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PHYSIOLOGICAL CHANGES IN PREGNANCY Dr. Sreejith V CO In labor • Beginning of labor : > 7 L/min • Uterine contraction : > 9 L/Min • Anesthesia : < 8 L/min • Post partum CO continues to increase upto 72 hours due to auto transfusion from uterus and reabsorption of edema fluid • CO falls to non pregnant values in a few wks after delivery Effect of these changes in CVD • CCF In ventricular dysfunction • The tachycardia reduces the time for diastolic filling in MS, with resultant increase in left atrial pressure. • Mitral regurgitation, the afterload reduction helps offset the volume load on the left ventricle that gestation imposes. Pulmonary capillaries LV dilation / hypertrophy Tricuspid Aortic stenosis Pulmonic Mitral Aortic stenosis at rest Cardiac output not sufficient to cause critically high LV intracavitary pressure / LV failure. Resistance arterioles Pulmonary capillaries (edema) LV failure / ischemia Tricuspid Aortic Stenosis Pulmonic Mitral Aortic stenosis with increased cardiac output / arteriolar vasodilation: Decreased SVR Fall in systemic BP and / or increase in LV intracavitary pressure ischemia or LV failure. Resistance arterioles– decreased SVR CO Variation with position Clinical Findings in Normal Pregnancy Elevated JVP [↑plasma vol] ↓B.S. at lung bases S1 Loud S2 wide split , accentuated [P2 delayed] S3 Flow murm @ aortic, pulm; ESM cervical venous hum, mammary souffle Apex slightly left & up , prominent impulse Pedal oedema : ↑ plasma vol & venous pressures Tachycardia low DBP PP ↑ [bounding pulses] Investiga Comments tion ECG •Tachycardia •LAD [ elev. Diaphragm] •Increased ventricular voltage •Increased Atrial & Ventricular ectopics •Q wave and inverted T in lead III, an attenuated Q wave in lead AVF, and inverted T in leads V1, V2, and, occasionally,V3 CXR •CE •Horizontal shift of heart •Fullness of Left cardiac border & pulmonary vasc Echo •LV mass increased, LVED increased, RV & both Atrial enlarges •Increased LVOT & RVOT velocities •[gradients less reliable marker of stenotic severity, 2D valve area best] •Pros. Valve- valve gradients, PHT serial changes to be measured •Systolic function increases first but may decrease in the last Hypercoagulable state … • Series of haemostatic changes, • • • • Increase in concentration of coagulation factors Platelet adhesivenes Diminished fibrinolysis Hypercoagulability and an increased risk of thrombo-embolic events. • Obstruction to venous return by the enlarging uterus Drug clearance • Increased intravascular blood volume • Higher dosages of drugs required to achieve therapeutic plasma concentrations, • Increase drug clearance • Raised renal perfusion • Higher hepatic metabolism CONGENITAL HEART DISEASES COMPLICATING PREGNANCY WHO CLASS IV RISK • PAH • Sev. Ventricular dysfunction (LVEF <30%, NYHA III - IV) • Sev. MS • sev. symptomatic AS • Marfan syndrome : Aorta >45 mm • BAV : Aorta > 50 mm • Severe coarctation Statistics • Hypertensive disorders : 6–8% • Congenital heart disease –western world • Rheumatic valvular disease in non-western • Leading causes of maternal death are acquired disease, • Myocardial infarction, • Aortic dissection, • Cardiomyopathy Cardiac evaluation • • • • • • Measure the bp, in left lateral recumbency Proteinuria Oximetry BNP < 100 pg/mL - negative predictive value ECG ECHO • Murmur and Dyspnoe • Flow velocities increased • TEE-safe • TMT• • • • • Pre pregnancy Safe in pregnancy also To assess the functional class, and saturation <70% of predicted functional aerobic capacity Cycle Radiological investigation • There is no evidence of an increased fetal risk at doses of radiation of 50 mGy • There may be a small increase in risk of childhood cancer. • (1:2000 vs. 1:3000) MRI • Useful to image Ao • Avoid gadolinium • Should be used in all patient s suspected of ascending Ao Enlargement Fetal Genetic Risk • The recurrence risk varies between 3% and 50% • Autosomal dominant Disoders - risk of 50%, • Marfan