Download Heart Disease in Pregnancy

Max Brinsmead MB BS PhD
May 2015
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In the UK this has increased over time
 Deaths in 1982 – 85
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in 2003 – 05
7.3 per million births
22.7 per million births
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Due mainly to increasing maternal age
and ↑ incidence of coronary artery disease
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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%
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Cardiomyopathy
33%
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Rheumatic heart disease
10%
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Congenital heart disease
10%
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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...
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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...
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ECG
Serum tropinins
CT or MRI
Angiography if required
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Unknown aetiology and no known risk factors
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25% will be associated with hypertension
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Sometimes due to viral myocarditis
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Can occur any time in the antenatal period and
up to 6 months postpartum
A patient who complains of increasing
dyspnoea
 Especially nocturnal orthopnoea
 Investigate by...
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▪ ECG
▪ CXR
▪ Echocardiography
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Mitral stenosis is the most common
And most serious
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But it is difficult to detect
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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
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Also a complication of Marfan’s Sydrome
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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
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Complete diagnostic work up
Multidisciplinary care
Patient education
Family Planning
 Contraception
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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
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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
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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 3rd stage
▪ The greatest risk of CCF is immediately postpartum
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Postpartum Care
▪ Consider thromboprophylaxis
 Family Planning
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The New York Heart Association (NYHA) Classification
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Class I
▪ No symptoms and no limitation to ordinary physical
activity
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Class II
▪ Mild symptoms (dyspnoea or angina) with slight limitation
to physical activity
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Class III
▪ Marked limitation of activity due to symptoms
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Class IV
▪ Symptoms at rest
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