Cardiac disease in pre pr gnancy

Transcription

1 IN THE NAME OF GOD

2 Cardiac disease in pregn nancy

3 MITRAL STENOSIS 33 y/o G3L2(2c/s) GA CC: LP & dyspnea PMHx: MS sinse 4 yrs ago due to Rheumatism PSHx: 2c/s DHx: metoral 50 mg q6h/ ASA/ Enoxaparin 40 daily/ Penicillin monthly/diltiazem 30 mg bid

4 PR: 110 RR: 28 T: 37 BP:110/75 FHR: 145 V/E : 1f Heart : diastolic murmur 2/6 Lung: crackle Abd: FH : 34w/ contraction + /

5 Last sono: s/c/ post/ nl/ 33w (OK) Echo at 1th trimester: EF:60% / Rheumatismal MV with mod to severe MS (1.4cm2)/ mild to mod MR/ PTMC score:6-7/ No PS / No AS/ mild TR/ mild PI/ Top nl PH( spap=35) at rest / REC: therapeutic abortion versus PTMC in pregnancy and TEE just before PTMC ECG: sinus tachycardia

6 Diagnosis Pulmonary edema

7 PLAN Cardiologist consult: Lasix 20 mg stat & q6h C/S and TL CCU Finally Discharged with Metoral / Ferosemide/ ASA/ Enoxaparine daily

8 MS Rheumatic endocarditis causes most mitral stenosis lesions. The normal mitral valve surface area is 4.0 cm2, and when stenosis narrows this to < 2.5 cm2, symptoms usually develop. The most prominent complaint is dyspnea due to pulmonary venous hypertension and edema. Fatigue, palpitations, cough, and hemoptysis are also common. With more severe stenosis, the left atrium dilates, left atrial pressure is chronically elevated, and significant passive pulmonary hypertension develops.

9 These women have a relatively fixed cardiac output, and thus the increased preload of normal pregnancy, as well as other factors that increase cardiac output, may cause ventricular failure and pulmonary edema. A fourth of women with mitral stenosis have cardiac failure for the first time during pregnancy.

10 With significant stenosis, tachycardia shortens ventricular diastolic filling time and increases the mitral gradient. This raises left atrial as well as pulmonary venous and capillary pressures and may result in pulmonary edema. Thus, sinus tach hycardia is often treated prophylactically with β-blocking agents. Atrial tachyarrhythmias, including fibrillation, are common in mitral stenosis and are treated aggressively. Atrial fibrillation also predisposes to mural thrombus formation and cerebrovascular embolization that can cause stroke. Atrial thrombosis can develop despite a sinus rhythm.

11 Pregnancy Outcomes In general, complications are directly associated with the degree of valvular stenosis. Recall that investigators from the large Canadian study found that women with a mitral-valve area < 2 cm2 were at greatest risk. In another study, Hameed (2001) described 46 pregnant women with mitral stenosis 43 percent developed heart failure and 20 percent developed arrhythmias. Fetal-growth restriction was more common in those women with a mitral valve area < 1.0 cm2.

12 Pregnancy Outcomes Prognosis is also related to maternal functional capacity. Among 486 pregnancies complicated by rheumatic heart disease predominantly mitral stenosis Sawhney (2003) reported that eight of 10 maternal deaths were in wom men in NYHA classes III or IV.

13 Management Limited physical activity is generally recommended. If symptoms of pulmonary congestion develop, activity is further reduced Dietary sodium is restricted Diuretics are given A β-blocker drug is usually given to slow the ventricular response to activity

14 If new-onset atrial fibrillation develops, intravenous verapamil, 5 to 10 mg, is given, or electrocardioversion is performed. For chronic fibrillation, digoxin, a β-blocker, or a calcium-channel blocker is given to slow ventricular r response Therapeutic anticoagulation with heparin is indicated with persistent fibrillation. Some recommend heparin anticoagulation for those with severe stenosis even if there is a sinus rhythm

15 Labor and delivery are particularly stressful for women with symptomatic mitral stenosis. Uterine contractions increase cardiac output by increasing circulating blood volume. Pain, exertion, and anxiety cause ta achycardia with possible rate- but with strict attention to avoid related heart failure. Epidural analgesia for labor is ideal, fluid overload. Abrupt increases in preload may increase pulmonary capillary wedge pressure and cause pulmonary edema. Wedge pressures increase most immediately postpartum.

