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By PROF.

AZRA SAEED AWAN PROF OBG UNIT II IIMC RAILWAY HOSPITAL RAWALPINDI

Incidence 3 3.5 % 3rd most common non-obst cause of maternal death Maternal mortality 0.5 % Most women with cardiac abnormality do well if they are asymptomatic or only mildly symptomatic before preg.

In addition to gestational HTN,previously healthy women may develop life threatening complication of cardiomyopathy, MI & Thromboembolism, Particularly in the peripartum & post partum period.

Cardiac output Stroke vol Heart rate BP Central Venous Pressure Pul. Capillary Wedge pressure Systemic vascular resistance

40 %

10-20 bpm

1st & 2nd Trimester

25 30 %

Pulmonary vascular 25 30 % resistance Serum colloid 10 15 % osmotic pressure Mean arterial 15 mmHg pressure

Heart rate,BP & cardiac output are influenced by anxiety & pain, posture, analgesia & anesthesia & mode of delivery Rise in stroke vol with each contraction is attenuated by good pain relief & further reduced by epidural analgesia & supine position. G/A is associated with a rise in BP & heart rate

One litre of blood may be return to circulation if there is no postpartum loss.


All the changes revert rapidly during the first week & more slowly over the following six weeks but even at a year significance changes still persist and a enhance by a subsequent preg

Venous dilation & increase blood flow Venous pressure rises upto 5 cm Blood pressure is reduce First heart sound - loud Second heart sound splitting Physiological third heart sound Systolic ejection murmur Venous hums & mammary souffles

Axis shift superiorly in late preg T Wave inversion in the right precordial

Enables any suspected cardiac abnormality to be recognized

ECOCARDIOGRAPHY

Class I No breathlessness / Uncompromise Class II Breathlessness on severe Class III exertion/ slightly compromised Breathlessness on mild Class IV exertion/moderately compromised Breathlessness at rest/severe compromised

Congenital

Acquired

Cardiomyopathy

Cynotic

Acynotic

PRENATAL

MATERNAL SURVILLANCE

Detail Hx &Ex Regular cardiology consultation /echocardiography Assess functional class of heart dis (NYHA) Routinely examine every wk / visit B.P, pulse, chest, cough, sore thoart, dental caries, wt gain.

Cyanotic heart disease DCM with CCF Pulmonary HTN Marfan syndrome Heart lung transplant IHD with persistent Angina or CCF

Restrict physical activity / adequate rest / avoid undue strain or stress especially in late preg Iron &Folic acid supplementation-treat anaemia vigorously Competent dental care and oral hygiene mandatory /tooth extraction covered with antibiotic Prompt T/M of respiratory infection

Avoid diuretic & do not restrict sodium Avoid supine position & abdominal compression Elastic stocking / tights (Prosthetic valve, Cardiomyopathy, Fallot,& Eisenmenger) Hospital admission if
Any deterioration of condition Acute complication Few days before term for rest & assessment

Avoid complete immobilization (danger of venous thrombosis) IOL for obstetric indication FETAL SURVILLANCE
IUGR Congenital anomaly scan 18-20 wks Fetal echo 20-22 wks Fetal growth charting charting & umbilical artery Doppler wkly after 32 wks if IUGR suspected then earlier 24 wks monthly size

IST STAGE OF LABOUR


Prop up Left lateral position Oxygen administration intermittently or continuously if any dyspnoea or cyanosis Restrict I/V fluid /prevent dehydration Oxytocin with extreme caution
Cardiomyopathy Fallot Eisenmenger S

Endocarditis prophylaxis

Prosthetic valve / bioprosthetic homograft Previous SBE Surgically corrected systemic-pulmonary shunts HCM / Cardiomyopathy Structural heart defect except repaired PDA, MV prolapse without regurgitation, ASD ,>6 months after Repair of VSD & ligation of PDA AMOXYCILLIN 1 GM I/V OR I/M PLUS GENTAMYCIN 120MG I/V OR I/M at the onset of labour or rupture of membrane Allergy to PENCILLIN then ERYTHROMYCIN / VANCOMYCIN 1GM and if RFTS derranged then KENAMYCIN

Adequate analgesia
Morphine derivatives Moderately / severe disease EPIDURAL ANAESTHESIA

CTG 2 hrly with intermittent fetal heart ascultation

Do not allow forceful bearing down for more than a few contraction Routine prophylactic instrumental delivery unnecessary C-SEC for obst. Indication with low threshold in dysfunctional labour under epidural or spinal anaesthesia preferably by experienced anaesthetic

Regional small serial boluses G / A Benzodiazepine & Narcotics Inhaled only low dose
NO EPIDURAL ANAESTHESIA IN EISENMENGER SYNDROME

Use I/V bolous inj syntocinon 5 units or infusion (careful in CCF ) ERGOMETRINE I/V OR I/M IS CONTRAINDICATED

Counsel for contraception (6 wk postpartum). Encourage to limit family size with optimal sparing.
Sterilization Oral contraception POP Barrier Contraception IUCD is no preferred

Reassess cardiac status after 6 wks

Off these, 70% are familial with autosomal dominant inheritance. CLINICAL FEATURES Chest pain or syncope, caused by left ventricular outflow tract obstruction Double apical pulsation(palpable fourth heart sound) Ejection systolic murmur (left ventricular outflow obstruction) Pan-systolic murmur (mirtal regurgitaion) Arrhythmias Heart failure.