syndrome, • Hypertrophic cardiomyopathy • long QT syndrome • General Population 1% Screening • Genetic screening – • chorionic villous biopsy can be offered in the 12th week • Fetal echocardiography • 19th to 22nd week • Nuchal fold thickness • • • • • 12th to 13th week For women over 35 years of age. The sensitivity for the presence of a significant heart defect is 40%, The specificity of the method is 99%. The incidence of congenital heart disease with normal nuchal fold thickness is 1/1000 General Principles of Obstetric care Antenatal Follow up • Ranging from routine follow up to continuous hospital admission • Preferably in Tertiary care centre with cardiac and cardiac surgical facilities • Clinical examination and follow up echo • Saturation Induction of Labor • Oxytocin and artificial rupture of the membranes are indicated when the Bishop score is favourable. • A long induction time should be avoided if the cervix is unfavourable. • Misoprostol or dinoprostone- there is a theoretical risk of coronary vasospasm and a low risk of arrhythmias. • Dinoprostone also has more profound effects onBP than prostaglandin E1 and is therefore contraindicated in active CVD. Vaginal or caesarean delivery • The preferred mode of delivery is vaginal • Caesarean delivery should be considered for obstetric indications • Cardiac Indications• • • • • • Dilatation of the ascending aorta >45 mm, Severe aortic stenosis, Pre-term labor while on oral anticoagulants Eisenmenger syndrome, Severe OR worsening heart failure Mechanical prosthesis Labor • Once in labor, the woman should be placed in a lateral decubitus position to attenuate the haemodynamic impact of uterine contractions. • Avoid maternal pushing, to avoid the unwanted effects of the Valsalva • Delivery may be assisted by low forceps or vacuum extraction. • Continuous electronic fetal heart rate monitoring is recommended. Anaesthesia • Lumbar epidural analgesia is recommendable to reduce pain • Regional anaesthesia can cause systemic hypotension and must be used with caution in patients with obstructive valve lesions. IE prophylaxis • Not recommended Post-partum care • Slow i.v. infusion of oxytocin • Prostaglandin F analogues to treat post-partum haemorrhage • Methylergonovine is contraindicated because of the risk of vasoconstriction and hypertension. • Meticulous leg care, elastic support stockings, and early ambulation are important to reduce the risk of thromboembolism Contraception • Barrier methods (condom) • The levonorgestrel releasing intrauterine device • The safest and most effective • 5% of patients experience vasovagal reactions at the time of implant • Progesterone only pills or dermal implants • Highly complex heart disease • (e.g. Fontan, Eisenmenger) • A copper intrauterine device is acceptable in noncyanotic or mildly cyanotic women. Percutaneous therapy • After 4th month in 2nd trimester • By this time • Organogenesis is complete • The fetal thyroid is inactive • Uterus size small Cardiac surgery with cardiopulmonary bypass • b/w 20th & 28th wk • 1st trimester : high risk of fetal malformations • 3rd trimester : high incidence of preterm delivery & maternal complications • Maternal complications are comparable to non-pregnant Cardiac problems Predictors of cardiac events • Prior cardiac event • • • • Heart failure Transient ischemic attack Stroke Arrhythmia • (NYHA) class higher than class II • Cyanosis • Left-sided heart obstruction • MVA < 2 cm2 • AVA < 1.5 cm2, • EF < 40% • Mechanical valve Predictors of Cardiovascular Events during Pregnancy • • • • NYHA class III / IV or cyanosis Previous cardiovascular event Left heart obstruction Ejection fraction ≤0.40 • No. of points 0 1 >1 % Adverse Events 4-12 27-30 62-100 Specific lesions Cyanosis • Fetal and maternal hypoxia • Increased thromboembolism • Increased right to left shunt • Worsening desaturation • Paradoxical embolism Cyanosis managment • Restriction of physical activity • Monitoring oxygen saturation • Supplemental oxygen • Prevention