16 Most consider vaginal delivery to be preferable in women with mitral stenosis. Elective induction is reasonable.

17 Congenitally Corrected Transposition of Great Arteries (CCTGA)

18 30 y/o G1 PMHx: CCTGA PSHx: Neg DHx: Digoxin / metohexale / ASA / Echo: CCTGA / EF: 30-35%/ mod TR/ PAP 30 (repeat every 3 month) Fetal echo: Nl

19 WHO class: 4 REC: therapeutic abortion The Pt refused

20 WHO 4 Very high risk of maternal mortality or severe morbidity; pregnancy contraindicated and termination discussed : 1) Pulmonary arterial hypertensionn 2) Severe systemic ventricular dysfu unction (NYHA III-IV or LVEF < 30%) 3) Previous peripartum cardiomyopathy with any residual impairment of left ventricular function 4) Severe left heart obstruction 5) Marfan syndrome with aorta dilated > 40 mm

21 Betamethasone at 28 w Elective C/S at 37w CCU Discharged with methohexal / digo oxin / enalapril REC: barrier

22 Congenital Heart Disease in Offspring Many congenital heart lesions appear to be inherited as polygenic characteristics. Because of this, some women with congenital heart lesions give birth to similarly affected infants. Environmental factors are also imp portant. One example is a study from Tibet in which the prevalencee of fetal heart disease was increased among women living at higher altitudes (> 3600 meters) and was presumably due to lower oxygen concentrations

23 Congenitally corrected transposition of the great arteries (CCTGA) is a rare heart defect. Only 0.5 to 1 percent of all people with heart defects have CCTGA.

24 In CCTGA both ventricles (pumping chambers) of the heart are reversed. Fortunately, the arteries are reversed too, so the heart actually "corrects" the abnormal development, thus the name "congenitally corrected transposition of the great arteries."

25 In CCTGA, the heart twists abnormally during fetal development, and the ventricles are reversed: The stronger left ventricle pumps blood to the lungs and the weaker right ventricle has the harder chore of pumping blood to the entire body. The right ventricle is not built to last as long as the left ventricle.

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27 Signs and symptoms of CCTGA People with CCTGA experience a wide variety of symptoms, depending on other problems with the heart. There are sick newborns, with low oxygen level, who need care immediately after birth, and there are healthy peoplee who can live a normal life for many years, without any treatment. Symptoms may include fainting from the block in the electrical conduction, or fatigue, as the heart is unable to pump enough blood to the body.

28 Treatment for CCTGA Treatment for CCTGA varies according to the type and severity of symptoms and associated defects. In some patients, especially those that have no additional heart defects, there may not be a need to do anything. For patients that do need surgery, the type of operation will vary according to the associated defects. There are several operations used in this condition

29 Outlook Because of enormous strides in medicine and technology, today many children born with congenitally corrected transposition of the great arteries go on to lead healthy, productive lives as adults. Outcomes are also better for those born without additional heart defects.

30 Can women with CCTGA have children? Most women with CCTGA can have children successfully. The exceptions are if your heart function is too weak, if you have serious lung problems, and/or if you have low oxygen levels in your body.

31 Pregnancy and long-term cardiovascular outcomes in women with CCTGA Int J Gynaecol Obstet May Kowalik E in Poland between April 1991 and April 2012 were retrospectively reviewed. RESULTS: Of the 20 pregnancies among 13 women identified, 19 (95%) were successful. Of the 19 deliveries, 14 (74%) were vaginal and 5 (26%) were cesarean. One patient required premature delivery for document ted deterioration of right ventricular function. There were no pregnancy-related maternal deaths. In 1 case, congenital heart disease was diagnosed in the offspring. CONCLUSION: Successful pregnancy can be achieved by most women with cctga. The most common cardiovascular complications are supraventricular arrhythmias but pregnancy does not seem to impair right ventricular function in the long term.

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