1. Pregnancy & Cardiovascular diseasesBy
Mohammad H. soliman
(MSc. Cardiology)

2. Expected cardiovascular changes in pregnancy
Measurement
Normal value
Change in pregnancy (%)
Heart rate
bpm
+ 10%–20%
Stroke volume mL
+ 30%
Cardiac output
L/min
+ 30%–50%
Blood volume
5 L
+ 20%–50%
Systemic vascular resistance
1, dyne/cm/sec
- 20%
Mean arterial pressure
mm Hg
Not significant
Oxygen consumption
250 mL/min
+ 20%–30%
Source: Clark SL, et al.1 and Elkayam U, Gleicher N. Hemodynamics and cardiac function during normal pregnancy and the puerperium. In: Elkayam U, Gleicher N, eds. Cardiac Problems in Pregnancy. 3rd ed. New York, NY: Wiley-Liss, Inc; 1998:3-19.

3. Figure 1 Physiological changes in pregnancy.8 Systemic and
pulmonary vascular resistance fall during pregnancy. Blood pressure
may fall in the second trimester, rising slightly in late pregnancy. Note
that cardiac output and stroke volume peak by 16 weeks gestation.

4. PRE-PREGNANCY COUNSELLING
To estimate maternal mortality as well as morbidity
Join antenatal care with a high risk pregnancy obstetric team.
Minimising maternal risk: e,g
if necessary by catheter or surgical intervention before conception
Estimation and minimising fetal risk e,g
maternal drug treatment may need changing before conception or once pregnant

5. Signs and symptoms of normal pregnancy versus heart failure

6. A risk index to predict complications
1. A prior cardiac event (including stroke, transient ischemic attack, or arrhythmia). 2. Cyanosis or poor functional class. 3. Left heart obstruction. 4. Systemic ventricular dysfunction.
One point was assigned for each risk factor present. No pregnancy received more than 3 points. Women with 0 points had an estimated risk of a cardiac event of 5% (low risk), those with 1 point had a risk of 27% (intermediate risk), and those with more than 1 point had a 75% risk of having a cardiac event (high risk). All three deaths in the study of 562 women occurred in pregnancies with more than one point.

7. Maternal mortality risk associated with pregnancy
Group I: Minimal risk of complications (mortality <1%)
-Pulmonic/tricuspid disease, ASD ,VSD ,PDA
-Bioprosthetic valve ,mild AR, mild PS
-Mitral stenosis, NYHA Class I or II
Group II: Moderate risk of complications (mortality 5% to 15%)
- Mitral stenosis with AF
-Artificial valve
-Mitral stenosis, NYHA Classes III or IV
-mild to mod AS,sever PS
-Previous myocardial infarction
Group III: Major risk of complications or death (mortality >25%)
- Sever Pulmonary hypertension
- Eisenmenger syndrome
- Complex cyanotic heart disease
- Sever AS or NYHA class III IV with any valvular disease

8. Valvular heart disease and pregnancy 1- mitral stenosis
The most common rheumatic valvular lesion in pregnancy
When the valve area falls below 1.5 cm2 filling of the left ventricle during diastole is severely limited, resulting in a fixed cardiac output
The pressure gradient across narrowed valve may increase greatly seconadry to increase in HR and blood volume
Increased left atrial pressure can result in arrhythmia
Decrease serum coloid osmotic pressure and excessive peripartum fluid administration predispose to pulm edema

9. Changes in NYHA class between 1st visit and follow up during pregnancy

10. Theraputic approach Aiming to: reduce heart rate
Decrease left atrial pressure
1- restriction of physical activity
2- drugs as B blockers and digoxin used to control HR
3- cautious use of diuretics
Vaginal delivery is permitted in most patients with MS
In symptomatic patients with moderate to sever MS continuous monitoring and use of IV dugs like diuretics digoxine BB and nitrates

11. Mitral valve repair or replacement
Should be considered only in sever cases of MS refractory to optimal medical therapy
Or when close follow up during pregnancy and labour is not possible
Risk of foetal death during surgery is % VS 2-12% in PBMV
Epidural anesthesia is the most apprpriate form of analgesia for both vaginal and abdominal delivery

13. 2-Mitral regurgitation
Most common causes is rheumatic and myxomatous degeneration
MR is well tolerated during pregnancy
New AF or sever hypertension can precipitate homodynamic deterioration
Women with sever MR are advised to under go surgical repair before conception