of venous stasis • Use of compression stockings • Avoiding the supine position • For prolonged bed rest, prophylactic heparin administration Pulmonary hypertension • When the pulmonary hypertension exceeds approximately 60% of systemic levels, more likely to be associated with complications. • Pulmonary hypertensive crises • Pulmonary thrombosis • Refractory right heart failure. • Occurs even in patients with little or no disability before or during pregnancy. • Maternal death –in the last trimester and in the first months after delivery Pulmonary hypertension • Maintain circulating volume, • Avoid systemic hypotension, • Avoid hypoxia, and acidosis which may precipitate refractory heart failure. • Supplemental oxygen - if there is hypoxaemia. • Prostacyclin or aerosolized iloprost , sildenafil, NO • Continuation of existing therapy • Teratogenic effects of bosentan. Eisenmenger • Pulmonary hypertension with cyanosis • With a live birth unlikely if oxygen saturation is ,85%. • Maternal death as high as 50% Eisenmenger • The risks and benefits of anticoagulation considered on an individual patient basis. • Diuretics • The lowest effective dose • Avoid haemoconcentration • Intravascular volume depletion. • Microcytosis and iron deficiency • frequently seen • Supplemental iron. ASD • Common L to R shunt complicating pregnancy • Prognosis • Pulm hypertension • Functional status • Size of shunt • Even large shunts are well tolerated if Pul. resistance < 3.0 WU • Prior closure make pregnancy safer Ventricular septal defect • Depends on the severity of PH • Functional status • LV dimentions • Small VSD- CLASS I • Pre-eclampsia may occur more often than in the normal population • Vaginal delivery Atrioventricular septal defect • Arrhythmias • Worsening of NYHA class • Worsening of AV valve regurgitation • PAH • Cyanosis • Paradoxical embolization • Offspring mortality due to the occurrence of complex congenital heart disease • Ostium primum ASD may be well tolerated Pulmonary valve stenosis • Relatively well tolerated if the right ventricular pressure is less than 70% of systemic pressure • Right ventricular failure • Arrhythmias. • Balloon valvuloplasty if PG>64 • CS- severe PS and in NYHA class III/IV despite OMT Tetralogy of Fallot • Pre repair • Arrhythmias , heart failure , thrombo-embolism • Progressive aortic root dilatation, • Endocarditis • Post repair • Palliation – depends on the degree of cyanosis • Dysfunction of the right ventricle • Moderate to severe pulmonary regurgitation • Screening for 22q11 deletion - % Pulmonary regurgitation • Severe pulmonary regurgitation • An independent predictor of maternal complication • Bad outcome in patients with impaired ventricular fn.. • Pulmonary valve replacement • Pre -pregnancy • Preferably bioprosthesis • TPVI – for refractory heart failure Ebstein’s anomaly • Outcome depend on • • • • The severity of the TR The functional capacity of the right ventricle Cyanosis Previous cardiac event • Usually be managed medically during pregnancy. • Echocardiographic surveillance of RV function • Early caesarean delivery If RV function deteriorates Transposition of the great arteries • Post operative- WHO risk class III. • Atrial repair • Atrial arrhythmia • Severe impairment of RV function • Great arterial repair • Obstruction • Regurgitation • Bradycardia or junctional rhythm - b-blockers cautious • An irreversible decline in RV function in 10% Congenitally corrected transposition of the great arteries • WHO risk class III . • Pre -disposed to developing AV block • B-blockers must be used with extreme caution. • An irreversible decline in RV function has been described in 10% • Class 4 • NYHA III or IV, • EF < 40% • severe TR Fontan circulation • Successful pregnancy is possible in selected patients with intensive monitoring - class III • Class 4 • Patients with oxygen saturation ,85% at rest, • Depressed ventricular function, and/or moderate to severe AV regurgitation • Protein-losing enteropathy Aortic Stenosis • Severe AS – CI • Bicuspid aortic valve - imaging of the ascending aorta before pregnancy, • CS Coarctation of the aorta • Repaired • Restenosis • Site rupture • Unrepaired • • • • • Hypertension Risk of aortic rupture Rupture of a cerebral aneurysm PIH Associated bicuspid aortic valve- aortic dilation Coarctation of the aorta • Close surveillance of BP • Avoid aggressive treatment to prevent placental hypoperfusion. • PCI is associated with a higher risk of aortic dissection • Should only be performed if severe hypertension persists despite maximal medical therapy and there is maternal or fetal compromise. • The use of covered stents may lower the risk of dissection. Aortic dilation • Marfan syndrome • Ehlers–Danlos syndrome • Bicuspid aortic valve • Turner syndrome • Annuloaortic ectasia • Tetralogy of Fallot • Aortic coarctation • Hyperrtension, Atherosclerosis Aortic dilation • Increased the susceptibility to dissection • Haemodynamic changes • Hormonal changes which lead to histological changes in the aorta • Dissection timing • Last trimester of pregnancy (50%) • The early postpartum period (33%) • The diagnosis of aortic dissection should be considered in all patients with chest pain during pregnancy as this diagnosis is often missed. Marfan syndrome, Bicuspid aortic valve • Factors for dissection • Family history of dissection, • Rapid growth • Following elective aortic root replacement, patients remain at risk for dissection in the residual aorta. • 50% of the patients with a bicuspid aortic valve and AS have dilatation of the ascending aorta • Associated Mitral regurgitation Ehlers–Danlos syndrome type 4 • Increased bruising • Hernias • Varicosities • Rupture of large vessels • Rupture of the uterus. • Contraindication for pregnancy Management of aortic complicaltions • Monitoring by echocardiography at 4–12 week intervals throughout the pregnancy and 6 months post-partum • b-blockers in patients with Marfan syndrome • Celiprolol - Ehlers–Danlos syndrome type IV • Fetal growth should be monitored when the mother is taking b-blockers. Surgery • Marfan syndrome - pre-pregnancy surgery is recommended when the ascending aorta is ≥45 mm, • Bicuspid AV - pre-pregnancy surgery should be considered when the ascending aorta is ≥50 mm. • If progressive dilatation occurs during pregnancy, before the fetus is viable, aortic repair with the fetus in utero should be considered. • When the fetus is viable, caesarean delivery followed directly by aortic surgery is recommended Mode of delivery • CS should be considered when the aortic diameter exceeds 45 mm • If 40– 45 mm, vaginal delivery with expedited second stage and regional anaesthesia is advised to prevent BP peaks, which may induce dissection. • Caesarean delivery may also be considered in patients with Ao 40-45, based on the individual situation. Hypertrophic cardiomyopathy • Frequently diagnosed for the first time in pregnancy by echocardiography. • Intermittent high catecholamine state of pregnancy ↑ LVOT obstruction • Epidural anaesthesia causes systemic vasodilation and hypotension in severe LVOTO • Fluids must be given judiciously and volume overload must be avoided • The implantation of an ICD should be considered in patients with high risk factors for sudden cardiac death • All other management is the same, except for amiodarone for rhythm control • Atenolol - class d Take home message • Hemodynamic of pregnancy • Normal abnormal cardiac findings • WHO class • Risk prediction • Basic principles of obstetric care • Common congenital cardiac problems QUESTIONS • Aortic diameter in Marfan syndrome above which pregnancy contraindicated • Normal increase in cardiac output • Risk of aotic rupture is maximum at which trimester • Safe limit of radiation exposure to foetus • Risk of fetus having congenital heart disease in general population • Only proven risk to fetus if exposed to low dose radiation is • Saturation below which pregnancy contraindicated • Beta blocker which is not class c Thank you