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Published byShawn Roberts Modified over 9 years ago
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Max Brinsmead MB BS PhD May 2015
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In the UK this has increased over time Deaths in 1982 – 85 7.3 per million births in 2003 – 05 22.7 per million births Due mainly to increasing maternal age and ↑ incidence of coronary artery disease In PNG there were 4 admissions to the antenatal ward for heart disease in 2010 amongst 12,109 deliveries
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Myocardial ischaemia/Infarction 33% Cardiomyopathy 33% Rheumatic heart disease 10% Congenital heart disease 10% In developing countries there is more rheumatic heart disease and less coronary artery disease
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Pregnancy increases the risk 3 – 4 fold But age >40 increases the risk 30 fold When infarction occurs 33% women will die Associated risk factors... ▪ Hypertension ▪ Pre eclampsia ▪ Diabetes ▪ Smoking ▪ Obesity ▪ Hyperlipidaema
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A high index of suspicion in patients at risk If they develop chest pain then early recourse to... ▪ ECG ▪ Serum tropinins ▪ CT or MRI ▪ Angiography if required
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Unknown aetiology and no known risk factors 25% will be associated with hypertension Sometimes due to viral myocarditis Can occur any time in the antenatal period and up to 6 months postpartum
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A patient who complains of increasing dyspnoea Especially nocturnal orthopnoea Investigate by... ▪ ECG ▪ CXR ▪ Echocardiography
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Mitral stenosis is the most common And most serious But it is difficult to detect So early referral and echocardiography is recommended when... Any diastolic murmur is detected There is any history suggestive of rheumatic fever
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Usually associated with systolic hypertension So keep this controlled Also a complication of Marfan’s Sydrome The spider people With dislocated lens May be a family history But 30% are spontaneous mutations Risk of aortic dissection is low if the aortic root diam is <40 mm
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Survival after corrective or palliative surgery now more common Cyanotic CHD carries the poorest prognosis And any degree of pulmonary hypertension is worrying In terms of frequency the problems are: Left ventricular outflow obstruction ± Bicuspid aortic valve Coarctation of the aorta Tetralogy of Fallot Right ventricular outflow obstruction Ebstein’s anomaly (<1%)
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Start Preconception ▪ Complete diagnostic work up ▪ Multidisciplinary care ▪ Patient education ▪ Family Planning Contraception ▪ COC’s are only relatively contraindicated for most ▪ But Progestin-only contraception may be better ▪ IUCD insertion may require resuscitation backup ▪ Mirena may be better than copper IUDs
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Antenatal Care ▪ Multidisciplinary care ▪ Preferably seen by same person for each visit Cardiac evaluation at each visit ▪ Know what to ask for (based on knowledge of the patient) ▪ Know what to look for (based on what was found before) ▪ Rising pulse rate at rest may be first sign of trouble Low threshold for admission ▪ Fetal echocardiography for those with CHD Delivery Planning ▪ Multidisciplinary meeting at 32 – 34 w ▪ Decide on timing, place and type of delivery ▪ Labour & Delivery in ICU may be the best option
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Intrapartum Care ▪ Multidisciplinary team ▪ Minimise cardiovascular stress ▪ Analgesia – best by epidural ▪ Caesarean only for the usual obstetric indications ▪ But this may include high risk of failed induction ▪ Assisted delivery ▪ 2 units Syntocinon IV or low dose Syntocinon infusion the safest option for the 3 rd stage ▪ The greatest risk of CCF is immediately postpartum Postpartum Care ▪ Consider thromboprophylaxis Family Planning
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The New York Heart Association (NYHA) Classification Class I ▪ No symptoms and no limitation to ordinary physical activity Class II ▪ Mild symptoms (dyspnoea or angina) with slight limitation to physical activity Class III ▪ Marked limitation of activity due to symptoms Class IV ▪ Symptoms at rest
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