14. 3-Mitral valve prolapse

15. 4-Aortic stenosis
AS is far less frequent than MS and most cases are congenital
Delivery is safe in patients whose functional tolerance is good
Valve repair or termination of pregnancy considered only after Appearance of symptoms like dyspnea, syncope or pulm. Oedema resistant to medical treatment

17. 5-Aortic regurgitation
It may be due to bicuspid aortic valve, rheumatic,or infective endocardities
It is well tolerated during pregnancy
In symptomatic patients diuretics,digoxine and hydralazine can be safely used

18. 6-Prothetic valves and pregnant woman
The risk of PV. related to increase in heamodynamic burden and increase incidence of thromboembolism
Selection of type of prosthesis should be individualized as
The bileaflet mechanical valves more durable, excellent hemodynamic profile, and relatively small risk of thromboembolic and bleeding complications with careful anticoagulation

19. In women who are not interested in anticoagulation or for whom close follow-up is not possible, a tissue valve is preferred
In the aortic position, homografts, pericardial valves, and stentless porcine xenografts have not been extensively used in pregnancy
The pulmonary autograft (Ross procedure) is an excellent elternative but associated more with structural valve deterioration

20. Thromboembolic complications Valve thrombosis (%) Emboli (%)
Outcome of pregnancy in women with mechanical or biological prostheses
Study
No. of pregnancies
Live births (%)
Thromboembolic complications
Valve thrombosis (%)
Emboli (%)
Mechanical valves
Hanania 95 53 11 9
Sbarouni
151 73 5
Born 35 63 8 3
Bioprosthetic valves 60 80 83 25
100
Adapted from Baughman (7).

21. Conditions warranting anticoagulation during pregnancy
Mechanical prosthetic valve
History of venous thromboembolism
Acute deep venous thrombosis
Antiphospholipid antibody syndrome
Inherited deficiency of naturally occuring anticoagulant
Chronic AF
Eisenmger’s syndrome

22. ACC/AHA Recommendation for Anticoagulation During Pregnancy in Patients With Mechanical Prosthetic Valves
1. The decision whether to use heparin during the first trimester or to continue oral anticoagulation throughout pregnancy should be made after full discussion with the patient and her partner.
2. High-risk women who choose not to take warfarin during the first trimester should receive continuous unfractionated heparin intravenously in a dose to prolong the mid-interval (6 h after dosing) activated PTT time to 2 to 3 × control value. Transition to warfarin can occur thereafter.
3. In patients receiving warfarin, the INR should be maintained between 2.0 and 3.0 with the lowest possible dose of warfarin, and low-dose aspirin should be added.
4. Women at low risk might be managed with adjusted-dose SC heparin (17,500 to 20,000 U twice daily to prolong the mid-interval (6 h after dosing) activated PTT time to 2 to 3 × control value.
5. Warfarin should be stopped no later than week 36 and heparin substituted in anticipation of labor.
6. If labor begins during treatment with warfarin, a cesarean section should be performed.
7. In the absence of significant bleeding, heparin can be resumed 4–6 h after delivery, and warfarin begun orally.

25. Anticoagulation options during pregnancy

26. Mode of delivery
Vaginal delivery is safe in most cases with PV using epidural anesthesia
Invasive heamodynamic monitoring indicated only in sever valve stenosis or HF
Heparin should be withdrawn 4 hours before CS or at onset of labor and resumed 6-12 h after
In high risk patient with previous endocarditis or heart valve prosthesis prophylactic antibiotics should be given

27. Congenital heart diseases
1- high risk patients
Any patient reaches NYHA III,IV is at high risk
The situations carries high risk as follow
1- sever pulm. HTN with or without septal defects (maternal mortality 30-50%)
2-sever left ventricular outflow obstruction
3- cyanotic heart diseases with maternal mortality about 2%and incidence of complications of 30%
Such as infective endocardities , arrhythmias
and CHF

28. Treatment of high risk patients
Pregnancy is not recommended
If pregnancy occurs termination of pregnancy is advised
Physical activity is restricted and bed rest
The patient should be hospitalized at the end of 2nd trimester
LMWH is given subcutaneous against thromboembolism
In sever aortic stenosis balloon valvotomy can relief symptoms it is done in the 2 nd trimester
In sever cyanotic heart disease :oxygen sturation,,heamatocrite,and HB monitoring is important

