2 HEART DISEASE IN PREGNANCY A.MALIBARY, M.D. Associate Professor
3 1. How do you grade the functional capacity of heart?
4 The New York Heart Association (NYHA) Grading of functional capacity of the heart:CLASS INo functional limitation of activitySymptoms with extra ordinary physical work.CLASS IIMild limitation of physical activity.Symptoms with ordinary physical workCLASS IIIMarked limitation of physical activitySymptoms with less than ordinary physical workCLASS IVSevere limitation of physical activitySymptoms at rest
5 2.What is the mortality associated with the various cardiac lesions ?
6 Mortality associated with specific cardiac lesions 1. Low risk of maternal mortality (less than 1%).(a) Septal defects.(b) New York Heart Association classes I and II.(c) Patent ductus arteriosus.(d) Pulmonary / tricuspid lesions.2. Moderate risk of maternal mortality (5-15%).(a) NYHA classes III and IV mitral stenosis.(b) Aortic stenosis.(c) Marfan’s syndrome with normal aorta.(d) Uncomplicated coarctation of aorta.(e) Past history of myocardial infarction.3. High risk of maternal mortality (25-50%).(a) Eissenmenger’s syndrome.(b) Pulmonary hypertension.(c) Marfan’s syndrome with abnormal aortic root.(d) Peripartum cardiomyopathy.
7 3. What is the prognosis for a woman with a cardiac disease depending on the NYHA classification?
8 Prognosis depending on the functional status v In general, women in NYHA classes I and II lesionsusually do well during pregnancy and have afavorable prognosis with a mortality rate of <1%.v Patients in NYHA classes III and IV may have amortality rate of 5% to 15%. These patients shouldbe advised against becoming pregnant.
9 4. What are the causes for increased cardiac output during a normal pregnancy?
10 Cardiac output begins to rise in the first trimester and continues as steady increase to peak at 32 weeks gestation by 30% to 50% of pre pregnancy level.Causes for increased cardiac output are1. Increases in stroke volume (early pregnancy)2. Increase in heart rate (late pregnancy)3. Decreased peripheral resistance4. Decreased blood viscosity
11 5. What are the causes for fall in the peripheral resistance?
12 The fall in the peripheral resistance is about 20-30% at weeks & returns to normal at term. This fall is due to1. Due to the trophoblastic erosion of endometrial vessels,the placental bed serves as a large arteriovenous shuntcausing lowered systemic vascular resistance2. There is physiological vasodilatation which is believed tobe secondary to endothelial prostacyclin and circulatingprogesterone.
13 6. What are physiological changes during labour ?
14 Physiological changes during labour and puerperium. 1.First stage.Cardiac output increases by15%. Uterine contractionsincreases venous return , causing increase in cardiacoutput & can cause reflex bradycardia.2.Second stageIncrease in intra abdominal pressure (valsalva’s)causes inecrease in venous return and cardiac output.3.Third stageNormal blood loss during delivery(around ml).It leads toa. Decrease blood volumeb. Decrease cardiac output.
15 7. What are the clinical features in a normal pregnancy which can mimic a cardiac disease ?
16 The clinical features in a normal pregnancy which can mimic a cardiac disease are1. Dyspnea - due to hyperventilation, elevated diaphragm..2. Pedal Edema3. Cardiac impulse- Diffused and shifted laterally from elevated diaphragm.4. Jugular veins may be distended and JVP raised.5. Systolic ejection murmurs along the left sternal border occur in 96% of pregnant women and are believed to be caused by increased flow across the aortic and pulmonary valves.
17 8. What are the criteria to diagnose cardiac disease during pregnancy ?
18 Criteria to diagnose cardiac disease during pregnancy: 1.Presence of diastolic murmurs.2.Systolic murmurs of severe intensity (grade 3).3.Unequivocal enlargement of heart (X-ray).4.Presence of severe arrythmias, atrial fibrillation or flutter
19 9. What are the indications for Termination of pregnancy?
20 The indications for Termination of pregnancy: Because of high maternal risks, MTP is indicated in:1.Eisenmenger’s syndrome.2.Marfan’s syndrome with aortic involvement3.Pulmonary hypertension.4.Coarctation of aorta with valvular involvement.Termination should be done before 12 weeks ofpregnancy.
22 Warfarin use in first trimester can be teratogenic and can cause fetal embryopathy( 15 to 25 % ) which includes· Nasal cartilage hypoplasia,· Stippling of bones,· IUGR and· Brachydactyly.
23 11. What are the risk factors for cardiac failure during pregnancy ?
24 Risk factors for cardiac failure during pregnancy InfectionAnemiaObesityHypertensionHyperthyroidismMultiple pregnancy
25 12. What is the prophylaxis for Sub acute bacterial endocarditis (SABE) while performing any obstetric and gynecological procedures during pregnancy?
26 Antibiotic prophylaxis consists of a. 2 gm ampicillin IV/plusb. 1.5mg per kg gentamicin /IV prior to theprocedure , followed by one more dose ofampicillin 8 hours later.In the event of penicillin allergy 1 gm vancomycin IV can be substituted.
27 13. Which is the ideal contraceptive for women with heart disease ?
28 Contraception1. OC pills are not ideal as they can cause thrombo embolism.2. IUCD can cause infection- endocarditis.3. Barrier contraceptives – Have high failure rates.4. Progestin only pills or Long acting injectable progesterone arebetterPILL - DesogestrelINJECTABLESa. Medroxy progesterone 150mg IM every 3 months.b. Norethisterone.200 mg every 2 months5. Sterilization is best.