Lectures 7, 8 Petrenko N.V., MD, PhD

Lectures 7, 8 Petrenko N.V., MD, PhD
Medical-Surgical Problems in Pregnancy Lectures 7, 8 Petrenko N.V., MD, PhD

CARDIOVASCULAR DISORDERS
about 1% of pregnancies complicated by heart diseases leading cause of maternal mortality Mortality rate 50% in case pulmonary hypertension

Physiologic adaptation to pregnancy
Increase blood volume on % Increase cardiac output 30-50% Decreased systemic vascular resistance The heart elevated upward and rotated forward to the left Pulse increase about beat/min after weeks, palpitation Disturbed rhythm: sinus arrhythmia, premature atrial contractions, premature ventricalar systole BP: I trim as prepregnancy level II trim decrease mm hHg After 20 weeks turn to prepregnancy level Increase clot factors (VII, VIII, IX, X, fibrinogen) Cardiac output changes during labor and birth Intravascular volume changes just after childbirth Cardiac hypertrophy

Physiologic adaptation to pregnancy
If cardiac changes are not well tolerated cardiac failure can develop during pregnancy, labour, postpartum If myocardial disease develops, valvular disease exists or congenital heart defect is present, cardial decompensation is anticipated

Pregnancy result in case of Cardiovascular Disorders
miscarriages Preterm labor and birth IUGR Congenital heart lesions (4-16%) Maternal mortality

Maternal cardiac disease risk group
Group I (mortality rate 1%) Corrected tetralogy Fallot Pulmonic/tricuspid disease Mitral stenosis (classes I, II) Patern ductus arteriosus Ventricular septal defect Atrial septal defect Group II (mortality rate 5-15%) Mitral stenosis with atrial fibrillation Uncorrected tetralogy Fallot Aortic coarctation (uncomplicated) Marfan syndrome with normal aorta Group III (mortality rate 20-50%) Aortic coarctation (complicated) Myocardial infarction Marfan syndrome with aortic involvement Pulmonary hypertension

Functional classification of organic heart disease (New York Heart Association, NYHA)
Class I: Asymptomatic at normal levels of activity Class II: Symptomatic at increased activity Class III: Symptomatic with ordinary activity Class IV: Symptomatic at rest Determination 3 month 7 or 8 month

Contraindications to pregnancy
Pulmonary hypertension Shunt lesions associated with Eisenmenger syndrome Complex cyanotic congenital heart disease Aortic coarctation complicated by artic dissection Poor ventricular function Marfan syndrome with marked aortic dilatation

Associated Cardiovascular Disorders
I Congenital cardiac disease Septal defects Atrial septal defect (ASD) Ventricular septal defect (VSD) Patent ductus arteriosus (PDA) Acyanotic lesions Coarctation of aorta Cyanotic lesions Tetralogy of Fallot

Associated Cardiovascular Disorders cont
II Acquired cardiac disease Mitral valve stenosis Aortic stenosis Ischemic heart disease Myocardial infarction (MI) Other cardiac diseases (PPCM) Pulmonary hypertension Marfan syndrome Infective endocarditis Eisenmenger syndrome Valve replacement Peripartum cardiomyopathy

Associated Cardiovascular Disorders
Increased number of successfully completed pregnancies Postpone conception 1 year after transplantation Vaginal birth is desired, yet there is an increased rate of cesarean birth Breastfeeding not advised when taking cyclosporine

Congenital Cardiac Disease Septal Defects

Arial septal defect Left-to-right shunt
Undetected because woman is asymptomatic Uncomplicated pregnancy Right-side heart failure or arrhythmia as a result of increased blood volume

Ventricular septal defect
Left-to-right shunt Diagnosed and corrected during infancy and childhood, not common in pregnancy Not complicated pregnancy Risk for: arrhythmias, heart failure, pulmonary hypertension Management Rest decrease of physical activity anticoagulants

Patent ductus arteriosus
Left-to-right shunt Diagnosed and corrected during infancy Possible complications arrhythmias, heart failure, pulmonary hypertension Endocarditis Pulmonary emboli Management Rest decrease of physical activity anticoagulants

