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Ma. Socorro C. Bernardino, M.D. FPOGS PREGNANT RHEUMATIC: Pre-natal and Post-natal Care.

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Presentation on theme: "Ma. Socorro C. Bernardino, M.D. FPOGS PREGNANT RHEUMATIC: Pre-natal and Post-natal Care."— Presentation transcript:

1 Ma. Socorro C. Bernardino, M.D. FPOGS PREGNANT RHEUMATIC: Pre-natal and Post-natal Care

2 “The management of cardiac disease during pregnancy poses a double challenge.....” (

3 “...To ensure maternal survival but at the same time promote fetal well-being and to allow a gestational period sufficient for adequate fetal maturity.” (

4 Management should be MULTIDISCIPLINARY – OB – Cardiologist – Anesthesiologist

5 – Accurate diagnosis – Assessment of the severity – Degree of impairment – Evaluation of concomitant therapy – Optimizing management Pregnancy Labor and Delivery

6 – Preconceptional counseling – Hemodynamic changes during pregnancy – Effects of Pregnancy on maternal cardiac disease – Effect of Maternal cardiac disease on pregnancy – General Measures for the care of pregnant patients with heart disease

7 HEMODYNAMIC CHANGES IN NORMAL PREGNANCY Non-pregnantPregnant Cardiac output (L/min) Heart rate (beats/min) Systemic vascular resistance (dyne.cm.sec) Pulmonary vascular resistance Colloid oncotic pressure (mmHg)

8 HEMODYNAMIC CHANGES IN NORMAL PREGNANCY Non-pregnantPregnant Mean arterial pressure Pulmonary capillary wedgepressure (mmHg) Central venous pressure Left ventricular stroke volume Clark et al, 1989

9 EFFECT OF PREGNANCY ON MATERNAL CARDIAC DISEASE – Periods during pregnancy when the danger of cardiac decompensation is great: – 16 weeks – start of hemodynamic changes in pregnancy – 32 weeks – hemodynamic changes of pregnancy peak and cardiac demands are at a maximum

10 DURING LABOR sympathetic response to pain + uterine contractions ml blood injected into general circulation/contraction 2. Increase in systemic vascular resistance increase stroke volume by 50% Stress in CVS

11 DURING LABOR During the second stage of labor, maternal pushing decreases the venous return to the heart decrease in cardiac output

12 AFTER DELIVERY AND PLACENTAL SEPARATION Sudden transfusion of blood from the lower extremities and the utero- placental vascular tree to the systemic circulation Large and abrupt increase in blood volume

13 EARLY SIGNS OF CARDIAC COMPROMISE – Starts at first trimester – Peak at weeks CO reaches maximum – Beyond 24 weeks CO maintained at high levels – Post-partum CO only begins to decline

14 “Intensive monitoring should be continued for at least 72 hours after delivery, preferably in a high care or intensive care environment” (Mulder BJM et al. Valvular heart disease in pregnancy. New England Journal of Medicine 2003)

15 When an underlying valvular disease is present, its not surprising that signs and symptoms of cardiac failure do occur “Following delivery the cardiovascular status of patient will normalize at 6-8 weeks post delivery” (Van Oppen ACA et al. A longitudinal study of the maternal hemodynamics during normal pregnancy. Obstetrics and Gynecology 1996; 88:40-6)

16 – EFFECTS OF MATERNAL CARDIAC DISEASE IN PREGNANCY – Pregnancy outcome is compromised by the presence of cardiac disease. Fetal Death – usually secondary to chronic severe or acute maternal deterioration Fetal morbidity – secondary to preterm delivery and fetal growth restriction> relative inability to maintain an adequate uteroplacental circulation

17 – EFFECTS OF MATERNAL CARDIAC DISEASE IN PREGNANCY Fetal morbidity – secondary to preterm delivery and fetal growth restriction Frequency of effects is related to severity of functional impairment of the heart and severity of chronic tissue hypoxia

18 THE LEVEL OF ANTEPARTUM CARE REQUIRED BY A PREGNANT WOMAN DEPENDS ON THEIR RISK CLASSIFICATION: GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS

19 NEW YORK HEART ASSOCIATION (NYHA) CLASSIFICATION FUNCTIONAL CLASSDESCRIPTION INo limitations of activities No symptoms from ordinary activity IIMild limitation of activity Comfortable with rest or mild exertion IIIMarked limitation of activity Comfortable only at rest IVShould be at complete rest, confined to bed or chair Any physical activity brings discomfort Symptoms occur at rest

