC HYPERTROPHIC CARDIOMYOPATHY
SUBAORTIC STENOSIS
MARFAN’S SYNDROME
OBSTRUCTION OF INFERIOR VENA CAVA BY UTERUS HEART RATE BLOOD LOSS AT DELIVERY BLOOD VOLUME
BLOOD VOLUME PULSE PRESSURE STEROID HORMONES
VENOUS RETURN LV FILLING LV OBSTRUCTION CARDIAC OUTPUT
PULMONARY CAPILLARY PRESSURE
DISTENSION OF AORTIC ROOT
>12 WEEKS
>12 WEEKS
MATERNAL MORTALITY DURING PREGNANCY
MATERNAL MORBIDITY DURING PREGNANCY MATERNAL MORTALITY FROM AORTIC DISSECTION OR RUPTURE
MAINTAIN VENOUS RETURN ADRENERGIC BLOCKAGE WILL LV OUT FLOW OBSTRUCTION
RX OF PULMONARY CONGESTION, ESPECIALLY DIURETICSAVOID PREGNANCY, MINIMIZE PULSE PRESSURE
•PULMONARY HYPERTENSION
•DEVELOPMENT ABNORMALITIES
EFFECTS OF PREGNANCY ON VARIOUS C.V.S. DISEASESE.
HYPERTENSION CORONARY ARTERY DISEASE CARDIAC ARRHTHMIAS D.V.T & PUL. THROMBO EMBOLISM
MANAGEMENT OF HEART FAILURE IN PREGNANCYA. GENERAL CONSIDERATION1. HIGHEST PRIORITY TO MATERNAL HEALTH2. FETAL WELLBEING SHOULD BE
CONSIDERED AS PART OF EACH DIAGNOSTIC MANAGEMENT CONSIDRATION
3. GENERAL MEASURES SHOULD BE TAKEN BEFORE DRUG INTERVENTION
4. DRUGS, DIAGNOSTIC STUDIES, SURGERY SHOULD BE CONSIDERED FOR MAXIMUM SECURITY OF MOTHER
MANAGEMENT
B.1. PRE-CONCEPTUAL COUNSELLING2. MINIMISE STRESS ON HEART3. AVOID ANXIETY4. AVOID SYSTEMIC INFECTIONS5. AVOID ANAEMIA6. DISCOURAGE SMOKING7. IMMUNIZE BEFORE PREGNANCY8. ANTIBIOTIC PROPHYLAXIS- AGAINST
BACTERIAL ENDOCARDITIS OR RECURRENCE OF RHEUMATIC FEVER
9. PROPER MANAGEMENT OF THROMBO- EMBOLIC EVENTS
MANAGEMENT
C. DRUGS AVOID DRUGS IF POSSIBLE. IF SITUATION, WHERE CARDIAC FAILURE CAN NOT BE
CONTROLLED WITHOUT DRUGS – THEY SHOULD NOT BE WITHHELD
DIURETICS INOTROPIC AGENTS BETA BLOCKERS ANTIARRHYTHMIC AGENTS. CALCIUM CHANNEL BLOCKERS VASODILATORS ANTICOAGULANTS