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Heart Failure in Pregnancy Council on Women’s Health Philippine Heart Association.

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Presentation on theme: "Heart Failure in Pregnancy Council on Women’s Health Philippine Heart Association."— Presentation transcript:

1 Heart Failure in Pregnancy Council on Women’s Health Philippine Heart Association

2 Introduction  About 2% of pregnancies involve maternal cardiovascular disease  Increased risk to both mother and fetus  Cardiac disease may sometimes be manifested for the 1 st time in pregnancy because of the hemodynamic changes  Signs and symptoms of a normal pregnancy may mimic the presence of cardiac disease

3 Case Presentation  AB a 22 year old married, bank teller  Visited for the first time an obstetrician  5 months PTC she had a positive pregnancy test  Felt perfectly well prior to consult  Few days ago started to have shortness of breath on climbing 2 flights of stairs, easy fatigability on walking 2 blocks and had palpitations

4 Pertinent PE  BP- 100/60 CR- 89/min RR- 21 cycles/min  Heart-AB at 5 th ICS LMCL, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex  Referred by the obstetrician to a cardiologist

5 Questions  Does AB have heart disease?  Is she experiencing heart failure symptoms?  What are the hemodynamic changes occurring in her?  What are the differential diagnoses?  How should you go about managing her? Medical? Surgical? Timing?  Can she tolerate the pregnancy?  What is the safest mode of delivery?

6 Question:  Does AB have heart disease?

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10 Question:  Is she experiencing heart failure symptoms?

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12 Pregnancy Clinical features mimicking heart disease:  Dyspnea- due to hyperventilation, elevated diaphragm  Pedal edema  Cardiac impulse diffuse and shifted laterally from elevated diaphragm  Jugular veins may be distended and JVP raised  Systolic ejection murmurs in LPSB in 96% of pregnant women

13 Question: How should we go about evaluating AB?  Evaluation of Heart Failure in Pregnancy 1. Detailed Hx and PE to determine FC lead ECG 3. Chest Xray - Optional 4. 2D Echo Doppler 5. Plasma B Type natriuretic peptide 6. Blood works-CBC,electrolytes, renal and thyroid function 7. TEE (seldom) 8. Fetal echocardiography

14 Differential Diagnoses of Heart Failure in Pregnancy  Pneumonia  Pulmonary embolism  Amniotic fluid embolism  Renal failure with volume overload  Acute lung injury

15 High risk pregnancies  Pulmonary hypertension  Dilated cardiomyopathy, EF≤40%  Symptomatic obstructive lesions -AS,MS,PS,CoA  Marfan syndrome with aortic root ≥40mm  Cyanotic lesions  Mechanical prosthetic valves

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17 Question:  What is the risk of AB? Can she tolerate her pregnancy?  Risk Scores 0 - 5% risk (low) % risk (interm) >1 - 75% (high)  Cardiac Diseases in Pregnancy Risk Score 1. A prior cardiac event ( arrhythmia,stroke,TIA,HF) 2.Baseline NYHA FC≥II or cyanosis(saturation≤ 90% 3. Systemic ventricular systolic dysfunction 4. Left heart obstruction - MVA ≤ 2 cm - aortic valve area≤ 1.5 cm - peak flow gradient ≥ 30mm Hg

18 Management  Medical  NYHA Class I or II -Limit strenuous exercise -Provide adequate rest -Supplemental iron and vitamins -Low salt diet -Regular cardiac and obstetric evaluation  NYHA III and IV -May need hospitalization for close monitoring

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20 Management  Percutaneous valvotomy?  Timing?

21 Management  Surgical  Cardiac surgery seldom necessary and should be avoided if possible  Higher risk of fetal malformations and loss  May induce premature labor  Optimal time wk gestation  Extracorporeal circulation- normothermic  Higher pump flow rate, higher pressure with a mean of 60 mmHg  Advise short bypass time

22 Management  Anticoagulation?  Warfarin  Unfractionated Heparin  Low Molecular Weight Heparin

23 What is Warfarin Embryopathy?  Used in 1 st trimester- teratogenic in 15-25% of cases 1. nasal cartilage hypoplasia 2. stippling of bones 3. IUGR 4. brachydactyl

24 SBE Prophylaxis?  Antibiotic – a) 2 gm ampicillin IV plus 1.5 mg/Kg gentamicin IV prior to procedure, followed by one more dose of ampicillin 8 hours later  If with allergy from ampicillin, 1 gm vancomycin may be used.

25 What is the Safest Mode of Delivery?  Vaginal delivery is feasible and preferable  CS is for an obstetric indication  Exception are anticoagulated patients  CS may be indicated in 1. Marfan syndrome, 2. severe pulmonary HPN 3. severe obstructive lesions eg AS

26  First stage- Cardiac output increased by 15%. Each uterine contraction releases 500 ml of blood leading to increases in CO and BP, later reflex bradycardia.  Second stage- Increase in intra-abdominal pressure(valsalva) causes decrease in venous return and CO  Third stage- Blood loss during delivery. Vaginal- 400 ml CS- 800 ml - these lead to reduced blood volume and CO Physiologic Changes during Labor and Puerperium

27 Hemodynamic Changes after Delivery  Abrupt increase in venous return because of autotransfusion from the uterus. Baby no longer compress the uterus.  Autotransfusion of blood continues hrs after delivery. Pulmonary edema may occur.

28 Thank You

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