20 “A New York Heart Association functional class III or IV has been estimated to carry a > 7% risk of mortality and a 30% risk of morbidity” “ Although women in these functional classes should be counselled against childbearing, it is not infrequent that they are encountered in the prenatal clinic (or even in labor ward, or at the theater door!” (Joubert IA and Dyer RA. Anaesthesia for the pregnant patient with acquired valvular heart disease.Update in Anesthesia. Issue Article 9)

21 FIVE RISK FACTORS PREDICATIVE OF POOR MATERNAL AND OR NEONATAL OUTCOME 1. Prior cardiac event – heart failure, transient ischemic attack or stroke 2. Prior arrythmia – symptomatic brady or tachy arrhytmia requiring therapy 3. New York functional > class II or the prescence of cyanosis 4. Valvular or outflow tract obstruction – Aortic valve area < 1.5 cm2 or mitral valve area < 2 cm2 – Left ventricular outflow tract pressure gradient > 30 mmHg 5. Myocardial dysfunction – Left ventricular EF < 40% – Restrictive or hypertrophic cardiomyopathy (Siu SC et al. Rik and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96: )

22 COMPLICATIONS ASCRIBED TO VALVULAR HEART DISEASE – 1. Increased incidence of maternal cardiac failure and mortality – 2. Increased risk of premature delivery – 3. Lower APGAR scores and low birth weight – 4. Higher incidence of interventional and assisted deliveries (Malhotra M et al. Maternal and fetal outcome in valvular heart disease. International Journal of Gynecology and Obstetrics 2004;84:11-6)

23 LOW Maternal and Fetal Risk HIGH Maternal and Fetal Risk HIGH Maternal Risk HIGH Neonatal Risk Asymptomatic aortic stenosis low mean outflow gradient (<50mmHg) with normal left ventricular function Severe aortic stenosis with or without symptoms Reduced left ventricular systolic function (LVEF <40%) Maternal age 35 yr Aortic regurgitation of NYHA class I or II with normal left ventricular syustolic function Aortic regurgitation with NYHA class III or IV symptoms Previous heart failureUse of anticoagulant therapy throught pregnancy Mitral regurgitation of NYHA class I or II with normal left vertricular systolic function Mitral regurgitation with NYHA class III or IV symptoms Previous stroke or transient ischemic attack Smoking during pregnancy Mild to moderate mitral stenosis (valve area >1.5cm2, gradient <5mmHg) without severe pulmonary hypertesion Mitral stenosis with NYHA class II, III or IV symptoms Multiple gestations Mitral valve prolapse with no mitral regurgitation or with mild to moderate mitral regurgitation and with normal left ventricular systolic function Aortic valve disease, mitral valve disease, or both, resulting in severe pulmonary hypertension (pulmonary pressure > 75% of systemic pressures) Mild to moderate pulmonary valve stenosis Aortic valve disease, mitral valve disease, or both, with left ventricular systolic dysunction (EF <40%) Maternal cyanosis NYHA class III and IV

24 MULTIDISCIPLINARY TEAM APPROACH: I. Primary care physician/high-risk pregnancy specialist - monitor fetal condition and maternal cardiac function at frequent intervals in order to determine if the physiological changes elicited by pregnancy are exceeding the functional capacity of the heart - use medications to limit the extent of changes and improve outcome. GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS

25 MULTIDISCIPLINARY TEAM APPROACH: II. Anesthesiologist - consulted early in pregnancy to assess anesthetic risk of the patient - discuss pain control during labor and delivery GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS

26 MULTIDISCIPLINARY TEAM APPROACH: III. Cardiologist - consult on a regular basis and be available if primary care physicians sees signs of compromise IV. Neonatologist - if fetus is affected by a congenital heart disease GENERAL MEASURES FOR THE CARE OF PREGNANT CARDIAC PATIENTS

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28  Patients who are otherwise healthy  require little or no specific treatment  usual obstetric recommendations and monitoring.  NYHA Class I or II  may need to limit strenuous exercise  adequate rest, supplementation of iron and vitamins  low-salt diet  regular cardiac and obstetric evaluations  NYHA Class III or IV  may need hospital admission for bed rest and close monitoring  may require early delivery if there is maternal hemodynamic compromise.

