Cardiovascular Diseases in Pregnancy - Dr Marcaida PDF

**OUTLINE** I. **Physiologic Considerations** II. **Prevalence** III. **Heart Disease Diagnosis** IV. **Peripartum Management Considerations** V. **Heart Diseases** VI. **Pulmonary Hypertension** VII. **Other Cardiovascular Conditions** VIII. **Reference** +-----------------------+-------...

**OUTLINE** I. **Physiologic Considerations** II. **Prevalence** III. **Heart Disease Diagnosis** IV. **Peripartum Management Considerations** V. **Heart Diseases** VI. **Pulmonary Hypertension** VII. **Other Cardiovascular Conditions** VIII. **Reference** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ PHYSIOLOGIC CONSIDERATIONS {#physiologic-considerations.TransOutline} ========================== ANATOMY {#anatomy.TransSubtopic1} ------- Heart As the diaphragm becomes progressively elevated by the uterus in the third trimester, the heart is displaced to the left & upward and rotated on its long axis Apex is moved laterally, producing larger cardiac silhouette in chest radiograph seen in the latter half of pregnancy Structurally, the expanding plasma volume seen during normal pregnancy is reflected by enlarging cardiac end-systolic and end-diastolic dimensions. PHYSIOLOGIC CHANGES {#physiologic-changes.TransSubtopic1} ------------------- These changes [begin early in pregnancy], [peak during the 2^nd^ and early 3^rd^ trimester], and remain relatively constant until delivery Multiple factors contribute to this overall altered hemodynamic function, which allows the physiological demands of the fetus to be met while maintaining maternal cardiovascular integrity The major hemodynamic changes in pregnancy include: Increased cardiac output by 30-50% The increase translates a cardiac output of 6 L/min during pregnancy. The additional 1.5 L/min supplies the expanding uterus, kidneys, skin, GI tract and the breast [Increased as early as 5^th^ week] to decreased systemic vascular resistance and increased heart rate Pregnancy-induced hypervolemia is [maximal after 28 weeks AOG] Expanded blood volume Reduced systemic vascular resistance and blood pressure Stroke volume increases by 25%-30% Resting pulse rate increased by 10 -15 bpm Heart rate \>115 bpm may warrant evaluation for pathology The following are decreased during pregnancy, which [occurs during 6-8 weeks AOG,] except MAP Peripheral vascular resistance decreases by 20% - 30% due to the vasodilation caused by Progesterone Systolic and Diastolic BP Significantly [lower 6 to 7 weeks] from LMP Mean Arterial Pressure Decreased during 2^nd^ semester **Insufficient hemodynamic changes can result in maternal and fetal morbidity** **Inability to adapt to these changes can expose underlying cardiac pathology** +-----------------------------------+-----------------------------------+ | **Table 1. Components of | | | Hemodynamic changes** | | +===================================+===================================+ | **Increased** | **Decreased** | +-----------------------------------+-----------------------------------+ | - Cardiac output | - Systemic Vascular resistance | | | or Total peripheral | | - Stroke Volume | resistance | | | | | - Plasma Volume | - Arterial pressure | | | | | - Cardiac preload | - Brachial and central systolic | | | pressure | | - End Diastolic Volume | | | | - Diastolic Pressure | | - End Systolic Volume | | | | | | - Resting Pulse/Heart Rate | | | | | | - Renin | | | | | | - Angiotensin | | +-----------------------------------+-----------------------------------+ ------------------------------------------------------------------------------------------------------------------ **Table 2. Physiologic considerations** ----------------------------------------- ------------------------------ ------------------------ ---------------- **Hemodynamic parameters** **Normal pregnancy** **Labor and Delivery** **Postpartum** Blood volume ↑ 40% -- 50% Increased Decreased Heart rate ↑ 10 -- 15 bpm Increased Decreased Cardiac Output ↑ 30% -- 50% Increased Decreased **⭐ Blood pressure** **↓ 10 mmHg** **Increased** **Decreased** Stroke Volume ↑ 1^st^ and 2^nd^ trimester\ Increased Decreased ↓ 3^rd^ trimester Systemic Vascular Resistance decreased Increased Decreased ------------------------------------------------------------------------------------------------------------------ +-----------------+-----------------+-----------------+-----------------+ | **Table 3. | | | | | Hemodynamic | | | | | changes in | | | | | pregnancy** | | | | +=================+=================+=================+=================+ | **Hemodynamic | **Pregnancy** | **Clinical | **Normal | | parameter** | | implication** | findings** | +-----------------+-----------------+-----------------+-----------------+ | Blood flow | ↑ | - Nose bleeds | - Bounding/co | | | | common | llapsing | | | | | pulse | | | | - Baseline | | | | | serum | - Prominent | | | | creatinine | non-displac | | | | lower in | ed | | | | pregnancy | apical | | | | | pulse | | | | | | | | | | | | | | | | | | | | - Ejection | | | | | systolic | | | | | murmur | | | | | | | | | | - Loud 1^st^ | | | | | heart sound | | | | | | | | | | - 3^rd^ heart | | | | | sound | | | | | | | | | | - Venous hum | | | | | | | | | | - Mammary | | | | | souffle | | | | | | | | | | - Relative | | | | | sinus | | | | | tachycardia | | | | | (10-20 bpm) | | | | | | | | | | - Ectopic | | | | | beats | | | | | | | | | | - Peripheral | | | | | edema | | | | | | | | | | - Warm/erythe | | | | | matous | | | | | extremities | | | | | | | | | | - Elevated | | | | | JVP in late | | | | | pregnancy | +-----------------+-----------------+-----------------+-----------------+ | Blood volume | ↑ | - Physiologic | - | | (plasma and | | al | | | RBC) | | anemia in | | | | | pregnancy | | | | | | | | | | - Higher risk | | | | | of cardiac | | | | | failure in | | | | | multiple | | | | | pregnancy | | +-----------------+-----------------+-----------------+-----------------+ | Systemic | ↓ | - Risk of | | | Vascular | | maternal | | | resistance | | fetal | | | | | compromise | | | | | in women | | | | | with fixed | | | | | cardiac | | | | | outputs | | | | | (stenotic | | | | | lesions) | | | | | | | | | | - Sinus | | | | | tachycardia | | | | | towards end | | | | | of | | | | | pregnancy | | +-----------------+-----------------+-----------------+-----------------+ | Stroke volume | ↑ | | | +-----------------+-----------------+-----------------+-----------------+ | Cardiac output | ↑ | | | +-----------------+-----------------+-----------------+-----------------+ | Heart rate | ↑ | | | +-----------------+-----------------+-----------------+-----------------+ | Blood pressure | ↓ | | | +-----------------+-----------------+-----------------+-----------------+ | Pulmonary | | Increased | | | capillary wedge | | susceptibility | | | pressure | | to pulmonary | | | | | edema | | +-----------------+-----------------+-----------------+-----------------+ | Colloid oncotic | ↓ | | | | pressure | | | | +-----------------+-----------------+-----------------+-----------------+ | Central Venous | | | | | pressure | | | | +-----------------+-----------------+-----------------+-----------------+ | Maternal oxygen | ↑ | Tendency to | | | consumption | | ischemia in | | | | | pregnant women | | | | | with cardiac | | | | | disease | | +-----------------+-----------------+-----------------+-----------------+ PREVALENCE {#prevalence.TransOutline} ========== 0.98% among 30, 053 delivery admissions in the PGH (2015 -- 2019) CHD (40.6%) RHD (37.2%) 2.83% among 3,043 delivery admission in PGH (2023) Leading cause of pregnancy-related mortality in the US 7.2 -- 17.2 deaths per 100,000 livebirths from 1985 -- 2015 Increasing number of women at advanced maternal age, comorbid pre-existing conditions and women with congenital heart disease High-Risk Maternal Cardiovascular Disorders and their Estimated Maternal Mortality Rate (%) Aortic Valve Stenosis -- 5% Severe Coarctation of the Aorta -- 5% Marfan Syndrome -- 10%-20% Peripartum Cardiomyopathy -- 15%-60% Severe Pulmonary Hypertension -- 50% Tetralogy of Fallot -- 10% HEART DISEASE DIAGNOSIS {#heart-disease-diagnosis.TransOutline} ======================= 1. In normal pregnancy: 1. functional systolic heart murmurs are common respiratory effort is accentuated edema frequently accrues in lower extremities after midpregnancy fatigue and exercise tolerance often develop Physiological adaptations of normal pregnancy can induce symptoms and alter clinical findings that may confound the diagnosis of heart disease +-----------------------------------------------------------------------+ | **Table 4. Clinical Indicators of Heart Disease During Pregnancy** | +=======================================================================+ | **Symptoms** | +-----------------------------------------------------------------------+ | - Progressive Dyspnea or orthopnea | | | | - Nocturnal cough | | | | - Hemoptysis | | | | - Syncope | | | | - Chest Pain | +-----------------------------------------------------------------------+ | **Clinical Findings** | +-----------------------------------------------------------------------+ | - Cyanosis | | | | - Clubbing of fingers | | | | - Persistent neck pain distention | | | | - Systolic murmur grade 3/6 or greater | | | | - Advanced systolic murmur = cvd diagnosis | | | | - Diastolic murmur | | | | - Any diastolic murmur points to a cardiac disease | | | | - Cardiomegaly | | | | - Persistent tachycardia and/or arrhythmia | | | | - Persistent split-second sound | | | | - Fourth heart sound | | | | - Criteria for pulmonary hypertension | +-----------------------------------------------------------------------+ DIAGNOSTICS {#diagnostics.TransSubtopic1} ----------- Electrocardiogram (ECG) Slight left-axis deviation Q waves in leads II, III and aVF Inverted T-waves in leads III, V1-V3 Chest radiograph Lead apron shield is used so fetal radiation exposure is minimal Slight heart enlargement is poorly detected because the heart silhouette normally is larger in pregnancy Echocardiogram Trans-esophageal echo Cardiovascular MR Best diagnostic tool Higher reproducibility Less hindered by body hiatus and ventricular geometry Not exposed to ionizing radiation Cardiac Catheterization Invasive But still acceptable, limited and not contraindicated Can be safely performed with