Download Cardiovascular disease in Pregnancy

Medical Disease in Pregnancy
Cardiovascular Disease
Cullen Archer, MD
Department of Obstetrics and Gynecology
Physiologic change in Pregnancy
• Cardiac output increases 30-35% during
pregnancy
• HR rises steadily throughout pregnancy
• Although elevated in pregnancy, SV
falls near term
• Architecture of heart is remodeled to
allow increased contractility
Physiologic change in Pregnancy
• Blood volume increases by 40%
• Afterload is decreased by early
vasodilation
• Colloid osmotic pressure is decreased
by 18% near term
• Promotes Na/H2O retention
• Increases plasma volume
Peripartum Physiology
• Baseline cardiac output increases 13%
by 8 cm. dilatation
• Largely due to increased SV
• Uterine contractions return ~ 500cc of
blood to the systemic circulation
• Increases preload and augments cardiac
output by 34% above pre-labor baseline
Postpartum physiology
• Within hours of delivery, marked
diuresis begins
• Fluid is mobilized from the expanded
extravascular space
• Intravascular space contracts
• By 2 weeks postpartum, cardiac output
falls 26% and is only 10% above values
measured at 24 weeks
Atrial Septal Defects
• Usually asymptomatic
• Large ASDs can be associated with
pulmonary HTN and L to R shunting
Ventricular Septal Defects
• Large unrestrictive VSDs permit
equalization of right and left pressures
• Eisenmenger’s syndrome
Congenital Aortic Stenosis
• Outflow obstruction
• Antepartum
• Peripartum
Pulmonic valve stenosis
• Usually tolerated well
• Severely stenotic valves
• Cautious use of IVF
• Shorten second stage
• Preconception counseling
Coarctation
• Usually post-ductal obstruction
• Symptoms related to hypertension
proximal to obstruction and
hypoperfusion distal to obstruction
• In pregnancy, risks are associated with
dissection and rupture
• MMR 3-4%
Uncorrected TOF
• Exacerbation of shunt
• Morbidity and mortality are associated
with pregnancy related decline in SVR
and peripartum blood loss
• MMR 4-15%
Eisenmenger’s syndrome
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Exacerbation of shunt
Progressive hypoxemia
Avoid sudden drops in SVR
MMR 30-70%
Advise against pregnancy or offer
termination
Mitral Stenosis
• Leading cause of cardiac maternal
mortality
• Elevated LA pressure  pulmonary
edema and pulmonary HTN
Mitral Regurgitation
• Usually a result of rheumatic fever
• Decreased peripheral vascular
resistance should decrease the amount
of MR and assist a poorly functioning
ventricle
• Severe MR with ventricular dysfunction
increases MMR as high as 5-10%
Aortic Regurgitation
• Rarely complicates pregnancy unless
LV systolic function is significantly
depressed
Peripartum cardiomyopathy
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Incidence 1/15,000 to 1/1300 live births
Etiology unknown
50% have return to normal function
Suspect when women present with CHF
after 36 weeks
Primary pulmonary hypertension
• Pregnancy contraindicated with severe
disease
• TTE vs. cardiac cath
• Treatments
• Peripartum considerations
Preeclampsia
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Hypertensive disorder of pregnancy
Newly onset after 20 weeks gestation
Proteinuria
Risk factors
HELLP Syndrome
• Definition
• Complications