Presentation on theme: "Heart Failure in Pregnancy"— Presentation transcript:
1 Heart Failure in Pregnancy Council on Women’s HealthPhilippine Heart Association
2 IntroductionAbout 2% of pregnancies involve maternal cardiovascular diseaseIncreased risk to both mother and fetusCardiac disease may sometimes be manifested for the 1st time in pregnancy because of the hemodynamic changesSigns 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 obstetrician5 months PTC she had a positive pregnancy testFelt perfectly well prior to consultFew 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 5th ICS LMCL, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apexReferred 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?
12 Pregnancy Clinical features mimicking heart disease: Dyspnea- due to hyperventilation, elevated diaphragmPedal edemaCardiac impulse diffuse and shifted laterally from elevated diaphragmJugular veins may be distended and JVP raisedSystolic ejection murmurs in LPSB in 96% of pregnant women
13 Question: Evaluation of Heart Failure in Pregnancy How should we go about evaluating AB?Evaluation of Heart Failure in Pregnancy1. Detailed Hx and PE to determine FC2. 12 lead ECG3. Chest Xray - Optional4. 2D Echo Doppler5. Plasma B Type natriuretic peptide6. Blood works-CBC,electrolytes, renaland thyroid function7. TEE (seldom)8. Fetal echocardiography
14 Differential Diagnoses of Heart Failure in Pregnancy PneumoniaPulmonary embolismAmniotic fluid embolismRenal failure with volume overloadAcute lung injury
15 High risk pregnancies Pulmonary hypertension Dilated cardiomyopathy, EF≤40%Symptomatic obstructive lesions AS,MS,PS,CoAMarfan syndrome with aortic root ≥40mmCyanotic lesionsMechanical prosthetic valves
17 Question: Cardiac Diseases in Pregnancy Risk Score Risk Scores 1. A prior cardiac event ( arrhythmia,stroke,TIA,HF)2.Baseline NYHA FC≥II or cyanosis(saturation≤ 90%3. Systemic ventricular systolic dysfunction4. Left heart obstruction- MVA ≤ 2 cm- aortic valve area≤ 1.5 cm- peak flow gradient ≥ 30mm HgWhat is the risk of AB? Can she tolerate her pregnancy?Risk Scores0 - 5% risk (low)1 - 27% risk (interm)>1 - 75% (high)
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 evaluationNYHA III and IV-May need hospitalization for close monitoring
21 ManagementSurgicalCardiac surgery seldom necessary and should be avoided if possibleHigher risk of fetal malformations and lossMay induce premature laborOptimal time wk gestationExtracorporeal circulation- normothermicHigher pump flow rate, higher pressure with a mean of 60 mmHgAdvise short bypass time
23 What is Warfarin Embryopathy? Used in 1st trimester- teratogenic in 15-25% of cases1. nasal cartilage hypoplasia2. stippling of bones3. IUGR4. 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 laterIf with allergy from ampicillin, 1 gm vancomycin may be used.
25 What is the Safest Mode of Delivery? Vaginal delivery is feasible and preferableCS is for an obstetric indicationException are anticoagulated patientsCS may be indicated in1. Marfan syndrome,2. severe pulmonary HPN3. severe obstructive lesions eg AS
26 Physiologic Changes during Labor and Puerperium 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 COThird stage- Blood loss during delivery. Vaginal- 400 ml CS- 800 ml- these lead to reduced blood volume and CO
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.