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Introduction
It is rare, but potentially serious and complicates approximately 1 per cent of all pregnancy
Prevalence depends on the incidence of rheumatic heart disease and undiagnosed or uncorrected congenital heart disease
Rheumatic heart disease remains an important cause of heart disease In developing countries. Congenital heart disease accounts for approximately 50% of heart disease in pregnant women in the UK.
Acquired ishaemic heart disease is more common due to smoking amongst women
Maternal Risks
Pulmonary hypertension & mitral stenosis is most likely condition that restrict an increase in pulmonary blood flow. 40-50% maternal mortality rate amongst women with pulmonary hypertension & Eisenmengers syndrome In cases of Fallots tetralogy, the maternal mortality is much lower (5%) because there is no pulmonary hypertension Other causes of heart disease that can cause maternal morbidity are cardiomyopathy, rupture or dissection of aorta & ischaemic heart disease Infective endocarditis is rare since the use of antibiotics become routine
Fetal Risks
At risks of growth restriction & preterm delivery in pregnancies complicated by cyanotic congenital heart disease. Uncorrected coarctation of the aorta is associated with fetal growth restriction in > 40% of cases due to reduced placental perfusion The incidence of CHD in population is 0.08%. If a parent is affected, the risk increased to 5%. Therefore all pregnant women with CHD should be referred for expert fetal cardiology scanning
Pre-pregnancy Management
Contraceptive plan for certain cases Explain the maternal and fetal risks Need for frequent hospital attendance and possible admission Intensive maternal and fetal monitoring during labor Maternal echocardiography Treat current medical problems Optimize medical therapy Do surgical correction (for certain cases) before pregnancy
Cardiologist involvement
Counselling on Contraceptive
Pregnancy
is not recommended in these women and contraception is mandatory, especially until corrective surgery can be accomplished. Several uncorrected lesions (mortality of up to 25% to 50%)
Eisenmengers syndrome Primary pulmonary hypertension Cardiomyopathy Congestive heart failure Marfans syndrome with aortic involvement
Contraceptive Device
Contraindications
of using combined oral contraceptive in woman with heart diseases Contraindications of using IUCD in prosthetic valves and endocarditis. Effective alternatives
Surgical method (best option): vasectomy, tubectomy Implantable progesterone-only contraceptive Barrier method condom but higher failure rate
Antenatal Management
Managed
in joint obstetric/cardiac clinic Risk factor for the development of heart failure
Respiratory / urinary infections Anemia, obesity, hypertension, arrhythmias Pain-related stress, fluid overload
Anticoagulation
in pregnancy
Warfarin teratogenic in 1st trimester Essential in patient with pulmonary hypertension, artificial valve replacement and in/at risk of atrial fibrillation 3 options depend on degree of thrombotic risk womans choice
Anticoagulation therapy
1st
option :
2nd
option :
3rd
option
Medical history
Progressively worsening SOB Cough with frothy pink sputum Paroxysmal nocturnal dyspnea Chest pain with exertion Syncope preceded by palpitation on exertion Hemoptysis NYHA classifications Patient with heart disease
Family history
Class I : patients have no limitation of physical activity. Ordinary physical activity does not cause fatigue, palpitation, dyspnea or anginal pain.
Class II : patients have slight limitation of physical activity. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.
Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain
Class IV : Patients have inability to carry on any physical activity without discomfort symptom of cardiac insufficiency or anginal syndrome may be present, even at rest.
If any physical activity is undertaken, discomfort is increased
Physical examinations
Inspection
Clubbing, cyanosis, pallor Pectus excavatum, precordial bulge Sustained right/left ventricular heave
Palpation
Auscultation
Loud systolic murmur, any diastolic murmur Ejection clicks, late systolic clicks, opening snaps
Lab examinations
ECG
Chest
radiograph
Exercise
stress testing
Indicated for preconception work-up for estimation of myocardial reserve to determine if a woman can safely carry a pregnant to term
Risk Stratification
Low risk generally tolerate pregnancy well
Uncomplicated septal defect Pulmonary stenosis Aortic and mitral regurgitation Hypertropic cardiomyopathy Acyanotic ebstein anomaly Corrected transposition without other defects
Treatment of HF in Pregnancy
The principles of treatment are the same as in the non-pregnant women Drug therapy:
Diuretics Vasodilator Digoxin Oxygen and morphine Fetal ultrasound to assess fetal growth Regular cardiotocography Consider premature delivery if there is evidence of fetal compromise
PNC 1.2 U IM every 4 week PNC V 250 mg 12 hourly (preferable) Erythromycin 250 mg 12 hourly (for those sensitive to PNC)
Aim
Additional points
Avoid IOL if possible Use prophylactic antibiotic Ensure fluid balance Avoid supine position Keep 2nd stage short(forcep/ventouse) Use syntocinon
Asthma in Pregnancy
Definition
Asthma
is a chronic inflammatory disease that causing reversible bronchial airway obstruction. Most common respiratory disease encountered in pregnancy and affects 14% of women of child-bearing age. Pregnancy outcomes in women with asthma are usually good.
Pregnancy itself does not increase the frequency or severity of asthma in most women. Problems may occur if :
Poorly controlled asthma Not compliant to medication Told not to continue medication Failure of the clinicians to recognize the severity of the asthma
If the asthma is effectively treated and controlled no risk Severe asthma high risk
Nocturnal symptoms
Need for reliever Lung function (PEF/FEV1)
none
None (twice/less/wee k) normal
Any
>2x/week
Treatment in General
Main goal of therapy is to maintain normal or nearnormal maternal pulmonary function to : Allow adequate fetal oxygenation Prevent exacerbations Allow the patient to maintain her usual activities To improve asthma management by giving educational interventions : Learn the proper use of portable peak flow meter to objectively evaluate asthma severity Monitor the patient inhalation technique Avoidance of potential asthma trigger is extremely important Smoking cessation
Treatment (prenatal)
Current
therapy should continue in pregnancy. Educate and reassure mother the safety of the medication and warn the patient not to stop their treatment Usually well controlled with :
If
in severe exacerbation:
Hospital admission Bronchodilator Oxygen Steroid
Medication
to avoid :
Prostaglandin F2 bronchospasm. Use prostaglandin E2 , oxytocin. General anesthesia atelectasis, chest infection. Use epidural anesthesia. Ergometrine bronchospasm. Use syntocinon. Aspirin and NSAIDs (eg : indomethacin) severe bronchospasm and ocular, nasal, dermal, gastrointestinal inflammation
Treatment (intrapartum)
Adequate
control :
Adequate hydration status Pain relief as necessary Continuous O2 monitoring. O2 saturation >95% at all times If exacerbation neb hydrocort (hydrocortisone)
Treatment (post-partum)
Continue
usual therapy and follow-up Breastfeeding is not contraindicated Inhaled beta2 agonist, cromolyn sodium, steroids (inhaled), ipratropium safe while breast feeding. Systemic steroids may enter into breast milk but only in small amounts if the total daily dosage contains < 40 mg of prednisone
Fetal
IUGR Preterm birth Low birthweight Neonatal hypoxia Increased overall perinatal mortality
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