1. Cardiac Disease in Pregnancy
Woman’s Hospital School of Medicine Zhejing University
He jin

2. Physiological Changes in the Cardiovascular System During Pregnancy
A thorough knowledge
is essential
In order to understand
the additional impact of cardiac disease

3. Physiological Changes
The first cardiovascular change associated with pregnancy
Peripheral vasodilation (induced by progesterone)
leading to
A decrease in systemic vascular resistance

4. Physiological Changes
Cardiac output increases
8 weeks : 20%
20-28 weeks :40-50%
Stroke volume increase 80ml/t
ventricular end-diastolic volume
wall muscle mass
contractility
Heart rate increase
10 to 15 beats per minute

5. Physiological Changes
Labour leads to further increases in cardiac output
In the first stage: 15%
In the second stage: 50%
blood back into the circulation with each uterine contraction: ml
pain and anxiety : sympathetic stimulation

6. Physiological Changes
After delivery
Cardiac output increases again immediately : 60-80%
uterine contraction
relief of caval compression
Within 1 h
rapid decline to pre-labour values

7. Table 1 -- Normal Hemodynamic Changes During Pregnancy
Hemodynamic Parameter
Change During Normal Pregnancy
Change during labor and delivery
Change during postpartum
Blood volume
↑ 40-50% ↑
↓ (autodiuresis)
Heart rate
↑ beats/min ↓
Cardiac output
↑ %
↑ additional 50%
Blood pressure
↓ 10 mm Hg
Stroke volume
↑ 1st and 2nd trimester; ↓ 3rd trimester
↑ (  mL per contraction)
Systemic vascular resistance

8. Types of CD during pregnancy
Congenital heart disease
Rheumatic heart disease
Pregnancy-induced hypertension heart disease
Peripartum cardiomyopathy
Other

9. Congenital heart disease
Left → right shunt
① atrial septal defect    
② ventricular septal defect    
③ patent ductus arteriosus
No shunt     ① pulmonary stenosis     ② coarctation of the aorta     ③ Marfan syndrome
right → Left shunt:f4、AS

10. Rheumatic heart disease
Mitral stenosis:
Increased blood volume during pregnancy
Intrapartum and early puerperium: blood volume back to the heart increased
Pulmonary circulation volume increase
Left atrial pressure increases
Pulmonary venous hypertension
Acute pulmonary edema.
Mitral incompetence: simply
Can tolerance pregnancy, delivery and puerperium.

11. Rheumatic heart disease
Aortic stenosis: severe
Pulmonary edema
Low discharge capacity heart failure
Aortic incompetence : severe
Left ventricular failure
Combined with bacterial endocarditis

12. PIH heart disease No history of heart disease and signs over the past
Sudden onset of systemic failure are dominated by left ventricular failure
Misdiagnosed as the flu and bronchitis
Early diagnosis is important
After eliminate the cause, most can be restored

13. PIH heart disease
Myocardial ischemia, interstitial edema, hemorrhage and necrosis spots
Blood viscosity increased to promote myocardial ischemia
Combined with severe anemia
Heart failure occurs

14. Peripartum Cardiomyopathy (PPCM)
Define: dilated cardiomyopathy
Interval: between the last 3 month of pregnancy up to the first 6 months postpartum
Women : without preexisting cardiac dysfunction
Fetal death:10~30%
Maternal mortality is approximately 9%
heart failure, pulmonary infarction, arrhythmia
These women should be counseled against subsequent pregnancies

15. PPCM The exact etiology : unknown Possible causes
infection, immunity, multiple pregnancy, hypertension, malnutrition
viral myocarditis
automimmune phenomena
specific genetic mutations

16. PPCM Typical signs Fatigue Dyspnea on exertion, orthopnea
Nonspecific chest pain
Abdominal discomfort and distension
palpitations, cough, hemoptysis, hepatomegaly, edema and other heart failure symptoms

17. PPCM Saymptoms Heart enlarged Myocardial contractility reduce
Ejection function reduced
ECG:
Arrhythmias, left ventricular hypertrophy, ST segment and T wave abnormalities

18. CD main threat to pregnant women
Heart failure
Subacute infective endocarditis
Hypoxia and cyanosis
Venous thrombosis and pulmonary embolism.

19. The impact of CD in pregnant women
Gestation period:
increased blood volume, heart burden
Delivery period:
uterine contractions
blood pressure↑
the blood flow increases
pulmonary artery pressure increased
sudden interruption of placental circulation
abdominal pressure plummeted

20. The impact of CD in pregnant women
Puerperium:
uterine contractions
retented Interstitial fluid returned to circulation
The greatest change period in systemic blood circulation and heart burden
32 to 34 weeks
Intrapartum
3 days postpartum
easily induced heart failure

21. The impact of CD in pregnant women
A validated cardiac risk score
Predict a maternal chance of having adverse cardiac complications
Table 2 Risk factor and maternal cardiac event rates
Risk factor 1
>1
Maternal cardiac event rates 5%
27%
75%

22. Table3 Predictors of Maternal Risk for Cardiac Complications
Criteria
Example
Points*
Prior cardiac events
heart failure, transient ischemic attack, stroke before present pregnancy 1
Prior arrhythmia
symptomatic sustained tachyarrhythmia or bradyarrhythmia requiring treatment
NYHA III/IV or cyanosis
Valvular and outflow tract obstruction
aortic valve area <1.5 cm2, mitral valve area <2 cm2, or left ventricular outflow tract peak gradient > 30 mm Hg
Myocardial dysfunction
LVEF <40% or restrictive cardiomyopathy or hypertrophic cardiomyopathy

23. The impact of CD in Fetal
Premature birth
Low birth weight
Respiratory distress
Fetal death
Neonatal death
Genetic heart disease