29. 2-Low risk patients
Patients with small or moderate shunts without pulm, HTN
Patients who have had cardiac surgery early in life without prothesis
Patients with mild , mod valve regurg.
With mild or mod LV out flow tract obstruction
Follow up done every trimester

30. Specific conditions 1- pulm stenosis
RVOT obstruction tend to be well tolerated during pregnancy
No deaths and low maternal complications 15% have been reported
In cases of sever RT ventricular failure balloon valvotomy is the method of choice

31. 2- Tetralogy of Fallot
Pregnancy in non-operated patient carries a risk for mother and fetus
The risk is high when O2 stauration below 85%
Close monitoring of BP and gases with avoidance of any further systemic dilatation
The risk in good repaired patient is very low
All patients with TF should have genetic counseling before conception

32. 3- Coarctation of aorta Should be repaired prior to pregnancy
The management of hypertension is difficult in non-operated patient
Toxemia doesn’t occur but treatment may cause very low pressure in distal segment
This may result in abortion or foetal death
Rupture of aorta is the commonest cause of death
BB should be prescribed with avoidance of volume excess and CO

33. 4-Eisenmenger syndrome
associated with a high risk of maternal morbidity and mortality
It is also associated with a poor fetal outcome, with a high incidence of fetal loss, prematurity, intrauterine growth retardation, and perinatal death
patients with Eisenmenger syndrome should be advised against pregnancy and early abortion should be recommended

34. Because of increased incidence of peripartum thromboembolism, anticoagulant therapy seems indicated in the third trimester of gestation and for 4 weeks post partum
Spontaneous labor is preferred to induction and should lower the chance of prematurely or the need for cesarean section
an attempt should be made to shorten the 2nd stage of labor by the use of forceps or vacuum extraction with good oxygenation

35. ANTIBIOTIC PROPHYLAXIS
for vaginal delivery in all patients with CHD (except those with an isolated secundum type of ASD or surgical ligation and division of PDA) seems reasonable

36. Cardiovascular disorders aquired during pregnancy 1- peripartum cardiomyopathy
(modified criteria for diagnosis )
1-Development of cardiac failure during pregnancy or within 6 months of delivery
2-Absence of a determinable cause for cardiac failure
3-Demonstrable impairment in left ventricular systolic function

37. ETIOLOGY A distinct etiology of PPCM remains unknown
Nutritional deficiences
Myocarditis
Infections
Autoimmune
Idiopathic
The incidence of peripartum cardiomyopathy is greater in multiparous women and in those with preeclampsia and twin pregnancies

39. Echocardiography

40. TREATMENT Non-pharmacological Pharmacological Salt restriction (4gm/d)
Water restriction (2 L/D)
Pharmacological
Pre-load reduction (diuretics, nitrates)
After-load reduction (hydralazine, nitrates, amlodipine)
ACE-I contraindicated during pregnancy
+ ionotropes (digoxin, dopamine, dobutamine)
Beta-blockers

41. Con. TREATMENT Immunosuppressive agents
May be initiated in patients with PPCM and biopsy-proven myocarditis, but efficacy is unclear
Empiric immunosuppression, in the absence of evidence of myocarditis, is not currently recommended

42. Figure 3 Cardiac causes of maternal deaths in the UK: confidential enquiry into maternal deaths 1997–99 (total maternal deaths = 409, cardiac deaths = 41).

43. 2-Hypertension in Pregnancy
Classification
Chronic hypertension
Preeclampsia-eclampsia
Preeclampsia Superimposed upon chronic hypertension or Renal Disease
Gestational hypertension (only during pregnancy)
Transient hypertension (only after pregnancy)

44. A.Chronic Hypertension
Defined as hypertension diagnosed
Before pregnancy
Before the 20th week of gestation
During pregnancy and not resolved postpartum

45. B.Gestational Hypertension
Diagnosis of gestational hypertension:
Detected for first time after midpregnancy
Gestational Hypertension:
Systolic >140
Diastolic>90
No proteinuria
If preeclampsia does not develop and
BP returns to normal by 12 weeks postpartum, diagnosis is transient hypertension.
BP remains high postpartum, diagnosis is chronic hypertension.
Proteinurea develops Preeclampsia is diagnosed (25% incidence)

