Heart disease in pregnancy.pdf

Heart disease in pregnancy Dr. Harry Surya R MD(UISU), DROG/MOG (UKM) Obstetric and Gynaecology Department University Science Islam Malaysia  Learning outcome Define physiological changes in the cardiovascular...

Heart disease in pregnancy Dr. Harry Surya R MD(UISU), DROG/MOG (UKM) Obstetric and Gynaecology Department University Science Islam Malaysia  Learning outcome Define physiological changes in the cardiovascular system in pregnancy. Describe the important preconception and genetic counselling in patient with heart diseases in pregnancy. List the risk assessment and level of care in patient with heart diseases in pregnancy. Outline the antepartum, intrapartum and postpartum management of heart diseases in pregnancy.  Epidemiology “According to the Report of the National Obstetrics Registry, the incidence of cardiac disease in pregnancy in Malaysia was 0.55% in 2013 and 0.45% in 2014.”. Clinical Practice Guidelines Heart Diseases in Pregnancy 2 nd edition (2016) It accounted for 51% of indirect deaths in the period 2009-2011 and 15.3% of total maternal deaths. Based on data from Confidential Enquiries into Maternal Deaths Malaysia 2011 Physiological changes in the Cardiovascular System in Pregnancy The rise in cardiac output (patients limited cardiac function or reserve to develop) → congestive cardiac failure. The increased preload (patients with obstructive lesions ie such as severe mitral or aortic stenosis) and/or ventricular dysfunction → worsening the condition Tachycardia → causes palpitations → impair ventricular filling especially in women with severe mitral stenosis. The hypercoagulable state (increase in clotting factors) → thromboembolism. The changes in renal blood flow → drug excretion → volume of distribution of drugs Compression of the inferior vena cava by the uterus → can lead to venous stasis and supine hypotensive syndromes. Haemodynamic changes during pregnancy  Physiological changes in pregnancy The haemodynamic changes return to pre-pregnant levels within 2-4 weeks following vaginal delivery and 4 to 6 weeks following caesarean section.  Physiological changes in pregnancy Blood volume Increased as pregnancy progress 40-50% peak at 32-36w POG then plateau till term Physiological anaemia ( RBC mass only increase by 17-40%) Cardiac output Increase 30-50% peak by 20-24w POG CO = SV x HR (initially increase in SV then increase in HR 20%) Fall in systemic vascular resistance Fall in blood pressure esp in 2nd trimester Increased pulmonary blood flow Reduce pulmonary vascular resistance Unchanged pulmonary artery pressure Supine hypotension syndrome in 3 rd trimester  Preconception and genetic counselling Pregnant women with cardiac disease are at risk of significant obstetric complications thus focus that every pregnancy is a planned pregnancy Counselling should be initiated at puberty and re-emphasised at age 16-18 and prior to marriage Those planning to get pregnant, this should be done at least 6 months before planned conception.  A thorough history particularly focusing on exercise capacity and past cardiac events. A detailed clinical examination. Cardiac radiograph and ECG/ ECHO should be reviewed. A review of medications with potential harm to the fetus (discontinuing fetotoxic medications and substituting with safer alternative). Women with treated hypertension should be informed about anti-hypertensive medications that are safe in pregnancy Preconception counselling preferably at every medical review or at least annually. involves An assessment for comorbidities (e.g. obesity, hypertension, diabetes mellitus, connective tissue disease). A review of past pregnancies. Advising against smoking, vaping and alcohol consumption, A dental review - good dental hygiene is important and should be stressed. Prescribing folic acid at least 3-6 months prior to conception. Multidisclipinary approach  Types of cardiac disease Congenital heart disease Rheumatic heart disease Valvular heart disease Myocardial infarction/ ischaemic heart disease Arrythmias (conductive problems) Peripartum cardiomyopathy etc Risk of Recurrent Congenital Heart Lesions in the Fetus of Parents with CHD  Risk assessment and level of care Risk assessment : Low risk Uncomplicated septal defects Aortic & mitral regurgitation Pulmonary stenosis Hyperthropic myocardiopathy Acynotic Ebstein anomaly Corrected transposition without other defects Moderate risk Prosthetic