Medical Disease in Pregnancy Cardiovascular Disease Cullen Archer, MD Department of Obstetrics and Gynecology

Physiologic change in Pregnancy Cardiac output increases 30-35% during pregnancy HR rises steadily throughout pregnancy Although elevated in pregnancy, SV falls near term Architecture of heart is remodeled to allow increased contractility

Physiologic change in Pregnancy Blood volume increases by 40% Afterload is decreased by early vasodilation Colloid osmotic pressure is decreased by 18% near term Promotes Na/H2O retention Increases plasma volume

Peripartum Physiology Baseline cardiac output increases 13% by 8 cm. dilatation Largely due to increased SV Uterine contractions return ~ 500cc of blood to the systemic circulation Increases preload and augments cardiac output by 34% above pre-labor baseline

Postpartum physiology Within hours of delivery, marked diuresis begins Fluid is mobilized from the expanded extravascular space Intravascular space contracts By 2 weeks postpartum, cardiac output falls 26% and is only 10% above values measured at 24 weeks

Atrial Septal Defects Usually asymptomatic Large ASDs can be associated with pulmonary HTN and L to R shunting

Ventricular Septal Defects Large unrestrictive VSDs permit equalization of right and left pressures Eisenmenger’s syndrome

Congenital Aortic Stenosis Outflow obstruction Antepartum Peripartum

Pulmonic valve stenosis Usually tolerated well Severely stenotic valves Cautious use of IVF Shorten second stage Preconception counseling

Coarctation Usually post-ductal obstruction Symptoms related to hypertension proximal to obstruction and hypoperfusion distal to obstruction In pregnancy, risks are associated with dissection and rupture MMR 3-4%

Uncorrected TOF Exacerbation of shunt Morbidity and mortality are associated with pregnancy related decline in SVR and peripartum blood loss MMR 4-15%

Eisenmenger’s syndrome Exacerbation of shunt Progressive hypoxemia Avoid sudden drops in SVR MMR 30-70% Advise against pregnancy or offer termination

Mitral Stenosis Leading cause of cardiac maternal mortality Elevated LA pressure  pulmonary edema and pulmonary HTN

Mitral Regurgitation Usually a result of rheumatic fever Decreased peripheral vascular resistance should decrease the amount of MR and assist a poorly functioning ventricle Severe MR with ventricular dysfunction increases MMR as high as 5-10%

Aortic Regurgitation Rarely complicates pregnancy unless LV systolic function is significantly depressed

Peripartum cardiomyopathy Incidence 1/15,000 to 1/1300 live births Etiology unknown 50% have return to normal function Suspect when women present with CHF after 36 weeks

Primary pulmonary hypertension Pregnancy contraindicated with severe disease TTE vs. cardiac cath Treatments Peripartum considerations

Preeclampsia Hypertensive disorder of pregnancy Newly onset after 20 weeks gestation Proteinuria Risk factors

HELLP Syndrome Definition Complications