46. Drug Therapy of Hypertension in Pregnancy
Example
Comment
α2-adrenergic blockers
Methyldopa
Most commonly used. Safety well established. Drug of choice.
Beta-blockers
Atenolol, Metoprolol
Appear safe. Case reports of fetal bradycardia, growth retardataion.
α, β blockers
Labetolol
Appears effacious. Very scant safety data.
Arteriolar vasodilators
Hydralazine
Effacacious and safe during pregnancy and lactation.
ACE inhibitors
Captopril
Absolutely contraindicated during pregnancy due to fetal toxicity.
Calcium channel blockers
Diltiazem
Appear safe, but not as much data to support their use.
Diuretics
Furosemide
Appears safe, but limited efficacy.
Sodium nitroprusside   
Avoid in pregnancy due to potential for fetal thiocyanate toxicity
Magnesium sulfate
Treatment of choice for prevention of ecclamptic seizures.
Adapted from reference 7.

47. Treatment of Acute Severe Hypertension in Pregnancy
SBP > 160 mm Hg and/or DBP > 105 mm Hg
Parenteral hydralazine is most commonly used.
Parenteral labetalol is second-line drug (avoid in women with asthma and CHF.)
Oral nifedipine used with caution. (Short-acting nifedipine is not approved by FDA for managing hypertension.)
Sodium nitroprusside may be used in rare cases.

48. C.Preeclampsia-Eclampsia
Diagnosis
Gestational Hypertension:
Systolic >140
Diastolic>90
Proteinuria is defined as urinary excretion
0.3 g protein or greater in a 24-hour
+2 or greater on urine dip specimen

49. Criteria for Severe Preeclampsia
(one or more)
Blood Pressure: >160 systolic, >110 diastolic
Proteinurea: >5gm in 24 hours, over 3+ urine dip
Oligurea: less than 400ml in 24 hours
CNS: Visual changes, headache, scotomata, mental status change
Pulmonary Edema
Epigastric or RUQ Pain: Usually indicates liver involvement

50. Indications for Delivery in Preeclampsia
Gestational age 38 weeks
Platelet count < 100,000 cells/mm3
Progressive deterioration in liver and renal function
Suspected abruptio placentae
Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting

51. Preeclampsia

52. ARRHYTHMIAS
Serious cardiac arrhythmias are uncommon in pregnancy due to the low prevalence of heart disease in women in the reproductive age group
Pre-existing arrhythmias may be aggravated and new arrhythmias appear for the first time in pregnancy
Arrhythmias occurring in structurally normal hearts are uncommon and usually benign.

53. Tachyarrhythmias such as AF, VT and VF tend to be associated with SHD
DC cardioversion can be safely performed and should not be withheld if the arrhythmia is associated with haemodynamic instability
Although no drug is completely safe, digoxin, quinidine, procainamide and adenosine are well tolerated
BB are useful agents but use of atenolol, specifically during the first trimester may be associated with intrauterine growth retardation

54. COMPLETE HEART BLOCK it is usually congenital
Patients with CHB may remain asymptomatic during pregnancy and have an uncomplicated labor and delivery without treatment
Symptomatic patients with conduction abnormalities treated during pregnancy with either temporary or permanent pacemakers
It has been done with electrocardiographic and echocardiographic guidance in some cases to avoid ionizing radiation

55. Coronary artery disease and pregnancy
Familial hyper chlesterolimia, obesity smoking and diabetes is the main factors
Acute myocardial infarction during pregnancy is rare, occurring in 0.01 percent of pregnancies
Most myocardial infarctions occur during the third trimester in women over age 33
in situ coronary thrombosis, and coronary dissection occur more frequently than classic obstructive atherosclerosis

56. Medical therapy for acute myocardial infarction must be modified in the pregnant patient
Thrombolytic agents increase the risk of maternal hemorrhage substantially to 8%
Low dose aspirin and nitrates..BB Short-term heparin generally are safe.
(ACE) inhibitors and statins are contraindicated
Hydralazine and nitrates may be used as substitutes for ACE inhibitors.