limited fluoroscopy time Even during labor in highly selected patients FUNCTIONAL HEART DISEASE CLASSIFICATION {#functional-heart-disease-classification.TransSub-subtopic2} --------------------------------------- Pregnancy is a stress test of cardiovascular reserve However, no clinically applicable test accurately measures functional cardiac capacity NYHA CLASSIFICATION {#nyha-classification.TransSub-subtopic2} ------------------- The clinical classification of the New York Heart Association (NYHA) is based on past and present disability and is uninfluenced by physical signs **Table 5. Functional Heart Disease Classification** ------------------------------------------------------ --------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- **NYHA Class** **Levels of Clinical Impairment** I Uncompromised -- no limitation of physical activity These women do not have symptoms of cardiac insufficiency or experience anginal pain II Slight limitation of physical activity These women are comfortable at rest, but with ordinary physical activity, discomfort in the form of excessive fatigue, palpitation, dyspnea, or anginal pain results III Marked limitation of physical activity Comfortable at rest, but less than ordinary activity causes excessive fatigue, palpitation, dyspnea, or anginal pain IV Severely compromised -- inability to perform any physical activity without discomfort Symptoms of cardiac insufficiency or angina may develop even at rest. If any physical activity is undertaken, discomfort is increased. **From Dr. Marcaida's PPT** **Class** **Symptoms at rest** **Symptoms during physical activity** I NONE NONE II MILD III SEVERE IV PRESENT {#section.TransSub-subtopic2} WHO RISK CLASSIFICATION OF CVD AND PREGNANCY {#who-risk-classification-of-cvd-and-pregnancy.TransSub-subtopic2} -------------------------------------------- Most comprehensive risk stratification Especially useful for assessing maternal risk and for preconception counseling Pregnancy is contraindicated on the risk level WHO 3 and 4 Allows to determine how often cardiac evaluation is warranted +-----------------------------------+-----------------------------------+ | **Table 6. WHO Risk | | | Classification of CVD and | | | Pregnancy** | | +===================================+===================================+ | **Risk Category** | **Associated Conditions** | +-----------------------------------+-----------------------------------+ | **WHO 1** -- Risk **no higher** | Uncomplicated, small or mild PS, | | than general population | VSD, PDA, MVP | | | | | | Successfully repaired ASD, VSD, | | | PDA, TAPVD | +-----------------------------------+-----------------------------------+ | Cardiology consult once or twice | | | during pregnancy | | +-----------------------------------+-----------------------------------+ | **WHO 2** -- **small increase** | Uncomplicated unoperated ASD, | | in risk of maternal mortality and | repaired TOF, most arrhythmias | | morbidity | | +-----------------------------------+-----------------------------------+ | Cardiology consult each trimester | | +-----------------------------------+-----------------------------------+ | **WHO 2 or 3** -- depends on | Mild LV impairment | | individual case. Intermediate | | | increase in maternal mortality | Hypertrophic CM, Marfan's | | risk and moderate to severe rise | syndrome w/o aortic dilatation, | | in morbidity risk | Heart transplantation | +-----------------------------------+-----------------------------------+ | Individualized care | | +-----------------------------------+-----------------------------------+ | **WHO 3** -- **significant** | Mechanical valve, Systemic right | | increased risk of maternal | ventricle, Post-Fontan operation, | | morbidity and mortality | Cyanotic heart disease | +-----------------------------------+-----------------------------------+ | Cardiology consult monthly or | | | bimonthly | | +-----------------------------------+-----------------------------------+ | ⭐ **WHO 4** -- **very high risk** | Pulmonary arterial hypertension | | of maternal mortality or | | | **severe** morbidity; **pregnancy | Severe systemic ventricular | | contraindicated** | dysfunction (NYHA III-IV or LVEF | | | \40 | | | mm | +-----------------------------------+-----------------------------------+ | Pregnancy contraindicated | | | | | | If pregnancy occurs, cardiology | | | consultation monthly and OB | | | monitoring | | +-----------------------------------+-----------------------------------+ {#section-1.TransSub-subtopic2} CARPREG I {#carpreg-i.TransSub-subtopic2} --------- Index score for women with heart disease +-----------------------------------+-----------------------------------+ | **Predictors** | **Score** | +===================================+===================================+ | Prepregnancy history of cardiac | 1 point | | events (heart failure, stroke) or | | | arrythmias | | +-----------------------------------+-----------------------------------+ | Baseline NYHA functional class | 1 point | | \>II or cyanosis | | +-----------------------------------+-----------------------------------+ | Left heart obstruction | 1 point | | | | | MV area \