valves with anticoagulant Coarctation of aorta Risk assessment : High risk Pulmonary hypertension (pulm pressure>75% than systemic pressure) Eisenmenger syndrome Uncorrected cyanotic heart dis Severe mitral or aortic stenosis Poor LVF ( LVF < 40%) Marfan syndrome ( aortic root >40mm diameter) Level of care High risk Ideally in a tertiary centre with multi disciplinary approach Moderate risk Managed in hospitals with specialists Low risk Can be managed in clinic by primary care doctors  Assessment and risk stratification Good and thorough history taking : History of breathlessness, palpitations, near faints and chest pains. In patients with known cardiac disease, the WHO Risk Score and the NYHA Functional Class Past medical history of being told to have cardiac murmurs, having undergone cardiac surgery or procedures Family history of cardiac disease, arrhythmias or sudden death Clinical examination (please revise your cardiovascular examination technique) The heart rate and blood pressure (BP) should be measured manually. In patients with heart disease in pregnancy, the oxygen saturation should be measured by pulse oximetry. Examine for signs of heart failure  May be misinterpreted with pregnancy symptoms Normal findings in pregnancy mimic cardiac disease. Normal history: Palpitations Fatigue Decrease effort tolerance Lower extremities edema orthopnea Normal physical findings Mid diastolic murmur at left base Continuous murmur ??? Split S1 Distended or mildly increased neck veins Lower extremities edema ???  General Principles in the Management of Cardiac Disease in Pregnancy Referred as soon as possible for cardiac assessment and risk stratification. Obstetrics Risk Stratification Charts, heart disease is coded red. Women with WHO risk class I-II and NYHA I & II can be managed in their local hospital after at least one review by the physician/cardiac specialist. Women with WHO risk class II-III, III & IV and NYHA III & IV should be followed up in a tertiary centre by a multidisciplinary team with expertise in managing high risk pregnancies. Antepartum care Assess and risk stratify the maternal cardiovascular status Termination of pregnancy if indicated in high risk patient (only by 2 specialist decision) Review maternal medications for potential fetotoxicity Optimise maternal cardiovascular status + combine clinic. Formulate an individualised pregnancy care plan which includes time, place and mode of delivery Foetal assessments and surveillance (NT scan and Detailed scan) Maintain normal blood pressure Time, Place and Delivery mode Timing of delivery should be individualised according the women’s cardiac status, fetal wellbeing and Bishop score. In asymptomatic women → spontaneous labour is preferred. Women in NYHA/ WHO Risk II-III, III & IV, a planned delivery is advisable. Vaginal delivery is the preferred mode of delivery. Caesarean section should be reserved for obstetric indications and in certain case ie : heart failure (NYHA III & IV), severe obstructive cardiac lesions, etc Intrapartum Monitoring Haemodynamic and Cardiac status ECG, pulse and non-invasive blood pressure Oxygen saturation — oxygen supplementation to be given if oxygen saturation is < 95% Continuous fetal monitoring Strict input output chart (less than 80 mls/hours) Adequate analgesia preferable epidural Lateral decubitus position to avoid aortocaval compression in Iabour Prolonged and difficult labour should be avoided (shortened second stage) Post partum During the first few days of the puerperium, the patient needs to be monitored in the HDU/ICU/CCU Closed monitoring of fluid overload and PPH Minimum length of stay at hospital 3-5 days Contraception to avoid unplanned pregnancy and poor spacing Anticoagulant drug Appointment and follow up with cardiologist team  Summary Preconception and genetic counselling Risk assessment and level of care Good and thorough history taking Complete physical examination esp cardiovascular examination (cardiac status) Complication of heart diseases in pregnancy to the mother and to the foetus Antenatal and intrapartum management Contraception to avoid unplanned pregnancy  Reference 1. LC Kenny, Jenny E. (2017). Obstetrics by Ten Teachers, 20 th Ed. CRC Press Taylor & Francis Group. 2. Hanretty, KP. (2009). Obstetrics illustrated, 7th Ed.Churchill Livingstone, Elsevier. 3. Clinical Practice Guidelines Management of Heart Diseases in pregnancy 2nd edition (2016). Thank you