CASE : HEART DISEASE COMPLICATIONS IN PREGNANCY

I. History

H/O - Rheumatic Fever in Childhood

H/O Heart Disease - Surgery done for Heart Disease

Previous Pregnancy and outcome

H/O taking anticoagulants and antibiotics

H/O Congenital Heart disease in her mother

2. Clinical Examination

    On Inspection -

    Dyspnoea, Orthopnoea.

    Neck vein pulsations

    Clubbing of fingers, Cynosis

    Edema legs.

CLINICAL FEATURES

 SYMPTOMS

. Progressive dyspnoea

. Orthopnoea

 .   Nocturnal cough

 . Hemoptysis

. Syncope

. Chest pain

. Palpitations

SIGNS

.   Murmur

. S2 Split&Other Sounds

. Dilated Neck Veins

. Arrythmias

. Clubbing

. Cyanosis

SIGNS

. Hyper dynamic circulation of pregnancy causes alteration in CVS that mimics heart disease.

. Premature atrial &Ventricular ectopic beats,

of peripheral pulse volume,  d pulsation of neck vein, forceful apex beat due to 1"d CO suggest cardiomegaly. which occurs in    normal pregnancy should be differentiated from those occuring in heart disease.

DYSPNOEA

. Most frequent symptom

. Can occur in normal pregnancy

. Differentiated from heart disease by history whether present prior to pregnancy or not

CHEST PAIN

. Occurs due to ischemic heart disease,AS,HOCM

. Pulmonary hypertension ~ MI ~Arrythmias, VF ~sudden death.

HEMOPTYSIS

 . Seen in MS

ORTHOPNOEA & NOCTURNAL

COUGH are other presentations of heart disease.

PALPITATIONS

. Occurs commonly in pregnancy

. No correlation between dysrrythmia & symptoms

.   A palpitation often short&does not necessarily requires treatment.

.    Seen in HOCM

SYNCOPE

. Occurs in ill Trimester

. Peripheral resistance., ). Cardiac outputof-s

. Occurs in AS, HOCM, TOF, Eisenmingers syndrome

PALPITATIONS

. Occurs commonly in pregnancy

. No correlation between dysrrythmia & symptoms

. Palpitations often short&does not necessarily requires treatment

. Seen in HOCM

SYNCOPE

. Occurs in ill Trimester

. Peripheral resistance cardiac output~s

. Occurs in AS. HOCM, TOF, Eisenmingers syndrome

EDEMA

  .     Non specific for heart disease

  .      Occurs due to

  .       Pressure of gravid utreus

 .      in intravascular colloid osmotic pressure        exacerbated injudicious use of crystalloid soln

DILATED VEINS

Significant if mean Rt atrial pr       lOmm resulting ~in height of JVP

APEX BEAT

Significant If heart beat is shifted >2cm outside the MCL ca

NYHA CLASSIFICATION

CLASS - I - No limitation of physical activities,Ordinary physical activities does not cause palpitations, dyspnoea or   anginal pain.

CLASS - ll-Slight limitation of physical activity. Pt is Comfortable at rest.

CLASS - ill - Marked limitation of physical activity ,less than ordinary activity causes fati gue, pal pitati on, dyspnoea&angina

CLASS - IV - Inability to cany out any physical activity with out discomfort,syrnptoms of cardiac insufficiency or of anginal syndrome may be present even at rest. Any physical activity causes discomfort

MURMURS

. Can occur in normal pregnancy

. Early to midsystolic murmur which is soft & of grade I & II is normal

. ESM heard over Rt & Lt II ICS about 2cm from steral edge systolic or continuous modified by pressure of stethoscope occurs due to ot flow in mammary vessels

. Venous hum ,

. MIIn11llr ~r~ ~"ciih1~ in th~ n~ck

Murmurs should be attached clinical significance if systolic murmur is loud or long like

. Pan Systolic Murmur (VSD,MR, TR)

. Late Systolic Murmur (MR,MVP)

. Early Systolic Murmur louder than Gr3/6(AS)or that varying with respiration (PS)

. Or associated with other abnormalities like ejection click (pSorAS) . 

MURMURS associated with thrill,Diastolic murmur

MURMUR

Mid to late systolic murmur associated with or without mid systolic click ~ MVP Postural maneuvers are used to aid in As.