29 Bed rest/Activity restriction Diet Modification – dietary salt restriction (4-6 g daily) - limitation of fluid intake (1-1.5 l/day) GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM:

30 Prenatal visits – every 2 weeks until 28 weeks then weekly thereafter Emphasis: 1. Pulse rate check 2. Presence of palpitations Lanoxin 0.25 mg tab OD Metoprolol – may cause fetal growth restriction GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM:

31 Prenatal visits – 3. Signs of congestion Furosemide 20 mg tab OD - may cause oligohydramnios GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM:

32 Prenatal visits – Fetal growth monitoring and status of amniotic fluid done with ultrasound Instruction: Left lateral decubitus position GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM:

33 Antibiotic prophylaxis: Pen V 250 mg cap BID or Erythromycin 250 mg cap BID GENERAL MEASURES FOR THE CARDIAC PATIENT ANTEPARTUM:

34 RHEUMATIC HEART DISEASE: RHEUMATIC FEVER Rheumatic fever seldom occurs for the first time young adults and usually preceeded by an episode during childhood (mean age 13) Uncommon in western countries but still prevalent in developing countries Women with a history of rheumatic fever should take daily penicillin before and throughout pregnancy

35 RHEUMATIC HEART DISEASE: RHEUMATIC FEVER Acute rheumatic fever is managed similarly in pregnant and non- pregnant patients Acute streptococcal infection mandates a full bactericidal dose for 10 days Manifestations of pericarditis, symptoms of heart failure, cardiac murmurs and heart enlargement necessitates prompt suppression with prednisone and bed rest

36 RHEUMATIC HEART DISEASE: CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - the most common rheumatic heart lesion - one of the most dangerous in pregnant women Pregnancy hemodynamic burdens: 1. Increase cardiac output 2. Increase heart rate 3. Expansion of blood volume 4. Increase demand for oxygen

37 RHEUMATIC HEART DISEASE: CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - Critical pregnancy periods: 1. Latepregnancy - Increased blood volume, CO and HR near term 2. During labor - further 10-15% increase in CO augmented during uterine contractions resulting in autotransfusion of 300 to 500 ml of blood

38 RHEUMATIC HEART DISEASE: CHRONIC RHEUMATIC HEART DISEASE Mitral stenosis: - Critical pregnancy periods: 3. Immediately after delivery - Increase in preload and blood volume from the contracted uterus and release of aortocaval compression - Elevated CO persists several days postpartum and gradually declines over a 2 week period

39  mitral stenosis ▪ increase in cardiac output with the increase in heart rate shortens the diastolic filling time and exaggerates the mitral valve gradient Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

40  added volume load may result in symptoms of dyspnea and heart failure in women with impaired LV function and those with limited cardiac reserve  Stenotic valvular lesions are less well tolerated than regurgitant ones  increased heart rate associated with pregnancy reduces the time for diastolic filling, which can be extremely troublesome for many patients, especially those with MS

41  exertional dyspnea and fatigue-1 st symptoms of MS  decreased exercise capacity  Orthopnea  paroxysmal nocturnal dyspnea  pulmonary edema  atrial fibrillation, or an embolic event  Rarely, patients may present with hoarseness, hemoptysis or dysphagia

42  Tocolytic agents that are positively chronotrophic are contraindicated  Magnesium sulfate PRETERM LABOR:

43  Both maternal and fetal outcomes are directly related to the severity of MS and the pre- pregnancy NYHA functional class

44  intrauterine growth retardation  low birth weight, prematurity  fetal/neonatal death  has been estimated at approximately  33% in severe MS  28 % in moderate MS  14% in Mild MS

45  Associated with 10% maternal mortality  Mortality rises to >50% in NYHA class III and IV  Mortality rises between 5-10% if with concomitant atrial fibrillation

46  Many px w/ moderate to severe MS can be managed successfully with medical therapy w/c includes strict control of heart rate,volume status and frequent monitoring

47  Reduce Heart rate  Beta Blockers or calcium Channel Blockers ▪ Metoprolol( beta blocker)-preferred beta blocker ▪ Atenolol-can cause IUGR,bradycardia and Death ▪ Digoxin-used in px w/AF for control of ventricular rate and is generally safe, well tolerated and has fewer side effects  Restriction of physical activity  Reduce left atrial pressure  Diuretics- caution must be exercised to avoiud uteroplacental hypoperfusion associared w/ use of diuretics

48 “Severe symptomatic disease, threatening maternal or fetal well-being is an accepted indication for either balloon vulvoplasty or valve replacement” “ Valve replacement is usually undertaken during 2 nd trimester. Cardiopulmonary bypass and hypothermia carry substantial risk for the fetus. Fetal bradycardia and death are not uncommon” (Unger F et al. Standards and concepts in valve surgery. Report of the task force: European Heart Institute (EHI) of the European Academy of Sciences and Arts and the International Society of Cardiothoracic Surgeons (ISCTS). Indian Heart Journal 2000;52:237-44)

49  Patients with severe mitral stenosis who develop decompensation during pregnancy should undergo percutaneous trans-mitral commissurotomy  Percutaneous mitral valvuloplasty can be performed with few or no complications to the mother or the fetus and excellent clinical and hemodynamic results

