Download Physiological Changes 1

Cardiac Disease
in Pregnancy
Physiological Changes
in the Cardiovascular System
During Pregnancy
• A thorough knowledge
– essential
• In order to understand
– the additional impact of cardiac disease
Physiological Changes 1
• The first cardiovascular change
associated with pregnancy
• Peripheral vasodilation (induced by
progesterone)
•
leading to
• A decrease in systemic vascular
resistance
Physiological Changes 2
•
•
•
•
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
Physiological Changes 3
• Labour leads to further increases in
cardiac output
• In the first stage: 15%
• In the second stage: 50%
– abdominal pressure plummeted
– pain and anxiety : sympathetic
stimulation
– pulmonary artery pressure increased
– blood back into the circulation with each
uterine contraction: 300-500 ml
Physiological Changes 4
• After delivery, cardiac output increases
again immediately : 60-80%
–
–
–
–
sudden interruption of placental circulation
uterine contraction
relief of caval compression
within 1 h: rapid decline to pre-labour values
• Puerperium:
– uterine contractions
– retented Interstitial fluid returned to circulation
– return to normal after 2 weeks
Physiological Changes 5
• The greatest change period in
systemic blood circulation and heart
burden
– 32 to 34 weeks
– Intrapartum
– 3 days postpartum
• Easily induced heart failure
Table 1 -- Normal Hemodynamic Changes During Pregnancy
Hemodynamic
Parameter
Blood volume
Change During
Normal Pregnancy
↑ 40-50%
Change during
labor and delivery
↑
Change during
postpartum
↓ (autodiuresis)
Heart rate
↑ 10-15 beats/min
↑
↓
Cardiac output
↑ 30-50 %
↑ additional 50%
↓
Blood pressure
↓ 10 mm Hg
↑
↓
Stroke volume
↑ 1st and 2nd
trimester;
↓ 3rd trimester
↑ (300-500 mL per
contraction)
↓
Systemic
vascular
resistance
↓
↑
↓
Types of CD during pregnancy
• Congenital heart disease
• Rheumatic heart disease
• Hypertensive disorders in pregnancy
heart disease
• Peripartum cardiomyopathy
• Other
• Left → right shunt
• ① atrial septal
defect
• ② ventricular septal
defect
• ③ patent ductus
arteriosus
Congenital heart
disease
• No shunt
① pulmonary
artery stenosis
② coarctation of
the aorta
③ Marfan
syndrome
• right → Left shunt:
• Tetralogy of Fallot 、
Eisenmenger's syndrome
Rheumatic heart disease
Mitral stenosis:
1Blood volume (during pregnancy)
2Blood volume back to the heart
(intrapartum and early puerperium)
Pulmonary circulation volume
Left atrial pressure
Pulmonary venous hypertension
Acute pulmonary edema
• Mitral incompetence: isolated
• can tolerance pregnancy, delivery and
puerperium.
Rheumatic heart disease
• Aortic stenosis: severe
• Pulmonary edema
• Low discharge capacity heart failure
• Aortic incompetence : severe
• Left ventricular failure
• Bacterial endocarditis
HDIP heart disease
• No history of heart disease and signs
• Sudden onset of systemic failure
left ventricular failure
Peripheral small artery resistance increased
Myocardial ischemia, interstitial edema,
hemorrhage and necrosis spots
Blood viscosity increased to promote myocardial
ischemia
water, sodium retention
HDIP heart disease
• Misdiagnosed as the flu and
bronchitis
• Early diagnosis is important
• After eliminate the cause, most can
be restored
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
PPCM
• The exact etiology : unknown
• Possible causes
– infection, immunity, multiple pregnancy,
hypertension, malnutrition
– viral myocarditis
– automimmune phenomena
– specific genetic mutations
PPCM
• Symptoms
• Fatigue
• Dyspnea on exertion, orthopnea
• Nonspecific chest pain
• Abdominal discomfort and distension
• palpitations, cough, hemoptysis,
hepatomegaly, edema
• other heart failure symptoms
PPCM
•
•
•
•
Typical signs
Heart enlarged
Myocardial contractility reduce
Ejection function reduced
•
•
•
•
ECG:
Arrhythmias
left ventricular hypertrophy
ST segment and T wave abnormalities
CD main threat to pregnant
women
• Heart failure
• Subacute infective
endocarditis
• Hypoxia and cyanosis
• Venous thrombosis and
pulmonary embolism
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
0
1
>1
Maternal
cardiac
event rates
5%
27%
75%
Table3 Predictors of Maternal Risk for Cardiac Complications
Criteria
Example
Poin
ts*
Prior cardiac
events
heart failure, transient ischemic attack,
stroke before present pregnancy
1
Prior
arrhythmia
symptomatic sustained tachyarrhythmia or 1
bradyarrhythmia requiring treatment
NYHA III/IV
or cyanosis
1
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
1
Myocardial
dysfunction
LVEF <40% or restrictive cardiomyopathy
or hypertrophic cardiomyopathy
1
Maternal Cardiac Lesions and Risk
of Cardiac Complications
•
•
•
•
•
Low Risk
Atrial septal defect
little
Ventricular septal defect
Patent ductus arteriosus
Asymptomatic aortic stenosis with low
mean gradient (<50 mm Hg) and normal
LV function (>50%)
• Aortic regurgitation with normal LV
function and NYHA functional class I or II
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
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
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
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
The impact of CD in Fetal
• Premature birth
• Low birth weight
• Respiratory distress
• Fetal death
• Neonatal death
• Genetic heart disease
Diagnosis
• History:
• Palpitations, difficulty breathing
or heart failure
• Organic heart disease
• Rheumatic fever
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 and/or grade Ⅲ or rough
systolic murmur over the whole
– a pericardial friction rub, diastolic gallop,
alternating pulse
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
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
Management
• Before pregnancy:
– 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
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
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
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
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
Mode of Delivery
• Vaginal delivery:
– cardiac function Ⅰ ~ Ⅱ grade
– not a fetal macrosomia
– cervical conditions are good
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
Management in intrapratum
• 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
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
Mode of Delivery
• 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
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
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