Activities that  Lt ventricular volume  degree of MVP

ARRHYTHMIAS

-Sinus bradycardia, tachycardia, atrial&ventIjcular premature contractions,SVT occurs In pregnancy

- VT ,multiform premature ventricular

complexes are less common in normal pregnancy. ., - AF suggests heart disease

-ASD can present with supra ventricular arrhythmias.

Cyanosis,clubbing,pulse deficit peripheral signs of endocarditic are other signs

J. INVESnGATIONS:

. CHEST X-RAY

. Radiation to abdomen &fetus is minimal

. Use of pelvic & abdominal shield is mandatory . CXR is not specific

. Pulmonary venous congestion,cardiomegaly, valve calcifications can be made out

ECG

. ST depression,flattening ofT wave in It side precordicalleads occurs in 14o/00fnorrnal pregnancy

. T wave inversion,Q wave in L III in seen in healthy pregnant women

. ECG is used in diagnosing dysrrythmias &rare causes of cardiomyopathy than in demonstrating structural abnormalities of heart

. Ischemic changes in ECG is important if associated with biochemical changes.

Blood Chemistry

. Haemoglobin , ~TC, ~ESR,& ~ LDH occurs even in normal pregnancy

. ~ of serum glutamic acid transarninases & CPKwith appropriate clinical setting is used in diagnosing MI.

. During puerperium interpretation of enzyme should be cautious because they are liberated in tissue destruction of involuting uterus.

. MB isoenzyme of CPK is specific to cardiac muscle.

ECHO

. Used to demonstrate structural changes in heart

. Bacterial vegetations. prosthetic valwlar dysfunction can be made out better by Transesophageal echo.done by attaching the transducer to a flexible endoscope. In Marfan' s echo showing significant aortic root dilatation.pregnancy should be discouraged

DOPPLER

. Used to study flow patterns . But prevalence of regurgitant flow across Rt sided valve is significantly greater in nonnal pregnant woman than in non pregnant state. Hence it should be considered

USG

. Important in establishing gestational age early

. Early obstetrical scan is important for confirmation of due date. . .. Diagnosing multiple pregnancies or fetal anomalies.

. USG done in 16-20 wks is used to study fetal heart & major vessels

. Those at risk for intrauterine growth retardation occurring in Eisenminger's should be subjected to serial USG every 2-4 wks in III Trimester

4. Differential Diagnosis

. Normal Physiological changes during pregnancy

. Anaemia

. Hypoproteinemia

5. Non - Surgical Management

. Class I &II

Admission 2 weeks earlier to EDD .

ClassIll&IV

Immediate Hospitalisation . AN Care

. Prevent Anaemia, Prevent Infections - RI . UTI. Limitation of activities

JP Care - Hospitalisation in tertiary care centre

Stage 1 : Propped up position, oxygen, sedation. Stage 2 :

Prophylactic outlet forceps or vacuum ~

Withheld prophylactic methergin Stage 3:

Ifbleeding, oxytocin to be used. Stage 4:

If patient is in failure, oxygen, Digoxin, IV , Oral Digoxin, Diuretics - Injection - Furesimid 40 to 80 mg IV. Sedation - Injection - Morphia 15 mg 1M

Antibiotics -Injection - Ambicillin 1.5 mg and Inj Garamycin 60 mg eighth hourly. - SHE Prophylaxis

Arrhythmia - Quinidine, Electro version.

6. Surgical Management

INDICATION FOR SURGERY

. BECAUSE OF THE ASSUMED RISK TO BOTH THE MOTHER AND FETUS, SURGER Y HAS BEEN CONFINED TO THE PERSON WHO IS REFRACTORY TO MEDICAL MANAGEMENT WITH EITHER INTRACTABLE HEART FAILURE (OR) INTOLERABLE SYMPTOMS.

. ONLY 0.5 TO 2% OF mE PATIENTS REQUIRE SURGERY

FOR . CORRECTABLE CARDIAC LESION: SURGERY . NON CORRET ABLE CARDIAC LESION - MTP

TYPES OF INTERVENTION

CWSED

OPEN

- PERCUTANEOUS BAlLOON MITRAL OR AORllC

VAL VUWPLASTY

VALVULOPLASTY

CLOSED COMMISSUROTOMY VALVE REPLACEMENT [MS} [AR} [AS] [MR.]