Some women may be asymptomatic, the diagnosis having been made because of screening following a diagnosis of HOCM in a first-degree relative or echocardiography to investigate a heart murmur detected in pregnancy. Effect of pregnancy on HOCM Mostly well tolerated in pregnancy and the stroke volume is usually able to increase. B-blockers should be continued or started in pregnancy for those women with symptoms. Epidural anaesthesia/analgesia carries the risk of hypotension with consequent increased left ventricular outflow tract obstruction. Any hypovolaemia will have the same effect and should be rapidly and adequately

This rare condition is specific to preg.It is defined as the development of heart failure in the absence of a known cause and without any heart disease prior to the last month of pregnancy.Onset is usually in the first month after delivery,but may occur in the last month of pregnancy and up to 5 months postparlum. Risk factors include: Multiple pregnancy Preg complicated by hypertension Multiparity Advanced maternal age Afro-Caribbean race.

Dyspnoea Reduced exercise tolerance Palpitations Pulmonary and/or peripheral oedema Symptoms relating to peripheral or cerebral emboli. Signs Tachycardia Pulmonary oedema Congestive cardiac failure Dysrhythmias Signs of pulmonary,carebral and systemic embolisation Systemic embolism occurs in 21-40% of those affected by peri-partum cardiomyopathy, and ischaemic stroke in about 5%

Unknown Myocarditis Autoantibodies Diagnosis Requires ECHO Diagnostic Criteria are

Left vent ejection fraction <45% Farctional shortening <30% ECHO shows the heart is enlarged with global dilation of all four chambers and markedly reduced left vent function.

Thromboprophylaxis Mandatory if Severly impaired left vent dysfunction Intracardiac thrombus Arrhythmias T/ M for heart failure Diuretics,vasodilators, digoxin, inotropes & after delevery ACE inhibitors Immunosupprissive Therapy Myocarditis documented by endomyocardial biopsy Myocarditis fail to improve with in to 2 wks of initiation of standard heart failure therapy Cardiac Transplantation Severe cases unresponsive to conventional and full supportive management Elective Delevery If diagnosed antenataly

Maternal mortality rate-25-50% About 50% pts make a spontaneous & full recovery Prognosis depends on normalisation of left vent size and function with in 6 months after delivery.Mortality is increased with persistent left vent dysfunction Women should be counselled against further preg if left vent size or function does not return to normal because of recurrence therefore, puerperial cardiomyopathy should not be casually diagnose and should be supported by echocardiography at least. For those whose cardiomyopathy resolves, the recurrence is not non (0-25%) Subsequent preg require high risk collaborative care.

Anticoagulation through preg The interests of the mother & fetus are in conflict.Continuation of Warfarin affords the mother the risk of thrombosis, where for the fetus, WARFARIN IS ASSOCIATED WITH INCREASE RISK OF Teratogenesis, Miscarriage, Stillbirth & intracerebral bleeding. LMWH is safe The choice of anticoagulant regimen will depend on Position of prothesis Types of valve replacement Pt choice Counselling thoroughly prior to preg regarding potential risk to herself and her fetus

WARFERIN should discontinue for 10 days to 2 wks prior to delivery to allow clerance of warfarin by fetus. While awaiting delivery , full anticoagulant doses of either s.c heparin or LMWH or I/V heparin should be used S.C heparin should be discontinued for labour & delivery.Dose of I/V is reduced to prophylatic level1000 units / hr

WARFERIN throughout preg HEPARIN b/ t 6 & 12 wks gestation followed by WARFARIN HEPARIN throughout

Full anticoagulant doses of heparin should be resumed a/f delivery Warfarin may be restarted 3 5 days following de\livery In the event of an urgent need to deliver a fully anticoagulated pt, Warfarin may be reversed with FFP & vit K, & heparin and LMWH with PROTAMINE SULPHATE

Pulm oedema & heart failure-Diuretic Tachycardia Beta Blocker Atrial fibrillation Digoxin &B-blocker SURGERY

Ballon valvectomy &Closed mitral valvotomy Surgical valvectomy-risk with fetal mortalityrates 515% for close & open 15-33%

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