Congenital Heart Disease Acyanotic Lesions

Coarctation of the aorta
Pregnancy safe for mother with uncomplicated coarctation Complications Hypertension Congestive heart failure Aortic rupture Management Rest Antihypertensive medications (beta-blockers) Vaginal birth with epidural anesthesia and shortening of the II stage (vacuum- or forceps assisted) Antibiotic prophylaxis

Congenital Heart Disease Cyanotic Lesions

Tetralogy of Fallot 1. Ventricular septal defect. 2. overriding aorta
3. right ventricular hypertrophy 4. pulmonary stenosis Right-to-left shunt Corrected at childhood Management Anticoagulant Oxygen hemodinamic monitoring

Acquired Heart Diseases

Mitral Stenosis The pressure gradient across the narrow valve increases secondary to the increased heart rate and blood volume Left atrial pressure increases, back pressure into the lungs causes breathlessness, swelling in the legs and may lead to atrial arrhythmias. Stretching of the atrium can also occur causing palpitations and arrhythmia.

Mitral Stenosis Maternal mortality rate in classes III and IV
5 %without arterial fibrillation 15% with arterial fibrillation There is marked increase in the following issues regarding the fetus Rate of prematurity Fetal growth retardation Low neonatal birth weight

Mitral Stenosis Therapeutic approach is:
to reduce the heart rate and decrease left atrial pressure Restrict physical activity Restrict salt intake diuretics Beta blockers Digoxin (if patient is in a. fib) Calcium channel blockers if medical therapy is ineffective surgery may be necessary after 20 weeks Balloon valvuloplasty Surgery (repair/replacement)

Mitral Stenosis Vaginal delivery can be permitted in most patients
Hemodynamic monitoring is recommended (Swan) and should be continued several hours following delivery

Aortic Stenosis AS lead to obstruction to left ventricular ejection
Mild AS is usually tolerated Moderate to severe AS is likely to be associated with symptomatic deterioration during pregnancy Women with valve area <1.0 should consider valve replacement prior to pregnancy

Aortic Stenosis Symptoms often develop in the 2nd and 3rd trimester
Exertional dyspnea Chest pain Syncope Fetal effects included Intrauterine growth retardation Premature delivery Reduced birth weight Increase in cardiac defects

Ischemic Heart Disease
MI is rare in childbearing woman Risk factors increase Age Smoking Stress Cocaine use Hyperbilirubinemia DM Family history of IHD Hypertension Oral contraceptives

Ischemic Heart Disease
Mangement Oxygen Aspirin Beta-blockers Nitrates Heparin Side-lying position Vaginal birth is preferable with avoiding of maternal pushing (vacuum- or forceps-assisted) Diuretic postpartum

Other Heart Diseases

Primary Pulmonary Hypertension
Constriction of the arteriolar vessels in the lung, leads to increase in the pulmonary artery pressure right ventricular hypertension, hypertrophy, dilatation, right ventricular failure with tricuspid regurgitation Associated with high maternal mortality estimated to be 50%, half of them occurs a few hours to several days post partum usually related to sudden death or progressive RV failure, although the exact cause of death is not clear Deterioration usually occurs in the second/third trimester

Symptoms may include Fatigue Dyspnea Chest pain Edema and ascites Syncope Diagnostic test Chest radiogram ECG EchoCG Dopler studies

Fetal effects include High incidence of prematurity Fetal growth retardation Fetal loss Pregnancy should be discouraged in all patients with primary pulmonary HTN

For patients who chose to continue pregnancy Nifedipin or prostacycline (for pulmonary vasodilatation) Anticoagulant Continuous hemodynamic monitoring during labor and delivery Antiembolic strocking Side-lying position Oxygen therapy Epidural analgesia

Marfan Syndrome Autosomal dominant genetic disorder characterized
weakness of the connective tissue, resulting in joint deformities, ocular lens dislocation, weakness of aortic wall and root Mitral valve prolapse (90%) Aortic insufficiency (25%) risk of aortic dissection and rupturing Pregnancy in patients with Marfan poses 2 problems Cardiovascular complications of the mother Risk of having a child who inherits Marfan’s syndrome Cardiovascular problems Dilation of the ascending aorta, may lead to development of aortic regurgitation and heart failure Proximal and distal dissections of the aorta with possible involvement of the coronaries