24. Maternal Cardiac Lesions and Risk of Cardiac Complications
Low Risk
Atrial septal defect
Ventricular septal defect  
Patent ductus arteriosus
Asymptomatic aortic stenosis with low mean gradient (<50 mm Hg) and normal LV function (EF >50%)
Aortic regurgitation with normal LV function and NYHA functional class I or II  

25. Maternal Cardiac Lesions and Risk of Cardiac Complications
Low Risk  
Mitral valve prolapse
(isolated or with mild to moderate mitral regurgitation and normal LV function)
Mitral regurgitation with normal LV function and NYHA class I or II
Mild to moderate mitral stenosis
(mitral valve area >1.5 cm2, mean gradient <5 mm Hg) without severe pulmonary hypertension)
Mild/moderate pulmonary stenosis
Repaired acyanotic congenital heart disease without residual cardiac dysfunction

26. Maternal Cardiac Lesions and Risk of Cardiac Complications
Intermediate Risk
Large left-to-right shunt
Coarctation of the aorta
Marfan syndrome with a normal aortic root
Moderate to severe mitral stenosis
Mild to moderate aortic stenosis
Severe pulmonary stenosis

27. Maternal Cardiac Lesions and Risk of Cardiac Complications
High Risk
Eisenmenger's syndrome
Severe pulmonary hypertension
Complex cyanotic heart disease
(tetralogy of Fallot, Ebstein's anomaly, truncus arteriosis, transposition of the great arteries, tricuspid atresia)
Marfan syndrome with aortic root or valve involvement   

28. Maternal Cardiac Lesions and Risk of Cardiac Complications
High Risk
Uncorrected severe aortic stenosis with or without symptoms
Uncorrected severe mitral stenosis with NYHA functional class II-IV symptoms
Aortic and/or mitral valve disease (stenosis or regurgitation) with moderate to severe LV dysfunction (EF <40%)
NYHA class III-IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology
History of prior peripartum cardiomyopathy

29. Diagnosis History: Palpitations, difficulty breathing or heart failure
Organic heart disease
Rheumatic fever

30. Diagnosis Signs and symptoms abnormal:
Exertional dyspnea, Paroxysmal nocturnal dyspnea , orthopnea, hemoptysis, recurrent exertional chest pain
Cyanosis, clubbing, jugular vein engorgement continuing.
Cardiac auscultation
a diastolic murmur of grade Ⅲ or rough systolic murmur over the whole
a pericardial friction rub, diastolic gallop, alternating pulse

31. Early signs of heart failure
Chest tightness, palpitations, shortness of breath after mild activity
Resting heart rate> 110 beats / min
Respiration> 20 times / min
Paroxysmal nocturnal dyspnea
The end of the lung wet rales persisted

32. Diagnosis: auxiliary examination
Noninvasive testing of the heart may include:
ECG: severe arrhythmias
atrial fibrillation, atrial flutter, Ⅲ degree atrioventricular block, ST segment and T wave abnormalities and changes
Chest radiograph
the heart was significantly expanded
Echocardiogram
expansion of the heart chamber
myocardial hypertrophy
valvular motion abnormalities
cardiac structural abnormalities

33. Management Before pregnancy: access to counselling
detailed examination to determine whether she is suitable to pregnant
access to counselling
specialized
multidisciplinary
preconception
In order to empower them to make choices about pregnancy

34. Not suitable for pregnancy ！
Cardiac function grade Ⅲ ~ Ⅳ
Those who previously had heart failure
A pulmonary hypertension, severe stenosis the main A, Ⅲ atrioventricular block, atrial fibrillation, atrial flutter,diastolic gallop;
Cyanotic heart disease
Active rheumatic or bacterial endocarditis

35. The main aims of management
To optimize the mother's condition during the pregnancy
considering ß-blockers
Thromboprophylaxis
pulmonary arterial vasodilators
To monitor for deterioration
Minimize any additional load on the cardiovascular system

36. Pregnant women with CD
Should be assessed clinically as soon as possible
A multidisciplinary team and appropriate investigations undertaken
The core members of the team should include:
Suitably experienced obstetricians
Cardiologists
Anaesthetists
Midwives
Neonatologists
Intensivists

37. Management of gestation period
Regular prenatal care
Early prevention of heart failure
adequate rest
appropriate weight limit
treatment the motivation of heart failure : infection, anemia,PIH
The treatment of heart failure
as same as those who are not pregnant

38. Mode of Delivery Vaginal delivery: Cesarean section:
cardiac function Ⅰ ~ Ⅱ grade
not a fetal macrosomia
cervical conditions are good
Cesarean section:
Marfan syndrome : expansion of the aortic root> 45 mm
use warfarin during delivery
sudden hemodynamic deterioration
severe pulmonary hypertension and severe aortic stenosis

39. Management in intrapratum
First stage of labor
Semi-recumbent position, oxygen masks, attention Bp, R, P, heart rate,
cedilanid : 0.4mg +5% GS20ml iv slow (when necessary)
antibiotics : during labor to 1 week after postpartum

40. Vaginal delivery Low-dose regional analgesia:usually recommended
providing effective pain relief
reduce the further increases in
cardiac output
myocardial oxygen demand
Be careful not to inhibit the neonatal breathing

41. Management in intrapratum
Second stage of labor:
episiotomy, facilitate instrumental delivery to shorten the stage
Third stage of labor:
Ergot disabled to prevent venous pressure increased
injection of morphine or pethidine immediately postpartum
abdominal pressure sandbags
control the liquid velocity

42. Management in puerperium
Monitoring heart rate, blood oxygen, blood pressure during delivery 24 hours
She could not breast-feeding
more than grade Ⅲ cardiac function
Prophylactic antibiotics
High-level maternal surveillance

43. Thanks four your listening