57. Drug therapy in pregnancy
Balancing act
maternal
treatment
fetal
effects
Little scientific evidence

58. Maternal fetal transfer
Placental transfer
Drugs & metabolites in fetus
Fetal GI absorption
Transfer via breastmilk

59. Drug Use Potential Side Effects Safe Use During Breastfeeding
Cardiovascular Drugs In Pregnancy
Drug
Use
Potential Side Effects
Safe
Use During Breastfeeding
Adenosine
Arrhythmia
None reported
Yes
No data
Amiodarone
IUGR, prematurity, hypothyroidism No
ACE inhibitors
Hypertension
Oligohydramnios, IUGR, PDA, prematurity, neonatal hypotension, renal failure, anemia, death, musculoskeletal abnormalities Ok
Beta-blockers
Hypertension, arrhythmias, MI, ischemia, HCM, hyperthyroidism, mitral stenosis, Marfan syndrome, cardiomyopathy
Fetal bradycardia, low birth weight, hypoglycemia, respiratory depression; prolonged labor
Digoxin
Arrhythmia, CHF
Low birth weight, Prematurity
Diuretics
Hypertension, CHF
Reduced utero- placental perfusion
Unclear
Flecainide
? fetal death; limited data
Limited data
Lidocaine
Arrhythmia, anesthesia
Neonatal CNS depression
Low Molecular Weight Heparin
Mechanical valve, hypercoaguable state, DVT, AF, Eisenmenger syndrome
Hemorrhage, unclear effects on maternal bone mineral density
Nitrates
Fetal distress with maternal hypotension

60. Hypertension, aortic dissection Fetal thiocyanate toxicity
Procainamide
Arrhythmia
None reported
Yes Ok
Sodium nitroprusside
Hypertension, aortic dissection
Fetal thiocyanate toxicity
Potentially unsafe
No data
Sotalol
Fetal bradycardia, IUGR
Limited data
Unfractionated Heparin
Mechanical valve, hypercoagulable state, DVT, AF, Eisenmenger syndrome
Maternal osteoporosis, hemorrhage, thrombocytopenia, thrombosis
Warfarin
Warfarin embryopathy, fetal CNS abnormalities, hemorrhage
Yes—after the 12th week of gestation
IUGR = intrauterine growth retardation, ACE = angiotensin converting enzyme, PDA = patent ductus arteriosus, MI = myocardial infarction, HCM = hypertrophic cardiomyopathy, CHF = congestive heart failure, CNS = central nervous system, DVT = deep venous thrombosis, AF = atrial fibrillation

61. Infective endocarditis
although it is rare complication in pregnancy, causes mortality in 10–30% of those affected
The development of a new cardiac murmur is common in pregnancy and can make the diagnosis of endocarditis difficult
predisposing factors in young women include MVP, CHD and intravenous drug abuse
The use of antibiotic prophylaxis during uncomplicated deliveries remains controversial
prophylaxis only for women who are at high risk is recommended

62. Antibiotic prophylaxis is recommended for the following:
High-risk category 
Prosthetic cardiac valves, including bioprosthetic and homograft valves 
Previous bacterial endocarditis 
Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot) 
Surgically constructed systemic pulmonary shunts or conduits

63. Moderate-risk category
Most other congenital cardiac malformations (other than above and below) 
Acquired valvular dysfunction (eg, rheumatic heart disease) 
Hypertrophic cardiomyopathy 
Mitral valve prolapse with valvular regurgitation and/or thickened leaflets
Endocarditis prophylaxis is not recommended for the following: (no greater risk than the general population) 
Isolated secundum atrial septal defect 

64. Surgical repair of ASD, VSD, or PDA
Previous coronary artery bypass graft surgery 
MVP without valvular regurgitation
Physiologic, functional, or innocent heart murmurs 
Previous Kawasaki disease without valvar dysfunction 
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

65. High-risk patient who has penicillin allergy
Recommended antibiotic prophylaxis for high-risk women undergoing genitourinary or gastrointestinal procedures
Category
Drug and dosage
High-risk patient
Ampicillin, 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 6 hr after procedure
High-risk patient who has penicillin allergy
Vancomycin HCl (Vancocin, Vancoled), 1 g IV over 2 hr,    plus gentamicin sulfate, 1.5 mg/kg IV 30 min before procedure

66. Anaesthesia during pregnancy
The choice of anesthesia depends on circumstances of the delivery and maternal cardiac status
Epidural anesthesia is well tolerated and provides effective analgesia.
-It minimize HR and BP changes associated with inadequate pain relief. With cautious fluid preloading, gradual increments in drug dosages and positioning in the lateral position,
-It should still be used with extreme caution in those with restricted cardiac output or right-to-left shunts.

67. summary
Women at low risk are those who have few or no symptoms and good LV function
Those of high risk need to be managed within or from a cardiac center
The mode and time of delivery should be discussed and vaginal delivery usually advised
Antibiotic prophylaxis is not advised for a normal delivery

68. Thank you