Marfan’s Syndrome Obstetrical complications Preconception counseling
Cervical incompetence Abnormal placental location (previa) Postpartum hemorrhage Preconception counseling Patients with more than mild dilation of the aorta, or history of aortic dissection should be advised against pregnancy Progressive dilation of the aorta during gestation may occur even with a normal-sized aorta Preconception echo evaluation allows for evaluation of the aortic root, CT, MRI. Periodic echocardiographic follow-up is recommended

Marfan’s Syndrome Management
Vigorous physical activity should be avoided Beta blockers (reduces the rate of aortic dilation) If substantial dilation/dissection should occur, depending on the stage of pregnancy therapeutic abortion, early delivery or surgical intervention should be considered

Infective endocarditis
Inflammation of endocardium Cause: microorganisms Clinical manifestation: incompetence of heart valves Congestive heart failure Cerebral emboli Treatment Antibiotics

Eisenmenger Syndrome Right-to-left or bidirectional shunting at atrial or ventricular level and combined with elevated pulmonary vascular resistance High risk of maternal (30-50%) and fetal (50%) morbidity and mortality Pregnancy is contraindicated (contraception or termination of pregnancy) Death usually (75%) occurs between the first few days and weeks after delivery, but the cause is unclear

Eisenmenger Syndrome Patients should be monitored closely for any signs of deterioration Early elective hospitalization is recommended Activity is strictly limited Hemodynamic monitoring is required Anticoagulant??? Prophylaxis of hypovolemia Oxygen Epidural analgesia

Hypertrophic Cardiomyopathy
Most cases have favorable outcomes Symptoms may worsen, especially in patients who were already symptomatic Increased SOB Fatigue Chest pain Syncope The risk of the fetus of inheriting the disease is as high as 50%

Valve replacement Risk of thromboembolism Anticoagulant???
+ hypercoagulability - maternal, fetal hemorrhage - risk of fetal abnomalities Porcine heterograft valves + do not require of anticoagulants - premature valve failure Heparin (beside coumadin) Before conception or as soon as possible 2-3 times a day, activated partial thromboplastin time Dicontinued at the time of active labour Reactivate within 6 h of VB or h after CS Low-molecular weight heparin

Peripartum Cardiomyopathy
A form of dilated CMP with LV systolic dysfunction that results in the signs and symptoms of heart failure Criteria Development in last month of pregnancy or the first 5 months after delivery Absence of heart disease prior to last month of pregnancy Absence of identifiable cause of heart failure LV systolic dysfunction Etiology is unknown Theories Genetic predisposition Autoimmunity Viral infection

Associated risk factors: Age - over 35 twin pregnancy gestational hypertension Multiparity African-american race use of tocolytic therapy Motality rate 25-50%

Clinical findings Left ventricular failure Dyspnea Fatigue Edema Enlarged heart S3, murmurs of MR and TR Tachycardia ST-T wave abnormalities arrhythmias

clinical course varies 50-60% of patients demonstrate complete recovery within the first 6 months The rest of the patients demonstrate either further clinical deterioration, leading to cardiac transplant or premature death, or persistent LV dysfunction and chronic heart failure No agreement on recommendation for future pregnancies Pregnancy contraindicated Persistent cardiomegaly Cardiac dysfunction

Management Acute heart failure treatment with O2, diuretics, digoxin and vasodilators (hydralazine is safe) Because of the increased incidence of thromboembolic events, anticoagulation therapy is recommended

Care management Preconceptual councelling Pregnancy Peripartum risk
Decisions after evaluation risk If possible – multidisciplinary approch (cardiologist, perinsatologist, anesthesiologist, ginecologist)

