1. Heart Failure in Pregnancy
Ramon M. Gonzalez, MD
Professor
UST Medicine and Surgery

2. AB a 22y/o married, bank teller
Visited for the 1st time an obstetrician
5 months PTC she had a (+) 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

3. Bp-100/60mmHg CR-89/min RR=21cycles/min
Heart- AB at 5th ICS LMCL, no thrills, regular rhythm, loud S1, Grade 3/6 mid-diastolic rumbling murmur at the apex
Referred by the obstetrician to a cardiologist

4. Cardiovascular changes in pregnancy
Parameter Percentage of change
_______________________________________________
Cardiac output % Increase
Intravascular volume % Increase
Heart rate % Increase
Systemic vascular
resistance % Decrease
Stroke volume % Increase
Systolic BP Minimal
Diastolic BP % Decrease at mid-pregnancy
O2 consumption % Increase

6. Periods of increase cardiac output
28-32 weeks gestation
Labor and Delivery
Immediately postpartum

7. Hemodynamics during labor
Parameter Stage of Labor Percentage of change ____________________________________________________ Cardiac output Latent phase 10% Increase Active phase 25% Increase Expulsive phase 40% Increase Immediate postpartum 70-80% Increase Heart rate All stages Increase CVP All stages Increase

8. Hemodynamics during puerperium
Parameter Postpartum Percentage of change _______________________________________________________________ Cardiac output W/in 1hr 30% above pre-labor values hr Just below pre-labor values 2 weeks 10% above pre-pregnant values weeks Baseline pre-pregnancy values Heart rate Immediate Decrease 2 weeks Pre-pregnant values Stroke volume 48 hr Remains above pre-labor values 24 weeks 10% above pre-pregnant values

9. What is the effect of pregnancy on heart disease?

10. Change in New York Heart Association (NYHA) functional class between first visit and follow-up during pregnancy in patients with predominant mitral valve disease.

11. Maternal outcome in patients with mitral stenosis
Congestive heart failure
43% vs 0% p<0.0001
Arrhythmias
20% vs 0% p<0.0001
Hospitalization
43% vs p 0.001
Mortality
0% vs 0% p 1.0

12. Conclusion Women with VHD had a high rate of clinical deterioration
Marked increase in morbid events during pregnancy, including CHF, arrhythmias and need to either initiate or increase cardiovascular drug therapy or to hospitalize patients during pregnancy.

13. What is the effect of heart disease on fetal outcome?

14. Fetal outcome in patients with mitral stenosis
Preterm delivery
35±7 vs 39±2wks p <0.0002
IUGR
24% vs 0% p <0.001
Stillbirth
4% vs 0% p 0.5
Birth weight
2845g vs 3372g p 0.02

15. Offspring risk for congenital heart defects
Defect Mother affected Father affected (%) (%) Aortic stenosis 13–18 3 Atrial septal defect 4– Atrioventricular canal 14 1 Coarctation of the aorta 4 2 Patent ductus arteriosus 3.5–4 2.5 Pulmonic stenosis 4–6.5 2 Tetralogy of Fallot Ventricular septal defect 6–10 2

16. Main Aims of Management
To optimize the mother’s condition during pregnancy
To monitor for deteriorations
Minimize any additional load on the cardiovascular system

17. Management of Cardiac Disease in Pregnancy: General Principles of Management
Women in NYHA class I and II proceed to pregnancy without morbidity.
All women with heart disease should be managed by a multidisciplinary team.
Antenatal management is directed towards avoiding cardiac decompensation.
Special attention should be directed toward both prevention and early recognition of heart failure.

18. Warning signs of heart failure
Persistent basilar rales, frequently accompanied by a nocturnal cough
A sudden diminution in ability to carry out usual duties
Increasing dyspnea on exertion
Clinical findings may include hemoptysis, progressive edema and tachycardia

19. Management of Cardiac Disease in Pregnancy: General Principles of Management
Even when pregnancy is well tolerated, infection, anemia, pain and anxiety, often result in clinical deterioration and require aggressive management.
A clear plan for the management of labor and delivery should be established in advance

20. Management during Pregnancy
In symptomatic patients, medical treatment should be the first line of management.
Cardiac drugs commonly used during pregnancy includes β blockers, hydralazine, diuretics and digoxin.
Advice bed rest and oxygen.

21. Management during Pregnancy
Fetal assessment to monitor the potential problems arising from heart disease and pharmacologic treatment of the mother.

22. Management: Labor and Delivery
Vaginal delivery is the preferred mode of delivery
A short and pain free labor and delivery - minimize hemodynamic fluctuation
Hemodynamic monitoring including O2 saturation, ECG, arterial pressure, pulmonary artery and wedge pressures and cardiac output especially in class III and IV patients

23. Management: Labor and Delivery
Epidural analgesia
produces good analgesia without major hemodynamic changes
It is administered in incremental doses
Slower onset of anesthesia, allows maternal CVS to compensate for occurrence of sympathetic blockade, resulting in lower risk of hypotension and decreased uteroplacental blood flow.

24. Management: Labor and Delivery
Epidural analgesia
spares the lower extremity “muscle pump,” aiding in venous return and also decreases the incidence of thromboembolic events.
During the 2nd stage – prevent maternal effort in “pushing”
Shorten the 2nd stage – vacuum or forceps delivery

25. Management: Labor and Delivery
Fetal heart rate monitoring during labor
Induction of labor
to optimize the timing of delivery in relation to anticoagulation and availability of medical staff
Cesarean section
obstetrics indication, specific cardiac lesions and deterioration of cardiac performance

26. Management: Postpartum
Oxytocin
administered by infusion and not by bolus
Methyergonovine and Carboprost
Produces severe hypertension, tachycardia and increased pulmonary vascular resistance

27. Management: Postpartum
High level maternal surveillance is required until the main hemodynamic changes after delivery have resolved.
Postpartum hemorrhage, infection, anemia and thromboembolism are much more serious complications in those with heart disease.

28. Management: Postpartum
Recent review of parturients with heart disease found that the worst cardiac compromise did not always occur at the time of delivery.

29. Thank You