VALVOTOMY

STENTING

PULMONARY STENOSIS

CORONARY ARTERY DL~E

Dissection of AORTA

. INDICA nONS FOR VALVOTOMY

. i) PULMONARY CONGESnON NOT RESPONDING TO DRUGS . ii) EPISODE OF PULMONARY EDEMA BEFQRE PREGNANCY. . iii) PROFUSE HEMOPTYSIS

. CRETERIA FOR VALVOTOMY

. - NO SIGNIFICANT INCOMPETENCE

. - NON CALCIFIED V AI.. VE

. - NO OTHER SIGNIFICANT V AI..UE INVOLVEMENT

OPEN HEART SURGERY

. INDICATION - LIFE THREATENING PULMONARY EDEMA REFRACTORY TO MEDICAL MANGEMENT OR IN PATIENTS WITH PRIOR VALVE REPLACMENT OBSTRUCTED JJY THROMBUS OR PANNUS.

. MMR: 5%PERINATALMORTALITYRATE: 33%

. DUE TO INADEQUATE PERFUSION OF THE PLACENTA DURING CARDIOPULMONARY BYPASS EITHER BECAUSE OF RELATIVE HYPOTENSION OR BECAUSE OF PULSATIBE BLOOD FLOW.

VALVE REPLACEMENT

Bio valve

ADVANTAGE: NO SIGNIFICANT RISK OF BLOOD CLOTS ON mE VALVE. SO mEY DO NOT REQUIRE ANTICOAGULANTS, THUS MJNIMISJNG THE RISK ASSOCIATED WITH W ARF ARIN/HEP ARIN DURING TIllS PREGNANCY AND SUBSEQUENT PREGNANCY. . 1) PORCINE VALVE (FROM TISSUE OF PIG)

DISADVANTAGE: HOWEVER DEGENERATION OCCURS DUE TO ACCELERATED CALCIFICATION AND REQUIRES REOPERATION AFTER 5 TO 10 YEARS.

n MECHANICAL VALVE

. VALVE OF CHOICE IN MOST YOUNG WOMEN WHO DO NOT DESIRE FUTURE PREGNANCY (OR) ARE FEARFUL OF REOPERATION..

. ADVANTAGE: DURABILITY MORE THAN 20 YEARS

. DISADA VANTAGE: SMALL POTENTIAL FOR BLOOD CLOT AND THEY MAY LEAD TO

STROKE.

. HENCE THE PATIENTS WITH MACHANICAL VALVE REQUIRE LIFE LONG ANTICOAGULANTS.

m. HOMOGRAFT VALVE

FROM HUMAN ORGAN DONOR mERE IS NO RISK OF BLOOD CLOTS,

HENCE NO NEED FOR ANTICOAGULANTS

COMPLICA nON OF VALVE REPLACEMENT INCIDENCE  3 TO 5%

BLEEDING INFECTION RENAL FAILURE STROKE

. FOLLOWUP:

.

. ECHO EVERY 6 MONmS TO CHECK THE FUNCTIONING OF . THE VALVE.

. ANTIBIOTICS PROPHYLAXIS BEFORE ANY PROCEDURES

STENT

DRUG ELUDING STENT IS A TYPE OF STENT COATED WITH AN AGENT THAT INffiBITS RESTENOSIS.

. THE AGENT IS AN ANTIBIOnC NAMELY RAP AMYCIN OR SIROLIMUS (CYTOTOXIC DRUG) WfllCH IS SLOWLY RELEASED INTO THE ARTERY FOR ABOUT 30 DAYS AFTER IMPLANTATION.

. THE DRUG INffiBITS CELL GROWTH AND DIVISION. T CELL ACTIVATION AND PROLIFERAnON. [T CELLS INITIATES AN INFLAMMATORY RESPONSE THAT COMMONL Y FOLWWS IMPLANT A nON AND THE INFLAMMATION CAN LEAD TO RESTENOSIS]

. INCIDENCE OF RESTENOSIS

. WITH AN UNCOATED STENT 15 - 25% . DRUG ELUDING STENT 3 TO 4%

VALVULAR HEART DISEASE

. MITRAL STENOSIS

. MOST COMMON VHD, THAT REQUIRES THEREPEUTIC INTERVEN1l0N DURING PREGNANCY AS THE TRANSMlTRAL FLOW INCREASE AND THE TIME OF DIASTOLE DECREASE DURING PREGNANCY DUE TO DECREASE IN C.O & H.R USUALLY AT 20 WEEKS OF GESTATION.