Assessment Interview Personal medical history
Heart disease (congenital, streptococcal infections, rheumatic fever, valvular disease, endocarditis, angina, MI) Factors increase stress of the heart (anemia, infection, edema) Review cardiovascular and pulmonary system Chest pain, edema on face, hand, feet, hypertension, heart murmur, palpitation,dyspnea, diaphoesis, pallor, syncope Cough, hemoptysis, shortness of breath, Medication Emotional status (depression, anxiety, fear of morbidity and mortality for herself and featus)

Assessment Examination Vital sign Oxygen saturation level
Pattern of edema Discomphort of pregnancy Weight gain Sign of potential cardiac decompensation

Sign of potential cardiac decompensation
Subjective symptoms Increasing fatigue or difficulty of breathing or both with usual activities Feeling of smothering Frequent cough Palpitations; feeling that her heart is racing Swelling of face, feet, legs, fingers Objective signs Irregular weak, rapid pulse (more 100b/m) Progressive generalised edema Cracles at the base of lungsafter 2 inspirations and exhalations Orthopnea; increasing dyspnea Rapid respirations (more 25 b/m) Moist, frequent cough Increasing fatique Cyanosis of lips and nail beds

Assessment Lab Urinalisis CBC Blood chemistry ECG EchoCG
Pulse oximetry Chest film Fetal ultrasound DFMC NST

Antepartum care Critical period weeks – hemodinamic changes reach their maximum Reduce emotional stress, hypertension, anemia, hyperthyroidism, obesity Class I and II 8-10 h of sleeping + 30 min naps after eating Activities: housework, shopping, exercise limited Class II Avoid any activities that causes even minor signs of cardiac decompensation Admit to the hospital near term Class III, IV Bed rest at the hospital

Antepartum care Treatment of infections of GI, UT, Respiratory
Adequate nutrition (folic acid, protein, fluid, fiber) Medication: anticoagulant – heparin (large molecule does not cross the placenta) Recurrent vein thrombosis Pulmonary embolus rheumatic heart disease Prostetic valves Cyanotic congenital heart defects Monitiring clotting factors (blood test) Avoid food high in vit K (raw, dark green and leafy vegetables Folic acid

Antepartum care Digoxin: crosses placenta
Procainamide: crosses placenta, no known teratogenic effects Verapamil: crosses placenta, can produce maternal hypotension Propranolol: crosses placenta, no known teratogenic effects, associated with fetak bradicardia, IUGR, preterm labour, neonatal respiratory depression Warfarin: crosses placenta, fetal anomalies, and hemorrhage, congenital malformation, preterm birth, stillbirth Furosemide: crosses placenta, no known teratogenic effects, thiazides: crosses placenta, neonatal jaudice, thrombocitopenia, anemia Lidocaine: crosses placenta, safe as long as toxic leves avoided Quinidine: crosses placenta, no known teratogenic effects, neonatal thrombocytopenia Nifedipine: crosses placenta, maternal hypotension Diazoxide: crosses placenta, hyperglycemia, potential relaxant of uterine smooth muscle Sodium nitroprusside: crosses placenta, only in critical care unit

Antepartum care Heart surgery Ideal scenario – before pregnancy
If need present – early at the second trim Closed cardiac surgery – low risk Open heart surgery – high risk r/t with artificial circulation an temporary hypoxia

Intrapartum Care Routine assessment of laboring woman
Assessment of cardiac decompensation Arterial blood gases ECG BP, Ps, Oxymetry Position: elevated upper part of body or side-lying Management of discomfort: supportive care, epidural analgesia Preterm laboue: betaadrenergic agonist (ritodrine, terbutaline) Labour induction (syntocinon) Cervical rippening (prostaglandins) Vaginal birth in side-lying position Oxygen mask Episiotomy vacuum extraction Forceps CS: risk r/t with dramatic fluid shifts, sustained hemodinamic changes and increased blood loss Dilute oxytocin is indicated, ergot products are contraindicated

Postpartum Care First 24-48 h are the most hemodinamically difficult
Assessment Vital sign Oxygen saturation levels Lung and heart auscultation Edema Character of bleeding, uterine tone Fundal height Urinary output Pain Activity rest pattern Elevated the head of the bed Family member help Brestfeeding is not contraindicated