50  The “optimal time” appears to be between 20 and 28 weeks of gestation  Obstetric monitoring of the fetus during the procedure  Maternal functional class is an important predictive factor for maternal death. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

51  Anticoagulation with Warfarin or Heparin can be considered for px with severe left atrial dilatation and Severe MS despite the presence of sinus rhythm, because of the hypercoagulable state of pregnancy

52 PREGNANT RHEUMATIC: Labor and Delivery

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54  Labor and delivery in lateral decubitus position  Continuous monitoring with pulse oximetry  Control of rate of IV fluid administration to 75 cc/hr  Adequate pain relief (epidural narcotics) GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR:

55  Antibiotic prophylaxis  Short Vaginal delivery with excellent anesthesia  Cesarean section per obstetric indications  Invasive monitoring if needed  Medical therapy optimization of loading conditions  Prevention and treatment of pulmonary edema GENERAL MEASURES FOR THE CARDIAC PATIENT IN LABOR:

56 Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal procedures CategoryDrug and dosage High-risk patientAmpicillin, 2 g IM or IV, plus gentamicin sulfate (Garamycin), 1.5 mg/kg IV 30 min before procedure; ampicillin, 1 g IV, or amoxicillin (Amoxil, Trimox, Wymox), 1 g PO 6 hr after procedure High-risk patient who has penicillin allergyVancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr, plus gentamicin sulfate, 1.5 mg/kg IV 30 min before procedure

57 EPIDURAL ANESTHESIA – Desirable for vaginal delivery – Performed using small increments of local anesthetic to achieve T8-T10 level GENERAL ANESTHESIA – Best option for NYHA class III and IV – Avoid atropine, pancuronium, meperidine, ketamine

58  Shortening of the second stage of labor and assisted vaginal delivery is strongly recommended  Cesarean section are performed for Obstetrics indications

59 CARDIOVASCULAR DRUGS IN PREGNANCY:

60  ANGIOTENSIN-CONVERTING ENZYME INHIBITORS  contraindicated in pregnancy ▪ abnormal renal development in the fetus ▪ oligohydramnios and intrauterine growth retardation Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

61  BETA-ADRENERGIC RECEPTOR BLOCKERS ▪ been used extensively during pregnancy for treatment of arrhythmias, hypertrophic cardiomyopathy, and hypertension ▪ cross the placenta but are not teratogenic ▪ demonstrated to cause fetal growth retardation ▪ be associated with neonatal bradycardia and hypoglycemia Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

62  CALCIUM CHANNEL BLOCKERS ▪ used to treat both arrhythmias and hypertension ▪ limited data regarding use ▪ Most experience probably exists with verapamil, and no major adverse fetal effects have been recorded ▪ Diltiazem and nifedipine have also been used, but studies are limited. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

63  DIGOXIN ▪ used during pregnancy for many decades ▪ cross the placenta ▪ no adverse effects with its use have been reported Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

64  DIURETICS ▪ most commonly furosemide ▪ treat congestive heart failure during pregnancy and treatment of hypertension. ▪ may cause reduction in placental blood flow and have a detrimental effect on fetal growth. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

65  WARFARIN ▪ contraindicated in the first trimester of pregnancy ▪ crosses the placenta and may cause fetal embryopathy ▪ third trimester (about labor and delivery) ▪ immature fetal liver does not metabolize warfarin as rapidly as the mother's liver ▪ reversal of anticoagulation in the fetus may take up to 1 week because of the immature fetal liver Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

66 POST NATAL CARE:

67  Counseling on contraception  Permanent sterilization after delivery discussed during prenatal visits  Surgical management prior to the next pregnancy Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. Postnatal Care:

68  failure rate of approximately 15 pregnancies/100 woman-years of use  use of a barrier method depends on how critical it is for the woman to avoid pregnancy, compliance and the ability to use a condom correctly. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

69  Combination estrogen-progesterone oral preparations ▪ increased risk of venous thromboembolism, atherosclerosis, hyperlipidemia, hypertension, and ischemic heart disease ▪ congenital heart disease who have cyanosis, atrial fibrillation or flutter, mechanical prosthetic heart valves, or a Fontan circulation should avoid estrogen-containing preparations ▪ impaired ventricular function from any cause or with a history of any prior thromboembolic Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

70  Progesterone-only contraceptives  There is a paucity of data about adverse effects of progesterone agents on the cardiovascular system, but probably these are safe for most women with heart disease Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

71  fluid retention and irregular menstruation  cardiovascular contraindications are the same as those for progesterone Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

72  performed laparoscopically or via a laparotomy  tenuous cardiac hemodynamics ▪ risk of cardiac instability = cardiac anesthesia may be preferable  tubal sterilization has been accomplished with the use of an intrafallopian plug inserted endoscopically Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

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