. HENCE, INTERVEN1l0N SHOULD BE DONE IN EARLY 21M! TRIMESTER. . TYPE OF INITERVENTION

. CLOSED: PERCUTANEOUS BALLOON MITRAL VALVOTOMY

. COMMISSUROTOMY ~ OPEN :VALVEREPAIR

VALVE REPLACEMENT.

OUTCOME CLOSURE 

. MMR 5%

. PERINATAL 10-15% . MORTALITY

. COMPLICATIONS

. THROMBOEMBOLISM

. MITRAL REGURGITATION . CARDIAC TAMPONADE

AORTIC STENOSIS:

INCIDENCE 0 TO 6.5% 0.9 TO 3% <5%

~<20;0 >30%

MILD TO MODERATE AS - WELL TOLERATED

. SEVERE - SUDDEN DEA rn OR IRREVERSffiLE HEART FAILURE

. THERE IS ALSO DECREASED CEREBRAL, CARDIAC . AND UTERINE PERFUSION

INTERVENllON

VALVULOPLASTY

PERCUTANEOUS BALLOON ATRIAL VAL VOTONY

. INDICA nON

-FAnGUE

EJECTION FRACTION <600/0 SYNCOPAL ATTACKS

LVDH.ATAllON SHROTNESS OF BREATH

CONGENITAL HEART DISEASES

. ASD:

. ISOLITED ASD SUCCESSFUL AND UNCOMPLICATED PREGNANCY . VSD AND SMALL PDA : TOLERATE PREGNANCY

. COARCTATION OF AORTA - BAlLOON ANGIOPLASTY

--~ SURGICAL CORRECnON RECOlvfMENDED ONLY IF nIERE IS AORnC

DISSECnON, UNCONlROLLED HYPERTENSION, HEART FAILURE & REFRACTORY TO MEDICAL TREATEMENT

DISSEcnON OF AORTA

. TYPE A - INVOL VING THE ASCENDING AORTA

URGENT REPAIR - REPLACE ASCENDING AORTA . RESECT THE PRIMARY INTIMAL

. TEAR IF POSffiLE.

. RECONsnTUTE THE DISTAL FLOW INTO THE 1RUE AORnc LUMEN

. TVPE B - INDICA nON FOR SURGERY

.RUPTURE

. ACUTE EXPANSION

VITAL END ORGAN ISCHEMIA

7. Any other

ACUTE RHEUMATIC FEVER

. It usually presents as non-specific malaise joint pain which is likely to get missed. . Florid signs of swollen joints, rheumatic nodules skin rashes with which it usually

presents in children does not occur in adults

. Hence diagnosis is based on HlO sore throat, ~in ASO titre,ESR>8Omm, ~in CRP&ECG showing prolonged PR interval&QT interval

MORTALITY ASSOCIATED WITH PREGNANCY

. GROUPI<l%

VSD,ASD,PDA,Pulmonary or tricuspid disease,corrected TOF ,porcine valves,MS with I&ll

GROUP II 5-15% MS AF ,Artificial valves,MS with NYHA III& IV ,AS,coarctation of aorta- uncomplicated, uncorrected TOF ,previous MI,Marfan's with normal aorta.

. GROUP III 25-50%

PHT ,coarctition of aorta with complications, Marfan' s with aortic involvement.

INDICATION FOR PREGNANCY TERMINATION

Absolute

-PHT

-Dilated cardiomyopathy

-Marfans with carillo vascular involvement -Pulmonary A VF

Relative

~

! Parous women with ill,IV cardiac lesions

-I & II patients with history of cardiac failure in early pregnancy in between pregnancy -Done < 12 weeks by suction evacuation or dilatation and evacuation -Dilated cardiomyopathy

Induction of Labour can be done with adequate monitoring

-Use of anticoagulants - Inj Heparin ( fractionated) during 6 to 12 weeks and after 36 weeks and Puerperium.

-Tab. Warfarin from 12 to 36 weeks

-LSCS for Obstetric indication, coarctation of Aorta, pulmonary hyper tension -

Contraception - Barrier method, Tubectomy or Vasectomy for Husband. -

Breast feeding - Not contra indicated. -

Peripartum Cardio Myopathies -Heart Tran~n1antatinn