Anemia

Anemia Most common medical disorder of pregnancy
Iron deficiency anemia (90%) Folic acid deficiency anemia Sickle cell hemoglobinopathy Thalassemia

Anemia Anemia is the reduced ability of the blood to carry oxygen to the cells and the heart tries to compensate by increasing cardiac output increase workload of the heart and stresses ventricular function Therefore anemia with complication (preeclampsia) may result un congestive heart failure Increased risk of infection Slide 60

Definition of Anemia Hemoglobin below 11gm/dl in 1st and 3rd trimester and below 10.5gm/dl in second trimester. WHO 11gm/dl or less By this standard, 50% of women not on hematinics become anemic. Ht nonpregnant 38-45% pregnant 34% (result of hydratation)

Criteria for Physiologic Anemia
Hb: 10gm% RBC: 3.2 million/mm3 Peripheral smear showing normal morphology of RBC with central pallor

Iron Deficiency Anaemia
Symptoms: lassitude, weakness, anorexia, palpitation, dyspnea Signs: Pallor, glossitis, soft systolic murmur in mitral area due to physiologic mitral incompetence Degree: Mild: 8-10gm% Moderate: 7-8gm% Severe: <7gm%

Iron Deficiency Anemia
Prevention Iron supplements Vitamin C may enhance absorption Do not take iron with milk or antacids Calcium impairs absorption Slide 65

Iron Deficiency Anemia (continued)
Treatment Oral doses of elemental iron (60-80 mg/day) Continue therapy for about 3 months after anemia has been corrected GI side effect Constipation nausea vomiting Slide 66

Folic Acid Deficiency Anemia
Large, immature RBCs (megaloblastic anemia) Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from meals Nutritional risk Poor diet Cooking with large amount of water malabsorbtion Folate is essential for normal growth and development. Deficit leads to neural tube defects, cleft lip, cleft palate. Prevention Before pregnancy - Daily supplement of 400 mcg (0.4 mg) During pregnancy - Daily supplement of 600 mcg (0.6 mg) Risk group (NTD) - Daily supplement of 800 mcg (0.8 mg) Slide 67

Sickle Cell Disease Autosomal recessive disorder Abnormal hemoglobin
Causes erythrocytes to become distorted and sickle (crescent) shaped during hypoxic or acidotic episodes Abnormally shaped blood cells do not flow smoothly Can clog small blood vessels Recurrent crises: fever, pain in abdomen or extremities as rsult of vascular obstruction, tissue hypoxia,edema, RBS destruction, associated with anemia, jaundice, reticulocytosis Slide 68

Sickle Cell Disease (continued)
Pregnancy can cause a crisis Massive erythrocyte destruction and vessel occlusion Risk to fetus if occlusion occurs in vessels that supply the placenta Can lead to Fetus preterm birth IUGR skeletal changes small for gestational age fetal demise Mother UTI Leg ulcers Bone abnormalities Stroke Cardiopathy Congestive heart failure Preeclampsia postpartum hemorrhage Oxygen and fluids are given continuously throughout labor Perinatal mortality is high. Slide 69

Thalassemia is an inherited autosomal recessive blood disease. In thalassemia the genetic defect, which could be either mutation or deletion, results in reduced rate of synthesis or no synthesis of one of the globin chains that make up hemoglobin. This can cause the formation of abnormal hemoglobin molecules, thus causing anemia, the characteristic presenting symptom of the thalassemias. Manifestation: severe bone deformation caused by massive marrow tissue explanation β chain seen most often in United States Can inherit abnormal gene from each parent, causing β-thalassemia major (homozygous) If only one abnormal gene is inherited, then infant will have β-thalassemia minor (heterozygous) Slide 70

Thalassemia Infertility problem Complications of pregnancy Treatment
Stillbirth IUGR Preeclampsia Preterm labour Treatment Hemotransfusion

Thalassemia Woman with β-thalassemia minor has few problems, other than mild anemia Iron supplements may cause iron overload Body absorbs and stores iron in amounts that are higher than usual Slide 72

