Download Congenital heart disease

Congenital heart disease
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(CHD) found in pregnancy are
Atrial aseptal defect (ASD),
ventricular septal defect (VSD)
patent ductus arteriosus (PDA)
pulmonary stenosis
aortic stenosis
an tetralogy of Fallot.
• The majority of these lesions should have
been surgically corrected in childhood
• resulting in a growing population of
women with CHD achieving a pregnancy.
Uncorrected lesions may cause "
• pulmonary hypertension,
• cyanosis
• severe left ventricular failure and are therefore
present a greater risk in achieving successful
pregnancy outcome.
• Congenital heart disease is also associated with
increased fetal complications such as fetal loss,
IUGR, pre-term birth and an increased risk of
fetal CHD
• Particularly high-risk cardiac conditions for
pregnancy include the following.
Eisenmenger's syndrome
• -A large leh–right shunt of blood is apparent usually
through a VSD, ASD or PDA, which is still patent.
• -This results in an increase in the pulmonary blood flow,
which over time leads to fibrosis and the development of
pulmonary hypertension and cyanosis . When the rightsided heart pressures exceed leh heart pressures, the
shunt reverses, with worsening cyanosis.
• Women with this condition are advised against
pregnancy as maternal mortality lies in the region of 30–
50%. Risk of prematurity contributes to the high perinatal
mortality rate.
Marfan syndrome
• -This syndrome is caused by an autosomal dominant
defect on chromosome 15.
• - It is a connective tissue disease affecting the
musculoskeletal system, the cardiovascular system and
eyes. The cardiovascular abnormalities are the most lifethreatening as the elastic fibres in the media of the blood
vessels weaken.
• - Dilatation of the ascending and descending aorta
results, followed in some instances by dissection or
rupture, or both.
• - Pregnancy poses a significant risk because of the
increased stress on the cardiovascular system.
• -There is a 50% chance of a child inheriting Marfan syndrome if one
parent is affected.
• - Women who have minimal cardiovascular involvement and normal
aortic root dimensions have a befer pregnancy outcome.
• - Careful monitoring is required throughout pregnancy, including the
use of serial echocardiography to identify progressive aortic root
dilatation.
• -Prophylactic antihypertensive therapy using beta-blockers is
recommended to reduce blood pressure and the rate of aortic
dilatation Robe. Some individuals with Marfan syndrome also
present with dural ectasia which, unless mild, presents an increased
risk of a spinal cerebrospinal fluid (CSF) leak in the case of
accidental dural puncture during epidural:
• - consequently, epidural anaesthesia is not
usually recommended.
• -Whilst Marfan syndrome is a genetic condition,
approximately 15% of cases are as a result of
new mutation and thus some individuals
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remain undiagnosed and do not seek any
preconception counselling.
• -Pregnant women with Marfan syndrome should
be referred to the specialist team containing a
cardiologist for immediate assessment and
investigation.
Aortic dissection (acute)
• may occur in pregnancy in association with
severe hypertension (systolic >160 mmHg) due
to pre-eclampsia, coarctation of the aorta or
connective tissue disease such as Marfan
syndrome.
• The woman typically presents with severe chest
or intrascapular pain.
• Early diagnosis using computed tomography
chest scan, MRI or transoesophageal
echocardiogram is critical, as maternal mortality
is high.
Acquired heart disease
-Rheumatic heart disease
• -inflammation and scarring of the heart
valves and results in valve stenosis, with
or without regurgitation.
• - The mitral valve is most ohen affected
with stenosis, occurring in two-thirds of
cases.
• This condition is ohen diagnosed for the
first time during pregnancy, presenting as
severe breathlessness and tiredness.
• -It tends to appear in immigrant or refugee
women who have not had access to
medical care.
• -Most women with valvular heart disease can be
treated medically, aiming to reduce the heart's
workload.
• -During pregnancy, this involves:
• - bed rest
• -oxygen therapy
• - use of cardiac drugs,
• e.g. diuretics (to reduce the fluid load)
• digoxin (to reduce and regulate the heart rate)
• heparin (to reduce the risk of thromboembolic
disease).
• Women with more severe symptomatic disease
may require surgical intervention such as
balloon valvuloplasty or valve replacement,
• although both of these procedures carry a
degree of maternal and fetal mortality.
• Antibiotic prophylaxis is no longer recommended
for all women with valvular lesions during labour
although it may still be advisable for those who
have mechanical valves.
Myocardial infarction and ischaemic heart
disease
• -Myocardial infarction (MI) and ischaemic heart
disease (IHD) are an increasing cause of
maternal death .
• - Identifiable risk factors include:
• - increasing maternal age
• -obesity
• - diabetes
• -pre-existing hypertension
• - smoking, family history
• -poor socioeconomic status.
• A myocardial infarction is most likely to occur in
the third trimester of pregnancy and the
peripartum period,
• - when haemodynamic changes are at their
optimum creating a higher risk of thrombotic
events due to the hypercoagulability induced by
hormonal changes.
• - In the immediate postpartum period,
spontaneous coronary artery dissection is the
most common cause of MI.
• - Typically, women present with ischaemic chest
pain in the presence of an abnormal ECG and
elevated cardiac enzymes, although these signs
and symptoms may be masked during labour
and birth
• -Atypical features include abdominal or
epigastric pain and vomiting.
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Coronary angioplasty is the fine line therapy to
improve the patency of blocked arteries
Peripartum cardiomyopathy
• -Peripartum cardiomyopathy is relatively rare but
is potentially fatal, with mortality rates ranging
from 25% to 50%. A number of these deaths
occur shortly aher the onset of signs and
symptoms.
• - The incidence of this type of cardiac disease
varies from 1 : 300 to 1 : 4000 pregnancies, with
heart failure developing very rapidly in some
cases.
• -Predisposing factors to peripartum
cardiomyopathy comprise of :
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-multigravidae
- multiple pregnancies
- family history
- ethnicity
-smoking
- diabetes
-hypertension
-pre-eclampsia
-malnutrition
- pregnant teenagers or older pregnant women and
prolonged use of beta-agonists
• -Commonly women have no previous history of heart
disease and diagnosis is usually made within a specific
period of time between the last month of pregnancy and
the first 5 months postpartum
• -Inflammation and enlargement of the myocardium
(cardiomegaly) give rise to leh ventricular heart failure
and thromboembolic complications.
• - Presenting features include orthopnoea and dyspnoea,
chest pain and palpitations, new resurgent murmurs and
pulmonary crackles, raised jugular pressure, ankle
oedema and fatigue.
• -Treatment involves the use of oxygen, diuretics, and vasodilators to
decrease pulmonary congestion and fluid overload, followed by
inotropic agents to improve myometrial contractility and
anticoagulation therapy.
• As the cardiomegaly resolves there should
be a corresponding improvement in the
woman's condition but this process may
take up to 6 months and there is a risk of
recurrence in a subsequent pregnancy.
• -In some women, leh ventricular
dysfunction persists and unless a heart
transplant is performed mortality can be
high