Nursing Care Teach woman which foods are high in iron and folic acid Teach woman how to take supplements Do not take iron supplements at the same time when drinking milk Do not take antacids with iron When taking iron, stools will be dark green to black Slide 73

Nursing Care The woman with sickle cell disease requires close medical and nursing care Teach her to prevent dehydration and activities that cause hypoxia Teach her to avoid situations where exposure to infections are more likely Teach her to promptly report any signs of infections Slide 74

Pulmonary Disorders

Pulmonary disorders Asthma Cystic fibrosis
Adult respiratory distress syndrome (ARDS)

Asthma Acute respiratory illness caused by alergens, marked changes in ambient temperature or emotional tension In response to stimuli reversible narrowing of the hyperactive airways makes difficult to breath Manifestation Expiratory wheezing Productive cough Thick sputum Dyspnea Effect of pregnancy Improve (50%) Stay same (25%) Worsen (25%) Peak of symptoms: weeks

Asthma Treatment Relief of acute attack
Prevention or limitation of later attacks Adequate maternal and fetal oxygenation These goals can be achieved in pregnancy by eliminating environmental triggers (e.g., dust mites, animal dander, pollen), drug therapy (e.g., bronchodilators, antiinflammatory agents), patient education Respiratory infections should be treated and mist or steam inhalation employed to aid expectoration of mucus. Acute episodes may require albuterol, steroids, aminophylline, beta-adrenergic agents, and oxygen.

Asthma Labour Postpartum
medications for asthma are continued in labor and postpartum. Pulse oximetry Pain relief – epidural analgesia Morphine and meperidine are histamine-releasing narcotics and should be avoided Postpartum Risk for hemorrhage, management with oxitocin Medication cont. during postpartum period and lactation Return to pre-pregnancy status within 3 month after delivery

Cystic Fibrosis autosomal recessive genetic disorder in which the exocrine glands produce excessive viscous secretions causing problems with both respiratory and digestive functions. Respiratory failure and early death (early twenties) may occur. Genetic counseling is encouraged to identify carriers of the disease. In women with good nutrition, mild obstructive lung disease, and good chest x-rays, pregnancy is tolerated well Increased risk of maternal and perinatal mortality is related to severe pulmonary infection. Complication chronic hypoxia frequent pulmonary infections. Women with cystic fibrosis show a decrease in their residual volume during pregnancy, as do normal pregnant women, and are unable to maintain vital capacity. Presumably the pulmonary vasculature cannot accommodate the increased cardiac output of pregnancy. The results are decreased oxygen to the myocardium, decreased cardiac output, increased hypoxemia. A pregnant woman with less than 50% of expected vital capacity usually has a difficult pregnancy.

Cystic Fibrosis Fetal effects Mothers effects Treatment Labour
Preterm birth IUGR Neonatal deth Mothers effects GDM Liver disease Pancreatic insuficiency Malnutrition Treatment Pancreatic enzyme Parental nutrition Antibiotics Labour monitoring for fluid and electrolyte balance. Because sodium lost through sweat can be significant, and hypovolemia can occur. Oxygen by face mask, monitoring by pulse oximetry Epidural or local analgesia Postpartum Breastfeeding appears to be safe as long as the sodium content of the milk is not abnormal Pumping and discarding the milk is done until the sodium content has been determined.

Adult respiratory distress syndrome
Lungs are unable to maintain levels of oxygen and carbon dioxide within normal limits (shock of lung) Severe hypoxemia, in spite levels of inspired oxygen, is accompanied by an increase in pulmonary permeability, decrease in lung, and shunting of blood As result of chest trauma, drug ingestion, pneumonia, inhalation of gastric contents during anestesia, DIC, preclampsia, eclampsia, abruptio placentae. Dead fetus syndrome. Amniotic fluid embolism

Adult respiratory distress syndrome
Management Find and correct underlying cause Early intubation and mechanical ventilation? With positive end-expiratory pressure Vasoactive, inotropic agents Corticosteroids Maintaining offluid balance Result depends of cause

Дякую за увагу!

Other Medical Disorders in Pregnancy
Neurologic disorders Epilepsy Multiple sclerosis (MS) Bell’s palsy Autoimmune disorders Systemic lupus erythematosus (SLE) Myasthenia gravis (MG)

Effect Of Epilepsy On Pregnancy
Data on 1st trimester losses, PROM, ante-partum hemorrhage, operative vaginal delivery and CS are inconclusive. Increased incidence of IUGR, cognitive dysfunction, microcephaly and perinatal mortality ( times normal). Increased incidence of congenital malformations.

Effect Of Epilepsy On Lactation
No studies on the effects of AED on either quantity or quality of breast milk. Breast feeding should be stopped if obvious sedation develops in an infant and is likely to relate to the presence of AED in breast milk.

Effects Of Epilepsy On Fetus And Neonate
1-There is increased risk for infants of epileptic mothers to have epilepsy. The risk of neonatal susceptibility depends on: Nature of the mother’s seizure disorder. Genetic factors. Seizures arises during pregnancy. Metabolic & toxic consequences of seizures and AEDs. 2-Increase perinatal morbidity.

Other Medical Disorders in Pregnancy
Gastrointestinal disorders Cholelithiasis and cholecystitis Inflammatory bowel disease Surgery during pregnancy Appendicitis

Key Points Stress of normal maternal adaptations to pregnancy on a heart whose function is already taxed may cause cardiac decompensation Cardiac arrest in pregnant women requires that standard advanced cardiac life support guidelines be implemented with modifications Uterus must be displaced laterally Defibrillation paddles should be placed one rib interspace higher

Key Points Maternal morbidity and mortality is significant risk complicated by mitral stenosis Normal hemodynamic values are significantly altered as a result of pregnancy Anemia, the most common medical disorder of pregnancy, affects 20% of pregnancies Asthma is most common respiratory crisis complicating pregnancy

Key Points Pruritus is common symptom in pregnancy-specific inflammatory skin diseases Epilepsy is most common neurologic disorder of pregnancy and can be confused with eclampsia History of seizures and no signs of preeclampsia point to epilepsy Cholecystitis and cholelithiasis are common gastrointestinal problems in pregnancy

Key Points Autoimmune disorders (e.g., SLE, MG) show predilection for women in reproductive years; associations with pregnancy not uncommon Enlarged uterus, displaced internal organs, and altered laboratory values may confound differential diagnosis when the need for immediate abdominal surgery occurs

Key Points Preoperative care for pregnant woman differs from that for nonpregnant woman in one significant aspect: Presence of at least one other person, the fetus

Signs of CHF During Pregnancy
Severe pitting edema of the lower extremities or generalized edema Palpitations Changes in fetal heart rate Indicating hypoxia or growth restriction Persistent cough Moist lung sounds Fatigue or fainting on exertion Difficulty breathing on exertion Orthopnea Slide 98

Treatment Drug therapy
Under care of both obstetrician and cardiologist Priority care is limiting physical activity Drug therapy May include beta-adrenergic blockers, anticoagulants, diuretics Vaginal birth is preferred because it carries less risk for infection or respiratory complications Slide 99

Physical Exam Normal pregnancy is often accompanied by symptoms of:
fatigue decreased exercise capacity hyperventilation dyspnea palpitations lightheadness syncope

Physical Exam LE edema is common
RV heave is usually present in the second and third trimesters Pulmonary trunk and pulmonic valve closure are often palpable

Physical Exam The S1 is increased with exaggerated splitting that may mimic S4 Innocent systolic murmurs may be heard as a result of the hyperkinetic circulation of pregnancy They are midsystolic and soft Heard best over the pulmonic area and radiate to the suprasternal notch

Physical Exam Continuous murmurs
Venous hum, heard over the right supraclavicular fossa Mammary souffle heard over the breast late in gestation and decreases when pressure is applied with the stethoscope

Hypertension Defined in pregnancy as >140/90
Complicates 8-10% of pregnancies May effect maternal morbidity/mortality: abruptio placenta pulmonary edema respiratory failure DIC Cerebral hemorrhage Hepatic failure Acute renal failure

Hypertension Chronic HTN
HTN that preceded pregnancy or is detected prior to the 20th week Occurs 1 in 5 pregnancies Drug therapy is recommended for high risk characteristics of preeclampsia (poor obstetric history, renal insufficiency, diabetes, severe HTN with evidence of end-organ involvement) Low risk patients (SBP ) and normal exam, normal ekg and echo, antihypertensive therapy has not been shown to prevent the development of preeclampsia or affect fetal outcome

Hypertension Gestational HTN
Begins after 20 weeks and resolves by the 6 postpartum week Transient (without proteinuria) Preeclampsia (proteinuria) Preeclampsia should be considered and seizure prophylaxis should be instituted empirically in patients with BP >160/110

Hypertension Preeclampsia-Eclampsia Usually occurs after 20 weeks
SBP>140/ DBP>90 and proteinuria The disease is highly suspect even in the absence of proteinuria if symptoms of headache, blurred vision, pulmonary edema, elevated LFT, low platelets Usually reversible within hours after delivery

Hypertension The majority of patients with SBP> and DBP <110 are at low risk of cardiovascular complications and are candidates for nondrug therapy Indications for drug therapy include SBP>160, DBP>110 End-organ damage (LVH, renal insufficiency)

Hypertension Management
Methlydopa is the preferred therapy but may also use labetalol and nefedipine. An effective prepregnancy regimen can often be continued with the exception of ACE inhibitors or ARBs ACEI/ARB may cause significant fetal risks including damage to the cardiovascular, renal and central nervous systems Delivery is the only definitive treatment of preeclampsia

Prosthetic Heart Valves
Increased thromboembolic events have been reported during pregnancy in women with prosthetic valves, incidence as high as 10-15% 2/3rds of these patients presented with valve thrombosis which led to death in 40%

Oral anticoagulants can cross the placenta and be harmful to the fetus Exposure during the first 8-12 weeks can be associated with a teratogenic effect leading to warfarin embryopathy (nasal deformity) as well as other complications intracranial bleeding Congenital anomalies Fetal wastage Spontaneous abortion/fetal loss

ACCP recommendations for anticoagulation in pregnant patients with porsthetic heart valves Unfractionated heparin(UFH) SQ q12 hours throughout pregnancy following PTT levels LMWH (Lovenox) throughout pregnancy following anti-Xa levels LMWH or UFH until week 13, then coumadin until middle of third trimester, then restart UFH/LMWH until delivery

Imaging CXR - radiation exposure is minimal Echo - safe
Stress testing - use low level exercise protocol to obtain 70% maximal heart rate, use with fetal monitor CT scan - radiation may vary MRI- no known risk to the fetus Cardiac cath - relatively high doses of radiation, obtain access via the brachial artery rather than femoral to limit fetal radiation

Imaging Radiation exposure 5 rads - low risk
5-10 rads - provide counseling regarding the low risk of problems 10-15 rads - during the first 6 weeks, individual consideration for termination >15 rads - termination recommended

Case 34 year old female presents to the emergency room 2 weeks after giving birth to twins. Her pregnancy and delivery were uneventful. She now is feeling short of breath. She notes that she can not sleep flat at night anymore.

On physical exam she has bibasilar rales and is tachycardic with an S3 present.
What disease state do you suspect? What testing would you like to order?

EKG: ST with non-specific ST-T wave abnormalities
CXR: pulmonary edema with cardiomegaly Echo: dilated LV with depressed ejection fraction at 30%

How would you treat this patient?
What does the diagnosis of peripartum cardiomyopathy mean for her long term prognosis?

Treatment is similar to other forms of heart failure
Diuretics Vasodilators Digoxin 50-60% of patients make a full recovery within 6 months.

Nutritional Anemias Easily fatigued Skin and mucous membranes are pale
Symptoms Easily fatigued Skin and mucous membranes are pale Shortness of breath Pounding heart Rapid pulse (with severe anemia) Slide 120

Lectures 7, 8 Petrenko N.V., MD, PhD

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Lectures 7, 8 Petrenko N.V., MD, PhD

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